This rule set forth terms used throughout Chapter 5160-56 of
the Administrative Code.
directive" refers to written instructions recognized under state law that are
related to the provisions of health care when the individual is incapacitated.
Samples of advance directive documents include a living will, a declaration as
defined in Chapter 2133. of the Revised Code, and a durable power of attorney
for health care as defined in Chapter 1337. of the Revised Code.
(B) "Advanced practice registered nurse
(APRN)" refers to a registered nurse (RN) authorized to practice as a clinical
nurse specialist, certified registered nurse anesthetist, certified nurse
midwife or certified nurse practitioner in accordance with section
4723.43 of the Revised Code.
"Attending physician" refers
to a health professional identified by the individual at the time of the
election of hospice, as having primary responsibility in the determination and
delivery of the individual's medical care while under hospice, and one who is:
(1) A doctor of medicine or osteopathy
licensed and legally authorized under Chapter 4731. of the Revised Code to
practice medicine and surgery or osteopathic medicine and surgery; or
(2) A "nurse practitioner" who meets the
training, education, and experience requirements of a certified, advanced
practice nurse in accordance with section
4723.43 of the Revised Code.
APRNs are prohibited from certifying or recertifying a terminal
A "physician assistant" (PA) who meets the training,
education, and other specifications of a licensed physician assistant in
accordance with Chapter 4730 of the Revised Code. PAs are prohibited from
certifying or recertifying a terminal diagnosis.
"Authorized representative" has the same
meaning as a person, in accordance with rule
Administrative Code, who is at least eighteen years old, or a legal entity who
stands in place of the individual as defined in this rule. If an individual has
designated an authorized representative, all references to "individual" in
regards to an individual's responsibilities shall include the individual's
authorized representative. Actions or failures of an authorized representative
will be accepted as the action or failure of the individual. An authorized
representative may make health care decisions on behalf of the individual who
is mentally or physically incapacitated, or at the request of the terminally
ill individual. These decisions may include the termination of medical care,
the election of the hospice benefit, or the revocation of election of the
hospice benefit on behalf of a terminally ill individual. Documentation of the
authorization must be maintained in the individual's hospice record.
(E) "Beginning date of service" means the
first billable date on which a designated hospice provider delivers hospice
services to an individual.
"Benefit period" or "election benefit period" refers to a span for which the
individual is enrolled in the hospice benefit. Benefit periods consist of two
ninety day benefit periods, followed by an unlimited number of sixty day
benefit periods. The benefit periods may be used consecutively or at intervals.
The election benefit period is subject to the conditions set forth in this
chapter to include revocation, and must be utilized in sequential order:
(1) An initial ninety-day period (limited to
one during the individual's lifetime);
(2) A second subsequent ninety-day period
(limited to one during the individual's lifetime);
(3) An unlimited number of subsequent
"Bereavement counseling" refers to counseling services furnished to the
individual's immediate family or caregiver before and after the individual's
death, to assist the family with issues related to grief, loss, and adjustment.
Bereavement counseling must be made available by the designated hospice for a
period up to one year following the individual's death.
"Certification of the terminal illness"
refers to the clinical judgment made by a medical director or physician member
of the interdisciplinary group (IDG) and the individual's attending physician
about the life expectancy of an individual should a terminal illness run its
normal course. As a requirement pursuant to
(October 1, 2017), in order to receive
hospice care, the individual must be certified by a hospice medical director or
physician member of the IDG and the individual's attending physician as being
terminally ill with a medical prognosis that the individual's life expectancy
is six months or less.
"Concurrent care for children" refers to a federal provision which allows for
curative treatment and hospice care to be covered simultaneously for
individuals under age twenty-one.
"Continuous home care" is a level of
hospice care covered by medicaid in accordance with
(October 1, 2017). A continuous home
care day is one on which an individual who has elected to receive hospice care
is at home and not in an inpatient facility, and when the care provided in the
home consists predominantly of nursing care. Continuous home care may involve a
home health aide (also known as a hospice aide) or homemaker services, or both.
Continuous home care is only furnished during brief periods of crisis and only
as necessary to maintain the terminally ill individual at home.
(K) "Core hospice services" are nursing care,
medical social services, counseling services, and physician services that must
routinely be afforded and/or provided directly to the individual by employees
of the hospice.
federal fiscal year" refers to the annual period from October first to
September thirtieth, as set by the federal government for accounting and
services" are services provided to the terminally ill individual and the family
members or other persons caring for the individual at home, including dietary
counseling, training the individual's family or other caregiver to provide
care, and for the purpose of helping the individual and the family members
and/or caregiver with adjustment to the approaching death.
(N) "Designated hospice provider" refers to
the hospice responsible for the professional management of care provided to the
individual while enrolled in hospice.
