WSR 11-24-060

PROPOSED RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed December 5, 2011, 5:17 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 11-07-092.

Title of Rule and Other Identifying Information: Chapter 182-551 WAC, Subchapter I -- Hospice services.

Hearing Location(s): Health Care Authority, Cherry Street Plaza Building, Apple Conference Room (106A), 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://maa.dshs.wa.gov/pdf/CherryStreetDirectionsNMap.pdf or directions can be obtained by calling (360) 725-1000), on January 10, 2012, at 10:00 a.m.

Date of Intended Adoption: Not sooner than January 11, 2012.

Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail arc@hca.wa.gov, fax (360) 586-9727, by 5:00 p.m. on January 10, 2012.

Assistance for Persons with Disabilities: Contact Kelly Richters by January 3, 2012, TTY/TDD (800) 848-5429 or (360) 725-1307 or e-mail kelly.richters@hca.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: These proposed rules are necessary to:

(1) Establish that a family electing to receive hospice care for an individual under twenty-one years of age is no longer required to waive treatment for the terminal illness; and

(2) Require that a hospice physician or nurse practitioner must have a face-to-face encounter with every hospice patient to determine the continued eligibility of that patient prior to the one hundred eighty day recertification, and prior to each subsequent recertification and also attest that the visit took place.

Reasons Supporting Proposal: These required changes are in accordance with the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148).

Statutory Authority for Adoption: RCW 41.05.021,

Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act.

Statute Being Implemented: RCW 41.05.021.

Rule is necessary because of federal law, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act.

Name of Proponent: Health care authority, governmental.

Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, Health Care Authority, P.O. Box 45504, Olympia, WA, (360) 725-1306; Implementation and Enforcement: Ellen Silverman, Health Care Authority, P.O. Box 45506, Olympia, WA, (360) 725-1570.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has analyzed the proposed rules and concludes that they do not impose more than minor costs for affected small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to health care authority rules unless requested by the joint administrative rules [review] committee or applied voluntarily. However, the agency did draft a preliminary cost-benefit analysis and a copy of it may be obtained by contacting Ellen Silverman, RN, PhD, Nurse Clinical Consultant/Clinical Utilization Management Supervisor, Health Care Authority, Division of Healthcare Services, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1570, fax (360) 586-9727, e-mail Ellen.silverman@hca.wa.gov.

December 2, 2011

Kevin M. Sullivan

Rules Coordinator

OTS-4239.3


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1000   Hospice program -- General.   (1) The ((department's)) medicaid agency's hospice program is a twenty-four hour a day program that allows a terminally ill client to choose physical, pastoral/spiritual, and psychosocial comfort care ((rather than cure)) and a focus on quality of life. A hospice interdisciplinary team communicates with the client's nonhospice care providers to ensure the client's needs are met through the hospice plan of care. Hospitalization is used only for acute symptom management.

(2) A client, a physician, or an authorized representative under RCW 7.70.065 may initiate hospice care. The client's physician must certify the client as terminally ill and appropriate for hospice care.

(3) Hospice care is provided in a client's temporary or permanent place of residence.

(4) Hospice care ends when:

(a) The client or an authorized representative under RCW 7.70.065 revokes the hospice care;

(b) The hospice agency discharges the client;

(c) The client's physician determines hospice care is no longer appropriate; or

(d) The client dies.

(5) Hospice care includes the provision of emotional and spiritual comfort and bereavement support to the client's family member(s).

(6) ((Department-approved)) Medicaid agency-approved hospice agencies must meet the general requirements in chapter ((388-502)) 182-502 WAC, Administration of medical programs -- Providers.

[11-14-075, recodified as 182-551-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1000, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1000, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1010   Hospice program -- Definitions.   The following definitions and abbreviations and those found in WAC ((388-500-0005)) 182-500-0005, Medical definitions, apply to this subchapter.

"Authorized representative" ((means)) - An individual who has been authorized to terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill individual who is mentally or physically incapacitated. See RCW 7.70.065.

"Biologicals" ((means)) - Medicinal preparations including serum, vaccine autotoxins, and biotechnological drugs made from living organisms and their products.

"Brief period" ((means)) - Six days or less within a thirty consecutive-day period.

"Community services office (CSO)" ((means)) - An office of the department of social and health services (DSHS) that administers social and health services at the community level.

"Concurrent care" - Palliative and curative services for clients twenty years of age and younger who are enrolled in hospice and who are also able to receive other medicaid covered services not included in the hospice benefit. See WAC 182-551-1860.

"Discharge" ((means an)) - A hospice agency ends hospice care for a client.

