Current through all regulations passed and filed through September 16, 2024
This rule sets forth medicaid covered services that hospice
providers should furnish to individuals to the extent specified
by the individual's plan of care.
(A)
The designated hospice
will 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
will 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
will
ensure covered services provided to the individual are furnished by qualified
personnel pursuant to 42
C.F.R. 418.114 (October 1,
2023),
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
:
(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
:
(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,
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
(
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf).
(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
can 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
will 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
will 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
(
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf).
(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 should:
(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.
