Ohio Administrative Code › Title 5160:1 - Eligibility › Chapter 5160:1-5 - Medicaid for Other Covered Groups › Section 5160:1-5-02.1 - Medicaid: breast and cervical cancer project (BCCP) definitions

Current through all regulations passed and filed through July 1, 2024
(A) This rule
			 contains definitions generally used for BCCP.
(B) Definitions.
(1) "Breast and Cervical Cancer Project
			 (BCCP) medicaid" means the category of medicaid for qualified individuals in
			 need of treatment for breast or cervical cancer, including pre-cancerous
			 conditions and early stage cancer. BCCP medicaid is administered by the Ohio
			 department of medicaid (ODM) in coordination with the Ohio department of health
			 (ODH).
(2) "Breast or cervical
			 cancer diagnosis", for the purpose of BCCP medicaid, means that a treating
			 health professional has made a general determination that breast or cervical
			 cancer(s) or pre-cancerous condition(s) exists. For the purposes of BCCP
			 medicaid, breast or cervical cancer diagnosis does not require the
			 determination of the specific stage or grade of cancer or pre-cancerous
			 conditions.
(a) "Breast or cervical cancer
			 diagnosis" includes metastasized cancer known or presumed by a treating health
			 professional as a complication of breast or cervical cancer.
(b) "Date of diagnosis" is the date of the
			 screening or diagnostic service which the treating health professional utilized
			 to determine the individual's breast or cervical cancer diagnosis.
(c) "Pre-cancerous" means a condition, which,
			 if left untreated is known or presumed by a treating health professional to
			 develop into cancer.
(3)
			 "Centers for Disease Control and Prevention (CDC) Title XV grantee" means an
			 entity receiving funds under a cooperative agreement with CDC to support
			 activities related to the national breast and cervical cancer early detection
			 program.
(4) "Individual", for the
			 purpose of BCCP medicaid, means men or women in need of or receiving treatment
			 for breast or cervical cancer, breast or cervical pre-cancerous conditions,
			 and/or breast or cervical early stage cancer or eligible for BCCP
			 medicaid.
(5) "The National Breast
			 and Cervical Cancer Early Detection Program (NBCCEDP)" means the program of the
			 CDC established under Title XV of the Public Health Service Act.
(6) "The Ohio Department of Health Breast and
			 Cervical Cancer Project (ODHBCCP)" means NBCCEDP funded by the CDC and
			 administered by the Ohio department of health (ODH).
(a) "ODH BCCP breast and cervical cancer
			 screening provider" means an entity which has entered into a written agreement
			 with the ODH BCCP to provide specified breast and cervical cancer screening and
			 diagnostic services for ODH BCCP enrollees.
(b) "ODH BCCP designated local agency or
			 subgrantee" means an entity which has received a grant from ODH to implement
			 specified activities of the ODH BCCP.
(c) "ODH BCCP enrollee" means an individual
			 determined by ODH BCCP, or its designated local agencies or subgrantees, to
			 meet the eligibility requirements (e.g., age and income) for participation in
			 the ODH BCCP.
(d) "ODH BCCP
			 regional case manager" means an individual who determines an individual's
			 eligibility for BCCP, enrolls individuals, schedules services with health care
			 providers, and provides case management to individuals.
(7) "Screened for breast or cervical cancer
			 under NBCCEDP" means that a breast or cervical cancer screening was provided,
			 all or in part, by CDC Title XV funds.
(a)
			 For the purposes of BCCP medicaid, breast or cervical cancer screening includes
			 diagnostic test(s) following a breast or cervical cancer screen.
(b) For the purposes of BCCP medicaid, case
			 management services provided by a CDC Title XV grantee are not considered
			 breast or cervical cancer screening.
(8) "Treatment" means the provision of
			 medical services to control, minimize, or eliminate cancer or pre-cancerous
			 cells of the breast or cervix. "Treatment" includes the provision of hormonal
			 therapies to prevent recurrence of cancer following breast cancer surgery,
			 radiation, and/or chemotherapy. Monitoring services alone (e.g., Papanicolaou
			 smears, pelvic examinations, clinical breast examinations, mammograms) for
			 recurrence or new primary cancers are not considered treatment.
(a) "Needs treatment" means that according to
			 a written certification by the individual's treating health professional, which
			 is documented by the ODH BCCP, a breast or cervical cancer screening indicates
			 that the individual is in need of treatment for breast or cervical cancer.
			 Individuals who are determined to require only monitoring services (e.g.,
			 Papanicolaou smears, pelvic examinations, clinical breast examinations,
			 mammograms) are not considered to need treatment.
(b) "No longer receives treatment for breast
			 or cervical cancer" means:
(i) The
			 individual's course of treatment of breast or cervical cancer is completed,
			 or
(ii) The individual chooses to
			 delay or decline available treatment options.
(c) "Treating health professional" means an
			 individual licensed to provide breast or cervical cancer diagnosis and/or
			 treatment services.
(d) "Treatment
			 period" means the period of time, according to a written certification by the
			 individual's treating health professional, needed for the completion of
			 treatment of the individual's breast or cervical cancer or pre-cancerous
			 condition. A treatment period lasting more than twelve months from initial
			 eligibility requires both a review of continuing medicaid eligibility and
			 verification of need for continued treatment.
(9) "Uninsured" means not having creditable
			 coverage for health care services.
(a) For the
			 purposes of determining eligibility under BCCP medicaid, the following are
			 considered creditable coverage :
(i) Health insurance benefits consisting of
			 medical care (provided directly, through insurance or reimbursement, or
			 otherwise and including items and services paid for as medical care) under any
			 hospital or medical service policy or certificate, hospital or medical service
			 plan contract;
(ii) Health
			 maintenance organization contract offered by a health insurance
			 issuer;
(iii) Medicare, parts A
			 or B;
			 and,
(iv) Medicaid.
(b) For the purposes of
			 determining eligibility under BCCP medicaid, creditable coverage does not
			 include:
(i) Limited scope coverage such as
			 those which only cover dental, vision, or long term care;
(ii) Coverage for only a specified disease or
			 illness;
(iii) Coverage which
			 excludes treatment for breast or cervical cancer, including situations whereby
			 a period of exclusion has been applied, such as for a pre-existing condition or
			 the individual has exhausted the health insurance plan's covered benefits;