(O) "Dietary counseling" means intervention
and education regarding appropriate nutritional intake that is provided to the
individual and/or the individual's family by a qualified professional
including, but not limited to, a registered nurse, a dietitian and/or a
(P) "Dietitian" means a
person licensed to practice dietetics who meets the criteria set forth in
Chapter 4759. of the Revised Code.
(Q) "Election statement," "election of
hospice statement" and the "hospice election statement" refer to the required,
written acknowledgment of the individual's decision to receive hospice care in
lieu of curative care or treatment of the terminal illness.
(R) "Ending date of service" means the date
on which a designated hospice stops delivering hospice services to the
individual because of revocation of the medicaid hospice benefit, discharge
from the hospice benefit, change by the individual of the designated hospice,
or death of the individual in accordance with Chapter 5160-56 of the
of Care" or "Hospice Episode of Care" is a hospice election period or series of
election periods separated by no more than a sixty day gap. Each episode is
initiated by a start of care and is ended by a discharge to death or a gap in
hospice services of more than sixty days. An episode of care may include
multiple election benefit periods; however, a benefit period cannot span more
than one episode of care.
"General inpatient care" is a level of hospice care covered in accordance with
(October 1, 2017). A general
inpatient care day is a day on which an individual who has elected hospice care
receives care in an inpatient facility for pain control or acute or chronic
symptom management which cannot be managed in other settings.
"Home and community based services (HCBS)
waivers" refers to medicaid programs operated in accordance with Section 1915
(c) of the Social Security Act (the Act),
(as in effect
January 1, 2017) that allow individuals to receive covered services in their
own home or community rather than institutions or other isolated settings. The
HCBS waiver programs include those waivers administered by the Ohio department
of medicaid (ODM), the Ohio department of aging (ODA), and the Ohio department
of developmental disabilities (DODD).
"Hospice" refers to a public agency, a
private organization, or a subdivision of either, subject to the conditions of
participation pursuant to 42 C.F.R. Part 418
(October 1, 2017), that is
licensed in the state of Ohio and approved by the ODM to engaged in providing
care to terminally ill individuals.
"Hospice aide" refers to one who has
successfully completed a training and competency evaluation program for hospice
aide services, who meets the conditions of participation prescribed in
(October 1, 2017), and who
provides home care services pursuant to rule
of the Administrative
Code. For purposes of this chapter, hospice aide is interchangeable with the
term, "home health aide".
"Hospice care" refers to a comprehensive set of home based, inpatient and/or
outpatient services coordinated by an interdisciplinary group of health
professionals and volunteers as part of a written plan of care, to provide for
the physical, psychosocial, spiritual, and emotional needs of a terminally ill
individual and/or the individual's family members. Hospice stresses palliative
care as opposed to curative care.
(Y) "Hospice enrollment" refers to the
process of entering hospice data, such as benefit periods pursuant to rule
5160-56-03.3 of the Administrative Code, into the Ohio medicaid information
technology system (MITS) for an individual in receipt of hospice
(Z) "Hospice quality
reporting program" refers to a federal mandate pursuant to the Section 3004 of
Affordable Care Act of 2010 (as in effect January 1, 2017). HQRP requires all
Medicare-certified hospice providers to comply with data reporting requirements
prescribed by the centers for medicare and medicaid services (CMS). Annually,
by October 1, CMS publishes the quality measures a hospice must report. The act
of submitting data is what determines compliance with HQRP requirements. If the
required quality data is not reported by each designated submission deadline,
the hospice will be subject to a two percentage point reduction in their annual
provider span" refers to the date range (begin date to end date) that a valid
provider is considered the designated hospice provider. It is an assignment in
MITS that refers to the period of time during which an individual receives
hospice services from the designated hospice.
(BB) "Individual" refers to the beneficiary
eligible for medicaid, who is in need of, or under the care of the designated
hospice, and who is considering and/or who has elected the hospice benefit. For
decision making purposes, an individual may designate an authorized
representative to act on his or her behalf, in place of the
facility" refers to a facility that is either operated by or under contract
with a hospice for the purpose of providing general inpatient and/or respite
care to the individual.
"Inpatient respite care" is a level of hospice care covered in accordance with
(October 1, 2017). An inpatient
respite care day is a day on which the individual who has elected hospice care
receives care in an approved facility on a short-term basis for the purpose of
providing relief and respite for caregivers.
"Interdisciplinary group (IDG)" refers
to a group of professionals and volunteer staff who provide or supervise the
care and the services offered by the hospice in accordance with
(October 1, 2017).
"Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in rule
occupational therapist" means a person holding a valid license under Chapter
4755. of the Revised Code as an occupational therapist.
(HH) "Licensed occupational therapy
assistant" means a person holding a valid license under Chapter 4755. of the
Revised Code as an occupational therapy assistant (OTA).
