Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-56 - Medicaid Hospice Program
Section 5160-56-02 - Hospice services: eligibility and election requirements
Universal Citation: OH Admin Code 5160-56-02
Current through all regulations passed and filed through September 16, 2024
This rule sets forth the criteria that must be met for an individual eligible for medicaid to receive the Ohio medicaid hospice benefit.
(A) To be covered under Ohio medicaid, the designated hospice must ensure the following criteria are met prior to furnishing hospice care:
(1)
The
designated hospice has a certification of the terminal illness on behalf of the
individual, obtained in accordance with
42 C.F.R.
418.22 (October 1, 2017);
(2)
A hospice
election statement, completed by the individual, has been obtained by the
designated hospice pursuant to paragraphs (B) and (C) of this
rule;
(3)
The individual has a hospice plan of care initiated,
pursuant to paragraph (F) of this rule;
(4)
Other applicable
criteria are met which pertain to the individual and the election of
hospice:
(a)
The designated hospice shall ensure an individual eligible for both medicare
and medicaid hospice elects the hospice benefit under both programs. Hospice
services furnished to individuals who are dual eligible shall be billed to
medicare first.
(b)
If the individual has or later obtains third-party
coverage of hospice, the individual must elect the third-party coverage of
hospice to cover the same days the medicaid hospice benefit covers in order to
ensure medicaid is the secondary payor. If the individual revokes his or her
third-party coverage of hospice, the medicaid hospice benefit must be revoked
at the same time.
(c)
If the individual is a participant in the program of
all-inclusive care for the elderly (PACE), the individual must access hospice
services through the PACE site's network of providers.
(d)
If the individual
is enrolled in a medicaid managed care plan (MCP), the individual must access
hospice services through the MCP's network of providers.
(e)
If the individual
is enrolled in a home and community based services (HCBS) waiver, the
designated hospice shall assist the individual in coordinating concurrent care
and waiver services in accordance with rule
5160-56-04 of the Administrative
Code.
(B) At the time hospice is elected, the designated hospice must:
(1)
Assist the
individual with the election process; and
(2)
Provide the
individual with the following materials and written information:
(a)
A copy of the
agency's grievance procedures;
(b)
Information
regarding advance directives in accordance with Chapter 2133. of the Revised
Code; and
(c)
Any policies the hospice has regarding the
implementation of advance directives, including ensuring the individual's right
to formulate an advance directive, and the right to request a "do not
resuscitate" order. The hospice must maintain the individual's advance
directive in an accessible part of the individual's current hospice record and
include a notation in the individual's plan of care.
(C) The designated hospice shall maintain a record of the election statement completed by the individual.
(1)
The election statement shall be in writing and a notice
of the election filed by the designated hospice in accordance with
42 C.F.R.
418.24 (October 1, 2017). The medicaid
election statement may be combined with the medicare election statement or on a
separate form, provided it is clear the form denotes medicaid hospice has been
elected.
(2)
The election statement shall contain the
following:
(a)
Documentation that the individual elected the medicaid
hospice benefit;
(b)
The identity of the designated hospice responsible for
providing hospice care to the individual;
(c)
The individual's
acknowledgment that he or she has been given a full explanation of the
palliative rather than curative nature of hospice care as it relates to the
individual's terminal illness and the provisions and limitations of services as
specified in this chapter;
(d)
Acknowledgment
that the individual understands that certain medicaid services are waived by
the election, except when the individual is under age
twenty-one;
(e)
The identification of the individual's attending
physician (if any) with an acknowledgment that the identified attending
physician was the individual's own choice;
(f)
The individual's
acknowledgment that the attending physician was the individual's
choice;
(g)
The effective date of the election which may be the
first day of hospice care or a later date, but shall be no earlier than the
date of the election statement;
(h)
The individual's
signature; and
(i)
The date the election statement was
signed.
(3)
A copy of the completed election statement shall be
scanned and uploaded to the medicaid information technology system (MITS)
pursuant to rule
5160-56-03.3 of the
Administrative Code. The original form as completed, shall remain on file with
the designated hospice.
(4)
The election statement shall remain in effect as long
as the individual continues to meet all eligibility requirements of this
rule.
(D) While a hospice election is in effect, the designated hospice shall commence hospice care to the individual, beginning with enrolling the individual in the appropriate benefit period as defined in rule 5160-56-01 of the Administrative Code and pursuant to the remainder of this rule.
(1)
The initial
benefit period shall commence with hospice care on or after the date of
election and end on the ninetieth day, unless a discharge pursuant to rule
5160-56-03 of the Administrative
Code disrupts hospice care.
(2)
If at the end of
the initial ninety day period, the individual is recertified as terminally ill,
the designated hospice shall ensure the individual is enrolled in the second
subsequent ninety-day benefit period, continuing hospice services uninterrupted
until the end the second ninety-period, to the one-hundred eightieth day,
unless a discharge pursuant to rule
5160-56-03 of the Administrative
Code disrupts hospice care.
(3)
If at the end of
the subsequent ninety day period, the individual is recertified as terminally
ill, the designated hospice shall ensure the individual is enrolled in a
subsequent sixty day benefit period, and shall continue hospice services
uninterrupted for increments of sixty additional days as recertifications
occur, unless a discharge pursuant to rule
5160-56-03 of the Administrative
Code disrupts hospice care.
(E) For the duration of the election of hospice care, the individual must waive medicaid services if the services:
(1)
Are provided by a hospice other than the hospice
designated by the individual, unless provided under arrangement made by the
designated hospice;
(2)
Are related to the curative treatment of the terminal
condition for which hospice care was elected or a related condition, except for
the individual under age twenty-one; or
(3)
Are equivalent to
hospice care such as non-waiver services provided through home health and
private duty nursing services.
(F) The designated hospice shall follow the requirements as prescribed in this rule for an individual previously discharged from hospice, who has subsequently re-elected hospice care in accordance with paragraph (A)(3) of rule 5160-56-03 of the Administrative Code.
Replaces: 5160-56-02
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