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05/08/2019

You Asked... We Answered

This week's You Asked..We Answered questions ask: "Do we need to do a hospice face-to-face encounter for a Medicaid primary patient?" and "Do Medicaid-primary patients have discharge appeal rights when a hospice believes they are no longer appropriate, and the patient does not want to be discharged from hospice?"


You Asked: 

Do we need to do a hospice face-to-face encounter for a Medicaid primary patient?

We Answered:

Yes, a face to face encounter is necessary for a Medicaid primary patient as of October 1, 2017 when the new Medicaid rule package was affective. Please see the hospice eligibility rule below that references the hospice conditions of participation.

5160-56-02 Hospice services: eligibility and election requirements.

This rule sets forth the criteria that must be met for an individual eligible for Medicaid to receive the Ohio Medicaid hospice benefit.

(A) To be covered under Ohio Medicaid, the designated hospice must ensure the following criteria are met prior to furnishing hospice care:

(1) The designated hospice has a certification of the terminal illness on behalf of the individual, obtained in accordance with 42 C.F.R. 418.22 (October 1, 2017

Hospice Condition of Participation - §418.22   Certification of terminal illness.

(4) Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care


You Asked:

Do Medicaid-primary patients have discharge appeal rights when a hospice believes they are no longer appropriate, and the patient does not want to be discharged from hospice?

We Answered:  

LeadingAge Ohio checked with the Ohio Department of Medicaid representatives and they said, when it is the medical provider’s determination to discharge a patient, they do not have appeal rights. If it is a decision made by ODM that they disagree with, they can request a state hearing by visiting this website and clicking on “Click here to request a state hearing” or by calling the Bureau of State Hearings at (866) 635-3748. The hospice rule below also describes this process.

5160-56-03 Hospice services: discharge requirements.

(F) Any denial or termination of hospice care which is the result of an Ohio Department of Medicaid (ODM) decision shall be subject to the notice and hearing rights contained in Chapters 5101:6-1 to 5101:6-9 of the Administrative Code.


If you have a question you would like to see featured in You Asked/We Answered, email Anne Shelley, Director of Professional Development & HH/Hospice Regulatory Relations at ashelley@leadingageohio.org or Stephanie DeWees, Quality & Regulatory Specialist for Long Term Care at sdewees@leadingageohio.org.

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