(II) "Licensed physical therapist" means a
person holding a valid license under Chapter 4755. of the Revised Code as a
physical therapy assistant" means a person holding a valid license under
Chapter 4755. of the Revised Code as a physical therapist assistant
speech-language pathologist" means a person holding a valid license under
Chapter 4753. of the Revised Code as a speech-language pathologist and who is
eligible for or meets the educational requirements for a certificate of
clinical competence in speech language pathology granted by the "American
(LL) "Licensed speech-language pathology
aide" means a person holding a valid license under Chapter 4753. of the Revised
Code as a speech-language pathology aide.
(MM) "Long Term Care Facility (LTCF)" as
defined in section 3721.21 of the Revised Code is a
term used interchangeably in the Ohio medicaid information technology system to
refer to a nursing home, a facility or part of a facility that is certified as
a skilled nursing facility or a nursing facility under Title XVIII or XIX of
the "Social Security Act.
"Medicaid Information Technology System (MITS)" refers to the information
management system utilized by ODM, hospice and other providers, and state
agencies for medicaid billing and data management purposes. The "MITS Hospice
Portal" refers to the functionality in MITS maintained by ODM that gives
authorized entities access to data such as medicaid eligibility, hospice
enrollment status, claim and payment status, election and hospice service
spans, benefit periods, and payer and provider information.
"Medicaid Managed Care Plan" or a
"Managed Care Plan" has the same meaning as in rule
of the Administrative
(PP) "Medical director"
refers to the doctor of medicine or osteopathy employed by the designated
hospice to assume overall responsibility for the medical component of the
individual's plan of care, including consulting with other members of the
interdisciplinary team and collaborating with the individual's attending
physician if any.
is the federally financed medical assistance program operated under Title XVIII
of the Social Security Act (as in effect January 1, 2017).
(RR) "Non-core hospice services" are hospice
services that are the responsibility of the hospice to ensure are provided
directly to the individual by hospice employees or under a contractual
arrangement made by the hospice.
(SS) "Nursing facility" (NF) has the same
meaning as in section
5165.01 of the Revised
(TT) "Nursing services" are
services that require the skills of a RN, or a LPN under the supervision of an
RN. Services provided by an advanced practice registered nurse (APRN) who is
not the individual's attending physician or are not provided by a physician in
the absence of an APRN are included under nursing services.
(UU) "Oral Physician Certification Date"
refers to the date the verbal certification of the individual's terminally ill
is obtained by the hospice medical director (or physician member of the IDG),
and the patient's attending physician, if he/she has one.
(VV) "Palliative care" refers to patient and
family-centered care that optimizes quality of life by anticipating,
preventing, and treating suffering. Palliative care is at the core of hospice
philosophy and care practices, and is a critical component of the medicaid
means an individual who is currently licensed and authorized under Chapter
4731. of the Revised Code to practice as a doctor of medicine and surgery or
osteopathic medicine and surgery. An unlicensed individual who is authorized to
practice under the laws of the state in which the services are performed is not
a physician, even if the individual holds a staff or faculty
"Physician assistant" means an individual practicing in
accordance with Chapter 4730 of the Revised Code.
"Physician services" refers to services as defined in Chapter 5160-4 of the
Administrative Code. Physician services may be provided by a physician, or an
advanced practice registered nurse acting within his or her scope of practice
as defined in section
4723.01 of the Revised Code, or
a physician assistant acting within his or her scope of practice under the
supervision, control, and direction of one or more physicians as defined in
section 4730.01 of the Revised
(ZZ) "Plan of Care" refers to an individualized
written plan established at the start of hospice care by the hospice
interdisciplinary group in collaboration with the attending physician (if any),
the individual and the primary caregiver (when feasible). The plan of care must
specify the hospice care and services necessary to meet the individual and
family-specific needs identified in the comprehensive assessment as such needs
relate to the terminal illness and related conditions.
(AAA) "Registered nurse" (RN) refers to a person
licensed to practice as a RN in accordance with the criteria set forth in
Chapter 4723. of the Revised Code.
Care" is a level of hospice care covered in accordance with
(as in effect January 1, 2016).
Routine home care shall be afforded to an individual in the individual's
residence when the individual is not receiving continuous home care.
(CCC) "Social worker" means a person registered under
Chapter 4757. of the Revised Code to practice as a social worker or independent
social worker. (DDD)
"Telehealth" has the same meaning as in rule
5160-1-18 of the Administrative
(EEE) "Terminally ill" means that a physician has
certified that the individual has a medical prognosis that his or her life
expectancy is six months or less if the illness runs its normal
(FFF) "Written Physician Certification Date" refers to
the date the completed certification of the individual's terminally ill is
signed by the hospice medical director (or physician member of the IDG, and the
patient's attending physician, if he or she has one.