5160-56-05 Hospice services: covered services.

For services outlined in this rule to be covered, a certification that the consumer is terminally ill must have been completed, and the hospice service must be reasonable and necessary for the palliation and management of the terminal illness and related conditions. The consumer must elect hospice care, and a plan of care must be established before the services are provided.

A hospice may furnish covered services to consumers who reside in a SNF, NF, ICF-MR, or any residence or facility not certified by medicare or medicaid or at the consumer's home.

When the consumer elects the hospice benefit, the hospice assumes responsibility for the professional management of the consumer's care. Professional management involves the assessment, planning, monitoring, directing and evaluation of the consumer's care across all settings.

(A) The following covered hospice services must be performed by appropriately qualified personnel, and the level of care provided must be based on the consumer's needs:

(1) Core hospice services include the following:

(a) Nursing care;

(b) Medical social services, provided by a social worker under the direction of a physician or attending provider;

(c) Counseling services, provided for the purpose of counseling or training the caregiver and helping the consumer and the family members and/or caregiver with adjusting to the approaching death, including but not limited to:

(i) Dietary;

(ii) Bereavement;

(iii) Spiritual; and

(iv) Additional counseling; and

(d) Physician services.

(2) Non-core services include the following:

(a) Short-term inpatient care that can be accessed on an intermittent, nonroutine, occasional basis for pain control and acute or chronic symptom management and/or respite;

(b) Medical appliances and supplies, including drugs and biologicals;

(c) Home health aide and homemaker services that enable the consumer to carry out the treatment plan;

(d) Physical therapy, occupational therapy, and speech-language pathology provided for symptom control or to enable the consumer to maintain activities of daily living and basic functional skills;

(e) All other medical treatment and diagnostic procedures provided in relation to the terminal condition, when medically indicated; and/or

(f) Transportation services must be provided or arranged for by the hospice:

(i) If there is no other means to transport the consumer, and the ambulance service is the safest way of transportation and it is related to the consumer's condition, the ambulance service becomes a covered hospice service; or

(ii) If the hospice determines that the consumer's need for transportation is for other than receiving care related to the terminal illness, the hospice may make arrangements for the appropriate level or type of transportation and the service may be covered under medicaid in accordance with Chapter 5101:3-24 of the Administrative Code.

(3) Hospice care for consumers residing in a nursing facility or ICF-MR:

(a) The facility has the responsibility to assure that the care outlined in the plan of care is performed by qualified staff and consistent with acceptable professional standards of practice. Those services include:

(i) Performing personal care services;

(ii) Assisting with activities of daily living;

(iii) Administering medication;

(iv) Socializing activities;

(v) Maintaining the cleanliness of the consumer's room; and

(vi) Supervising and assisting in use of durable medical equipment and prescribed therapies; and

(b) The hospice has the responsibility to cover hospice services outlined in paragraphs (A)(1) and (A)(2) of this rule.

(4) Hospice care for consumers enrolled in a home and community based services (HCBS) waiver program:

(a) Waiver services are provided by approved waiver providers if the service is a covered service for that waiver program prior to the election of the hospice benefit; and

(b) The hospice has the responsibility to cover hospice services outlined in paragraphs (A)(1) and (A)(2) of this rule.

(B) For any medicaid services that are unrelated to the treatment of the terminal condition for which hospice care was elected, providers must:

(1) Follow all applicable medicaid authorization policies and procedures; and

(2) Call the hospice before providing any services in order to clarify the consumer's restricted status.

Replaces: Part of 5101:3-56-02, Part of 5101:3-56-03, Part of 5101:3-56- 03.2, Part of 5101:3-56-05, Part of 5101:3-56-06, Part of 5101:3-56- 06.1, Part of 5101:3-56- 06.2

Effective: 03/02/2008
R.C. 119.032 review dates: 03/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 5/15/90, 5/16/90, 12/1/91, 4/1/94, 9/26/02, 1/1/04, 4/1/05