Lawriter - OAC - 5160-56-03 Hospice services: discharge requirements.

5160-56-03 Hospice services: discharge requirements.

This rule sets forth the requirements for discharging an individual from the designated hospice's care and/or the hospice benefit.

(A) Discharge refers to the end the hospice benefit and/or the designated hospice's care:

(1) Discharge from the designated hospice's care shall occur when the individual:

(a) Dies/expires;

(b) No longer meets the hospice enrollment or eligibility criteria;

(c) No longer is terminally ill, e.g., physician discharges or does not recertify the individual;

(d) Moves out of the service area;

(e) Enters a facility where the designated hospice has no access and/or cannot enter to provide care;

(f) Revokes the hospice benefit in accordance with paragraph (B) of this rule;

(g) Transfers to another hospice in accordance with paragraph (D) of this rule; or

(h) Is discharged for cause, such as compromising the safety of self or the safety of the hospice staff.

(2) The hospice provider must notify the Ohio department of medicaid (ODM) through the medicaid information technology system (MITS) or its designee of the individual's discharge from the designated hospice's care so that the designated hospice's services and billings coincide with the date of the individual's discharge and/or so that hospice services may continue with the new hospice when applicable, e.g., following a transfer.

(3) Except for the reason cited in paragraph (A)(1)(a) of this rule, the designated hospice shall complete a written summary statement which clearly states the reason(s) for the individual's discharge from the designated hospice's care. The original statement of discharge shall be retained by the hospice for its records, with a copy provided to the individual. As a reason for discharge, a hospice provider may not automatically or routinely discharge an individual at its "discretion" or request or demand that the individual revoke his or her election.

(4) With the exception of paragraph (A)(1)(g) of this rule, when an individual is discharged from a designated hospice's care, the current election period (as defined in rule 5160-56-01 of the Administrative Code) shall end and the individual shall be discharged from the hospice benefit entirely, making him or her no longer eligible to receive medicaid hospice services.

(B) The designated provider shall respect the right of the individual to revoke the election of the hospice benefit at any time during any given election period.

(1) Upon notice of the individual's intent to revoke, the designated hospice shall:

(a) Obtain a written statement, signed and dated by the individual, which states that the election of hospice care has been revoked by the individual for the remainder of the applicable benefit period. The designated hospice shall not accept a verbal revocation of the hospice benefit;

(b) Discharge the individual from hospice care, such that hospice coverage for the remaining days in that election period is forfeited and medicaid coverage of the benefits waived when hospice care was elected may resume; and

(c) Provide the individual with a copy of the written revocation statement and maintain the original for its record.

(2) An individual shall be permitted to re-elect the medicaid hospice benefit at any time after revocation pursuant to paragraph (C) of this rule, provided the individual meets all hospice eligibility requirements.

(C) If the individual remains eligible for hospice, a designated hospice may enroll an individual at any time after the re-election.

(1) The individual discharged from hospice care during the initial ninety-day period, who re-elects the hospice benefit, shall be enrolled in the second ninety-day benefit period; or

(2) The individual who revoked the hospice benefit or who was discharged from hospice care during the second ninety-day benefit period, or any subsequent sixty-day benefit period, who re-elects the hospice benefit, shall be enrolled in a subsequent sixty-day benefit period.

(D) The following requirements apply when an individual is discharged from the designated hospice's care due to individual's transfer to another hospice:

(1) The individual may change the designation of the hospice from which care is received once during each benefit period. The change of the designated hospice is not considered a revocation of the election from the period in which it is made.

(2) To change the designated hospice, the individual must file, with the hospice from which the individual has received care and the newly designated hospice, a signed statement which includes the following information:

(a) The name of the hospice from which the individual has received care;

(b) The name of the hospice from which the individual plans to receive care; and

(c) The date the change is to be effective.

(3) When an individual transfers from one hospice to another, his or her medicaid hospice benefit shall continue without interruption of care.

(E) The individual who has elected the hospice benefit and decided to revoke, terminate, or transfer his or her hospice benefit must do so on the same effective date for both the third-party covered or medicare hospice benefit and the medicaid hospice benefit. When the dual eligible individual revokes his or her medicare hospice benefit, the provider shall ensure the medicaid hospice benefit is revoked by the individual at the same time.

(F) Any denial or termination of hospice care which is the result of an Ohio department of medicaid (ODM) decision shall be subject to the notice and hearing rights contained in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.

Replaces: 5160-56-03

Effective: 10/1/2017
Five Year Review (FYR) Dates: 10/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03
Prior Effective Dates: 5/16/90, 12/1/91, 4/1/94, 9/26/02, 1/1/04, 3/2/08, 4/1/15.