Lawriter - OAC - 5160-56-04 Hospice services: provider requirements.

5160-56-04 Hospice services: provider requirements.

This rule sets forth the responsibilities, including the conditions of participation for a hospice engaged in the provision of medicaid hospice services. To be eligible to provide and to request reimbursement for hospice services, a designated hospice must:

(A) Be eligible to participate in the Ohio medicaid program upon execution of a provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code.

(B) Meet the medicare guidelines in accordance with 42 C.F.R. part 418 (October 1, 2017).

(C) Be licensed under Ohio law in accordance with Chapter 3712. of the Revised Code by the Ohio department of health.

(D) Comply with all requirements for medicaid providers in Chapter 5160-1 of the Administrative Code.

(E) Ensure that all hospice employees, volunteers, and contracted staff who provide direct services to hospice individuals are trained, licensed, certified, and/or registered in accordance with applicable federal and state law.

(F) Not discontinue or diminish the hospice care provided to the individual because of the inability of the individual to pay or receipt of medicaid reimbursement for such care pursuant to the medicare requirements outlined in Section 1861 (dd)(2)(D) of the Social Security Act, 42 U.S.C. 1395x(dd)(2)(D) (as in effect January 1, 2017).

(G) Arrange for another individual or entity to furnish services to the individual in accordance with 42 C.F.R. 418.56 (October 1, 2017) when the designated hospice cannot provide services to the individual. This arrangement must include a signed agreement which shall remain on file at the hospice agency.

(H) Assume responsibility for the professional management of the individual's hospice care. Professional management involves the assessment, planning, monitoring, directing and evaluation of the individual's hospice care across all settings. The designated hospice must provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.

(I) Facilitate concurrent care and services with other medicaid providers for which the individual under age twenty-one is eligible. As a responsibility for the professional management of the individual's hospice care, the designated hospice shall:

(1) Ensure hospice services are maintained and coordinated with concurrent care services;

(2) Document the delineation in which services and the assessment process are coordinated between medicaid hospice and non-hospice providers to avoid the duplication of equivalent or similar scope of services; and

(3) Maintain up-to-date contact information for providers of concurrent care and services.

(J) Have a signed agreement with the nursing facility, the intermediate care facility for individuals with intellectual disabilities (ICF-IID), the general inpatient facility, and/or the inpatient respite care facility in which the individual resides and/or receives services. The terms of the agreement must not violate the medicaid provider agreement as set forth in rule 5160-1-17.2 of the Administrative Code and must not violate the individual's freedom of choice of providers. This agreement must remain on file at the hospice agency and contain, at a minimum, the following:

(1) A stipulation that the designated hospice maintains responsibility for the professional management of the individual's hospice care;

(2) A delineation of the manner in which contracted services are coordinated and supervised by the hospice;

(3) A delineation of the role of the hospice and the facility in the admissions process, patient/family assessments, and the interdisciplinary group conferences; and

(4) A stipulation that the facility must have a valid medicaid provider agreement in accordance with rule 5160-1-17.2 of the Administrative Code and accept the payment from the hospice as payment in full as negotiated.

(K) Ensure all necessary care and services set forth in this chapter are furnished to the individual and that such care and services are specified in the individual's plan of care in accordance with the standards set forth in 42 C.F.R. 418.56 (October 1, 2017) for:

(1) Approaching service delivery;

(2) Care planning;

(3) Contents of the plan of care;

(4) Reviewing and revising the plan; and

(5) Coordinating hospice and non-hospice services.

(L) Designate a registered nurse who is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each individual's and family's needs and implementation of the plan of care.

(M) Ensure hospice care is coordinated for an individual enrolled in a home and community based waiver program. A collaborative effort must occur between the designated hospice and the waiver case manager or the service and support administrator (SSA) as applicable to maintain a continuum of the overall care provided to the individual.

(1) Case management of hospice services shall be provided by the designated hospice in accordance with this chapter;

(2) Case management of waiver services shall be provided by the waiver case manager; and

(3) The hospice must provide services to a waiver individual in accordance with a comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers. The administrating agency of the waiver or its designee shall assist in the coordination of care by:

(a) Reviewing and approving the comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers;

(b) Resolving any issues resulting from the comprehensive plan for the concurrent provision of waiver services by waiver and hospice providers;

(c) Resolving any issues of interpretation when implementing the requirements in this chapter; and

(d) Applying any exceptions to the requirements of this chapter on a case-by- case basis.

Replaces: 5160-56-04

Cite as Ohio Admin. Code 5160-56-04

Effective: 10/1/2017
Five Year Review (FYR) Dates: 10/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.02
Prior Effective Dates: 5/1/90, 5/15/90, 5/16/90, 12/1/91, 4/1/94, 9/26/02, 2/3/05, 4/1/05, 3/2/08, 2/1/11, 4/1/15.