This rule set forth terms used throughout Chapter 5160-56 of
the Administrative Code.
(A) "Advance
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.
(C) "
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
diagnosis.
(3) 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.
(D)
"Authorized representative" has the same meaning as rule 5160-1-33 of the
Administrative Code. a person, in accordance with
rule 5160:1-1-01 of the 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.
(F)
"
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
sixty-day periods.
(G)
"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.
(H) "
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
42 C.F.R.
418.22 (October 1,
2017
2023), 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 (if the individual has an attending
physician) as being
terminally ill with a medical prognosis that the
individual's life expectancy is six months or less.
(I) "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.
(J) "
Continuous home care" is a level of
hospice care covered by medicaid in accordance with
42 C.F.R.
418.302 (October 1,
2017
2023). 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.
(L) "Corresponding federal fiscal year"
refers to the annual period from October first to September thirtieth, as set
by the federal government for accounting and budgeting purposes.
(M) "Counseling 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
physician.
(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
Administrative Code.
(S) "Episode
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.
(T)
"
General inpatient care" is a level of
hospice care covered in accordance with
42 C.F.R.
418.302 (October 1,
2017
2023). 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.
(U) "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),
42 U.S.C.
1396n(c) (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).
(V) "
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
2023),
that is licensed in the state of Ohio and approved by the ODM to engaged in
providing care to
terminally ill individuals.
(W) "
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
42 C.F.R.
418.76 (October 1,
2017
2023), and who
provides home care services pursuant to rule
3701-19-16 of the Administrative
Code. For purposes of this chapter,
hospice aide is interchangeable with the
term, "home health aide".
(X)
"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)
ODM
provider web portal for an
individual in receipt of
hospice
care.
(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 payment update.
(AA) "Hospice 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
the ODM provider web
portal 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
individual.
(CC) "Inpatient
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.
(DD)
"
Inpatient respite care" is a level of
hospice care covered in accordance with
42 C.F.R.
418.302 (October 1,
2017
2023). 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.
(EE) "
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
42 C.F.R.
418.56 (October 1,
2017
2023).
(FF) "Intermediate care facility for
individuals with intellectual disabilities" has the same meaning as in
section
rule
5123:2-7-01
5124.01
of the Administrative
Revised Code.
(GG) "Licensed 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 therapist.
(JJ) "Licensed physical therapy assistant"
means a person holding a valid license under Chapter 4755. of the Revised Code
as a physical therapist assistant (PTA).
(KK) "Licensed 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 Speech-Language-Hearing
Association."
(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
ODM provider web
portal 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.
(NN) "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.
(OO)(NN) "
Medicaid Managed Care
Plan
Organization"
or a "Managed Care Plan" has the same
meaning as in rule
5160-26-01 of the Administrative
Code.
(PP)(OO) "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.
(QQ)(PP) "Medicare" is the
federally financed medical assistance program operated under Title XVIII of the
Social Security Act (as in effect January 1, 2017).
(RR)(QQ) "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)(RR) "Nursing
facility" (NF) has the same meaning as in section
5165.01 of the Revised
Code.
(TT)(SS) "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)(TT) "Oral Physician
Certification Date" refers to the date the verbal certification of the
individual's
terminally ill
terminal
illness 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)(UU) "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 hospice benefit.
(WW)(VV) "Physician" 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
appointment.
(XX)(WW) "Physician
assistant" means an individual practicing in accordance with Chapter 4730. of
the Revised Code.
(YY)(XX) "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
Code.
(ZZ)(YY) "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)(ZZ) "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.
(BBB)(AAA) "
Routine Home
Care" is a level of
hospice care covered in accordance with
42 C.F.R.
418.302 (as in effect
January 1, 2016
October 1, 2023).
Routine home care shall be afforded
to an
individual in the
individual's residence when the
individual is not
receiving
continuous home care.
(CCC)(BBB) "
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 Code.
(EEE)(CCC) "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 course.
(FFF)(DDD) "Written
Physician Certification Date" refers to the date the completed certification of
the individual's
terminally ill
terminal illness 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.