"Election period" ((means)) - The time, ninety or sixty days, that the client is certified as eligible for and chooses to receive hospice care.

"Family" ((means)) - An individual or individuals who are important to, and designated in writing by, the client and need not be relatives, or who are legally authorized to represent the client.

"Home and community services (HCS) office" ((means an)) - A department of social and health services (DSHS) aging and disability services administration (ADSA) office that manages the state's comprehensive long-term care system which provides in-home, residential, and nursing home services to clients with functional disabilities.

"Home health aide" ((means)) - An individual registered or certified as a nursing assistant under chapter 18.88A RCW who, under the direction and supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist, assists in the delivery of nursing or therapy related activities, or both, to patients of a hospice agency, or hospice care center.

"Home health aide services" ((means)) - Services provided by home health aides employed by an in-home services agency licensed to provide home health, hospice, or hospice care center services under the supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist. Such care may include ambulation and exercise, medication assistance level 1 and level 2, reporting changes in client's conditions and needs, completing appropriate records, and personal care or homemaker services, and other nonmedical tasks, as defined in this section.

"Hospice agency" ((means)) - A person or entity administering or providing hospice services directly or through a contract arrangement to individuals in places of temporary or permanent residence under the direction of an interdisciplinary team composed of at least a nurse, social worker, physician, spiritual counselor, and volunteer. (Note: For the purposes of this subchapter, requirements for hospice agencies also apply to hospice care centers.)

"Hospice care center" ((means)) - A homelike noninstitutional facility where hospice services are provided, and that meets the requirements for operation under RCW 70.127.280 and applicable rules.

"Hospice services" ((means)) - Symptom and pain management provided to a terminally ill individual, and emotional, spiritual, and bereavement support for the individual and individual's family in a place of temporary or permanent residence.

"Interdisciplinary team" ((means)) - The group of individuals involved in client care providing hospice services or hospice care center services including, at a minimum, a physician, registered nurse, social worker, spiritual counselor, and volunteer.

"Palliative" ((means)) - Medical treatment designed to reduce pain or increase comfort, rather than cure.

"Plan of care" ((means)) - A written document based on assessment of client needs that identifies services to meet these needs.

"Related condition(s)" ((means)) - Any health condition((s))(s) that manifests secondary to or exacerbates symptoms associated with the progression of the condition and/or disease, the treatment being received, or the process of dying. (Examples of related conditions: Medication management of nausea and vomiting secondary to pain medication; skin breakdown prevention/treatment due to peripheral edema.)

"Residence" ((means)) - A client's home or place of living.

"Revoke" or "revocation" ((means)) - The choice to stop receiving hospice care.

"Terminally ill" ((means)) - The client has a life expectancy of six months or less, assuming the client's disease process runs its natural course.

"Twenty-four-hour day" ((means)) - A day beginning and ending at midnight.

[11-14-075, recodified as 182-551-1010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1010, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1010, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1200   Client eligibility for hospice care.   (1) A client who elects to receive hospice care must be eligible for one of the following medical assistance programs, subject to the restrictions and limitations in this chapter and other WAC:

(a) Categorically needy ((program (CNP))) (CN);

(b) ((Limited casualty program - Medically needy program (LCP-MNP);

(c) Children's health (V);

(d) State children's health insurance program (SCHIP);

(e) CNP -- Alien emergency medical;

(f) LCP-MNP -- Alien emergency medical; or

(g) General assistance-expedited disability (GAX).)) Children's health care as described in WAC 388-505-0210;

(c) Medically needy (MN);

(d) Medical care services as described in WAC 182-508-0005 (within Washington state or designated border cities); or

(e) Alien emergency medical (AEM) as described in WAC 388-438-0110, when the medical services are necessary to treat a qualifying emergency medical condition.

(2) A hospice agency is responsible to verify a client's eligibility with the client or the client's department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO).

(3) A client enrolled in one of the ((department's)) medicaid agency's managed care ((plans)) organizations (MCO) must receive all hospice services, including facility room and board, directly through that ((plan)) MCO. The ((client's managed care plan)) MCO is responsible for arranging and providing all hospice services for ((a)) an MCO client ((enrolled in a managed care plan)).

(4) A client who is also eligible for medicare hospice under part A is not eligible for hospice care through the ((department's)) medicaid agency's hospice program. The ((department)) medicaid agency does pay hospice nursing facility room and board for these clients if the client is admitted to a nursing facility or hospice care center (HCC) and is not receiving general inpatient care or inpatient respite care. See also WAC ((388-551-1530)) 182-551-1530.

