Current through all regulations passed and filed through September 16, 2024
This rule sets forth medicaid covered services that hospice
providers may or must furnish to individuals to the extent specified by the
individual's plan of care.
(A) The
designated hospice shall ensure the hospice services furnished to an individual
in accordance with this rule are reasonable and necessary for the palliation
and management of the terminal illness and related conditions.
(B) Unless otherwise specified, covered
services shall be furnished to the individual in his or her residence,
including the individual's home, a relative's home or any other type of living
arrangement, a skilled nursing facility (SNF), a nursing facility (NF), an
intermediate care facility for individuals with intellectual disabilities
(ICF-IID), or a hospice inpatient unit.
(C) The designated hospice shall ensure
covered services provided to the individual are furnished by qualified
personnel pursuant to
42 C.F.R.
418.114 (October 1, 2017), who are employed
by the hospice, under an individual contract, or under arrangement with another
provider.
(D) The following
services are covered by medicaid when furnished or arranged by the designated
hospice based on the individual's needs, appropriate level of care, and plan of
care:
(1) Core hospice services
may be provided through a combination of contracting
services and telehealth services as necessary:
(a) Nursing care;
(b) Medical social services, provided by a
social worker under the direction of a physician or attending
provider;
(c) Physicians' services,
including attending physician services, and services rendered by advance nurse
practitioners or physician assistants acting as
attending physicians; and
(d)
Counseling services, including but not limited to dietary counseling,
bereavement counseling and spiritual counseling.
(2) Non-core hospice services
may be provided through a combination of contracting
services and telehealth services as necessary and appropriate:
(a) Physical therapy, occupational therapy,
and speech-language pathology provided for symptom control or to enable the
individual to maintain activities of daily living and basic functional
skills;
(b) Hospice aide, home
health aide and homemaker services that enable the individual to carry out the
plan of care;
(c)
Volunteers;
(d) Medical appliances
and supplies, including drugs and biologicals;
(e) Short-term inpatient care provided in
hospital, hospice inpatient unit, or a participating SNF or NF on an
intermittent, non routine basis for relief of the individual's caregivers,
and/or general inpatient care for the purpose of respite, pain control and
acute or chronic symptom management that cannot feasibly be provided in other
settings; and
(f) Any other item or
service provided in relation to the terminal condition, when medically
indicated, included in the plan of care and for which payment may otherwise be
made under medicaid.
(3)
Ambulance transports or an individual that are related to the terminal illness
and that occur after the effective date of election, are covered to the extent
specified by the individual's plan of care, when deemed the responsibility of
the hospice as specified in section 40.1.9 of the "medicare benefit policy
manual, chapter nine: coverage of hospice services under hospital insurance"
under hospital insurance,
www.cms.gov
(revised May 08, 2015).
(a) Transports to an
individual's home which occur on the effective date of the hospice election,
the date of admission, prior to the initial assessment or prior to establishing
the plan of care are not covered under the hospice benefit.
(b) If the hospice determines that the
individual's need for transportation is for any reason other than receiving
care related to the terminal illness, the hospice may make arrangements
pursuant to paragraph (G) of this rule for the appropriate level or type of
transportation and the service to be covered under the ambulance benefit for
medicaid in accordance with Chapter 5160-15 of the Administrative
Code.
(E)
Coverage for individuals who reside in a NF or ICF-IID:
(1) Pursuant to rule
5160-56-06 of the Administrative
Code, the room and board shall be covered for the individual when all of the
following applies:
(a) The individual has
elected hospice and is receiving hospice care;
(b) The individual resides in a NF, SNF or
ICF-IID; and
(c) All other payments
for room and board have been exhausted, making medicaid the payer of last
resort.
(2) The
designated hospice shall pay the facility per diem reimbursed to the designated
hospice by the Ohio department of medicaid in accordance with rule
5160-56-06 of the Administrative
Code. The following room and board services are covered pursuant to section
20.3 of the "medicare benefit policy manual, chapter nine: coverage of hospice
services under hospital insurance" under hospital insurance,
www.cms.gov (revised May 08, 2015):
(a) Performing personal care
services;
(b) Assisting with
ADLs;
(c) Administering
medication;
(d) Socializing
activities;
(e) Maintaining the
cleanliness of the individual's room; and
(f) Supervising and assisting in the use of
durable medical equipment and prescribed therapies.
(F) Hospice care for individuals
enrolled in a home and community based services (HCBS) waiver program:
(1) Waiver services are provided by approved
waiver providers in the amount and scope approved on the individual's plan of
care.
(2) The designated hospice
has the responsibility to cover hospice services pursuant to paragraph (M) of
rule 5160-56-04 of the Administrative
Code.
(G) For any
medicaid services that are unrelated to the treatment of the terminal condition
for which hospice care was elected, non-designated hospices and/or non-hospice
providers must:
(1) Follow all applicable
medicaid authorization policies and procedures; and
(2) Contact the designated hospice to
coordinate the individual's care and to clarify provider payment
responsibility.
