This rule sets forth the Ohio department of medicaid (ODM)
payment for hospice services and care.
ODM will directly pay the designated
hospice to care for an individual enrolled in medicaid hospice. Payment to the
designated hospice shall cover the array of services listed in rule
of the Administrative
Code, except for:
(1) Services pursuant to
paragraph (E) of this rule which are paid directly to the physician;
(2) Services furnished by a
non-hospice provider pursuant to paragraph (I) of this rule for the concurrent
care of an individual under the age of twenty-one.
Reimbursement rates paid by ODM to the
designated hospice shall be based on the level of care that is appropriate for
the individual for each day while receiving hospice care. Based on the
methodology set forth in
(as in effect January 1, 2016), the
medicaid payment for hospice care is made at predetermined rates in accordance
with paragraph (C) of this rule for levels of care as defined in rule
of the Administrative
(1) The medicaid payment for hospice
covers the cost of services rendered by the hospice either directly or under
designated hospices that are compliant with the hospice quality reporting
program in accordance with
(as in effect January 1,
2016), ODM will reimburse the full medicaid payment rate for hospice services,
up to the maximum payment rate prescribed for the county where services were
(3) For designated
hospices that fail to comply with the hospice quality reporting program as
federally mandated, ODM will reimburse the payment amount minus a two
percentage point reduction, as prescribed by CMS for the corresponding federal
designated hospice shall bill ODM the appropriate code and unit(s) for the
appropriate level of care. ODM will allow telehealth
services to be provided where in-person visits are mandated
Hospice providers must use code T2042 for
one unit per day to bill for routine home care afforded to an individual in his
or her home, who is not receiving continuous home care.
Routine home care days shall be paid
using a two-tiered system in accordance with
(as in effect January 1, 2016), where
the per diem for the first sixty days of hospice care is paid at a higher rate
and days sixty-one and thereafter are paid at a lower rate for the duration of
the individual's hospice episode of care. A minimum of a sixty day gap in
hospice services is required to reset the counter that determines which per
diem to apply.
(as in effect January 1, 2016),
routine home care may be eligible for an add-on payment for services provided
by a registered nurse (RN) authorized to practice under Chapter 4723. of the
Revised Code, and/or a social worker licensed to practice under Chapter 4757.
of the Revised Code during the last seven days of an individual's life, when
the discharge from hospice care is due to death.
The service intensity add-on (SIA) payment shall be billed
using code G0299 for the direct care provided in an in-person visit completed
by an RN. The SIA payment shall be billed using code G0155 for the direct care
provided during an in-person visit completed by a social worker.
The reimbursement rate for the SIA payment shall be equal to
the continuous home care hourly rate converted into fifteen minute increments,
up to a maximum of four hours (sixteen units) combined total per day for RN and
social worker visits. Visits solely for the pronouncement of death shall not be
counted for the service intensity addon payment.
(2) Hospice providers must use code T2043 for
one unit per hour, with a minimum of eight hours per day, to bill for
continuous home care.
providers must use code T2044 for one unit per day to bill for inpatient
(4) Hospice providers
must use code T2045 for one unit per day to bill for general inpatient
Hospice providers that deliver any component of services via
telehealth will add the GT modifier on those claims, in addition to the
appropriate procedure code listed in this paragraph.
with T2044 and T2045 are not eligible to be provided via
When the individual is a resident of a nursing facility (NF) or an intermediate
care facility for individuals with intellectual disabilities (ICF-IID), the
hospice may be reimbursed for room and board. This additional per diem amount
is reimbursable at ninety-five per cent of the rate established for the
long-term care facility, as reported to ODM for the individual pursuant to rule
5160-56-06 of the Administrative Code, and only on days where the individual
receives routine home care or continuous home care. To receive reimbursement,
(1) Must bill for room and bill
using code T2046.
(2) Must bill
patient liability until consumed to zero dollars.
(3) Must bill only for days that the
individual is in the NF or ICF-IID overnight and is medicaid
(4) Must bill for
individuals who are medicare and medicaid eligible, medicare for services
provided under the medicare hospice benefit and medicaid for the individual's
room and board.
Hospice providers that deliver any component of
services via telehealth will add the GT modifier on those claims, in addition
to the procedure code listed in this paragraph.
Separate payment may be made to a
physician for services involving direct patient care.
The physician may be an employee of the hospice, a practitioner
under contractual arrangement with the hospice, or an attending practitioner
who is not an employee of the hospice but is an eligible medicaid provider.
Separate payment cannot be made, however, for the following services:
(1) A physician service furnished on a
volunteer basis or on an administrative basis;
(2) A procedure classified as a technical
(3) Laboratory or
radiography services performed in connection with the physician
receipt of all third-party resources, including private insurance, and taking
into account patient liability for room and board, ODM may be billed for the
balance owed to the designated hospice, except for services covered by
individuals receiving hospice through managed care. For each day the medicaid
eligible individual is enrolled in hospice, the total reimbursement for hospice
services cannot exceed the medicaid per diem reimbursement rate.
Medicaid eligible residents of NFs or
ICF-IIDs who are enrolled in a medicare or medicaid hospice program are not
entitled to medicaid-covered bed-hold days. It is the hospice's responsibility
to contract with and pay the NF in accordance with rule 5160-3-16.4 of the
Administrative Code. It is the hospice's responsibility to contract with and
pay the ICF-IID in accordance with rule
to Section 1861(dd)(2)(A)(iii) of the Social Security Act,
U.S.C. 1395x(dd) (2)(A)(iii)
(as in effect January 1, 2017) there shall be a limitation on reimbursement for
inpatient care during the hospice cap period.
(I) For any services related to the terminal
illness, non-hospice providers must bill the designated hospice provider
directly unless the services were for concurrent care of the terminal illness
for individuals under age twenty-one. Providers billing for concurrent care
must comply with, and will only be reimbursed according to, all the
requirements for medicaid providers in Chapter 5160-1 of the Administrative
Ohio Admin. Code
Five Year Review (FYR) Dates:
Effective Dates: 05/01/1990, 05/15/1990, 05/16/1990, 12/01/1991, 04/01/1994,
09/26/2002, 01/01/2004, 04/01/2005, 03/02/2008, 02/01/2011, 04/01/2015,