This rule sets forth the Ohio department of medicaid (ODM)
payment for hospice services and care.
(A) ODM will directly pay the designated
hospice to care for an
individual enrolled in medicaid
hospice. Payment to the
designated
hospice shall
will cover the array of services listed in rule
5160-56-05 of the Administrative
Code, except for:
(1) Services pursuant to
paragraph (E) of this rule which are paid directly to the physician;
and
(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.
(B) Reimbursement rates paid by ODM to the
designated
hospice shall
will 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
42 C.F.R.
418.302 (as in effect
October 1,
January 1,
2016
2023), 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
5160-56-01 of the Administrative
Code.
(1) The medicaid payment for hospice
covers the cost of services rendered by the hospice either directly or under
contractual arrangement.
(2) For
designated hospices that are compliant with the
hospice quality reporting
program in accordance with 42 C.F.R.
418.312 (as in effect
January 1, 2016
October 1, 2023), ODM will reimburse the full medicaid
payment rate for
hospice services, up to the maximum payment rate prescribed
for the county where services were provided.
(3) For designated hospices that fail to
comply with the hospice quality reporting program as
federally mandated
for federal fiscal years
2014 through 2024, ODM will reimburse the payment amount minus a two
percentage point reduction, as prescribed by
CMS for the corresponding federal fiscal year.
(4)
For designated
hospices that fail to comply with the hospice quality reporting program for
federal fiscal year 2025 and subsequent fiscal years, ODM will reimburse the
payment amount minus a four percentage point reduction for the corresponding
federal fiscal year.
(C) The designated
hospice
shall
will
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:
(1) Hospice providers
must
should
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.
(a) Routine home care days
shall
will be
paid using a two-tiered system
in accordance with 42
C.F.R 418.302 (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.
(b) In accordance with
42 C.F.R
418.302 (as in effect
January 1, 2016
October 1, 2023),
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
will be
billed using code G0299 for the direct care provided in an in-person visit
completed by an RN. The SIA payment shall
will 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
will 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
should not be counted for the service intensity add-on
payment.
(2)
Hospice providers must
will use code T2043 for one unit per hour, with a
minimum of eight hours per day, to bill for continuous home care.
(3) Hospice providers
must
will use
code T2044 for one unit per day to bill for inpatient respite care.
(4) Hospice providers
must
will use
code T2045 for one unit per day to bill for
general inpatient care.
(5) 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.
(6) Services billed with T2044 and
T2045 are not eligible to be provided via telehealth.
(D) 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
that the long-term care facility
would have otherwise received from ODM if the
individual was not enrolled in hospice
,
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, the
hospice:
(1)
Must
Will bill for
room and bill using code T2046.
(2)
Must
Will bill
patient liability until consumed to zero dollars.
(3)
Must
Will bill
only for days that the individual is
residing in the NF or ICF-IID
overnight and is medicaid eligible, including the date of a live discharge from
hospice
.
(4)
Must
Will 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.
(5) 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.
(E) 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
service; or
(3) Laboratory or
radiography services performed in connection with the physician
service.
(F) After
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.
(G) 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
5123:2-7-08
5123-7-08
of the Administrative Code.
(H)
Pursuant to Section 1861(dd)(2)(A)(iii) of the Social Security Act,
42 U.S.C.
1395x(dd)(2)(A)(iii) (as in
effect January 1, 2017) there
shall
should 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
will 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
will
comply with, and will only be reimbursed according to, all the requirements for
medicaid providers in Chapter 5160-1 of the Administrative Code.
Notes
Ohio Admin. Code
5160-56-06
Effective:
10/1/2024
Five Year Review (FYR) Dates:
7/16/2024 and
10/01/2029
Promulgated
Under: 119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5162.03
Prior
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,
10/01/2017, 06/12/2020 (Emer.), 01/30/2021