(5) A client who meets the requirements in this section is eligible to receive hospice care through the ((department's)) medicaid agency's hospice program when all of the following is met:

(a) The client's physician certifies the client has a life expectancy of six months or less.

(b) The client elects to receive hospice care and agrees to the conditions of the "election statement" as described in WAC ((388-551-1310)) 182-551-1310.

(c) The hospice agency serving the client:

(i) Notifies the ((department's)) medicaid agency's hospice program within five working days of the admission of all clients, including:

(A) Medicaid-only clients;

(B) Medicaid-medicare dual eligible clients;

(C) Medicaid clients with third party insurance; and

(D) Medicaid-medicare dual eligible clients with third party insurance.

(ii) Meets the hospice agency requirements in WAC ((388-551-1300)) 182-551-1300 and ((388-551-1305)) 182-551-1305.

(d) The hospice agency provides additional information for a diagnosis when the ((department)) medicaid agency requests and determines, on a case-by-case basis, the information that is needed for further review.

[11-14-075, recodified as 182-551-1200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1200, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1200, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1210   Covered services, including core services and supplies reimbursed through the hospice daily rate.   (1) The ((department)) medicaid agency reimburses a hospice agency for providing covered services, including core services and supplies described in this section, through the ((department's)) medicaid agency's hospice daily rate, subject to the conditions and limitations described in this section and other WAC. See WAC 182-551-1860 for pediatric concurrent care.

(2) To qualify for reimbursement, covered services, including core services and supplies in the hospice daily rate, must be:

(a) Related to the client's hospice diagnosis;

(b) Identified by the client's hospice interdisciplinary team;

(c) Written in the client's plan of care (POC); and

(d) Made available to the client by the hospice agency on a twenty-four hour basis.

(3) The hospice daily rate includes the following core services that must be either provided by hospice agency staff, or contracted through a hospice agency, if necessary, to supplement hospice staff in order to meet the needs of a client during a period of peak patient loads or under extraordinary circumstances:

(a) Physician services related to the administration of POC.

(b) Nursing care provided by:

(i) A registered nurse (RN); or

(ii) A licensed practical nurse (LPN) under the supervision of an RN.

(c) Medical social services provided by a social worker under the direction of a physician.

(d) Counseling services provided to a client and the client's family members or caregivers.

(4) Covered services and supplies may be provided by a service organization or an individual provider when contracted through a hospice agency. To be reimbursed the hospice daily rate, a hospice agency must:

(a) Assure all contracted staff meets the regulatory qualification requirements;

(b) Have a written agreement with the service organization or individual providing the services and supplies; and

(c) Maintain professional, financial, and administrative responsibility.

(5) The following covered services and supplies are included in the appropriate hospice daily rate as described in WAC ((388-551-1510(6))) 182-551-1510(6), subject to the conditions and limitations described in this section and other WAC:

(a) Skilled nursing care;

(b) Drugs, biologicals, and over-the-counter medications used for the relief of pain and symptom control of a client's terminal illness and related conditions;

(c) Communication with nonhospice providers about care not related to the client's terminal illness to ensure the client's plan of care needs are met and not compromised;

(d) ((Medical equipment and supplies that are medically necessary for the palliation and management of a client's terminal illness and related conditions;)) Durable medical equipment and related supplies, prosthetics, orthotics, medical supplies, related services, or related repairs and labor charges in accordance with WAC 182-543-9100 (6)(c). These services and equipment are paid by the hospice agency for the palliation and management of a client's terminal illness and related conditions and are included in the daily hospice rate;

(e) Home health aide, homemaker, and/or personal care services that are ordered by a client's physician and documented in the POC. (Home health aide services are provided through the hospice agency to meet a client's extensive needs due to the client's terminal illness. These services must be provided by a qualified home health aide and are an extension of skilled nursing or therapy services. See 42 CFR 484.36);

(f) Physical therapy, occupational therapy, and speech-language therapy to manage symptoms or enable a client to safely perform ADLs (activities of daily living) and basic functional skills;

(g) Medical transportation services, including ambulance (see WAC 182-546-5550 (1)(d));

(h) A brief period of inpatient care, for general or respite care provided in a medicare-certified hospice care center, hospital, or nursing facility; and

(i) Other services or supplies that are documented as necessary for the palliation and management of a client's terminal illness and related conditions;

(6) A hospice agency is responsible to determine if a nursing facility has requested authorization for medical supplies or medical equipment, including wheelchairs, for a client who becomes eligible for the hospice program. The ((department)) medicaid agency does not pay separately for medical equipment or supplies that were previously authorized by the ((department)) medicaid agency and delivered on or after the date the ((department)) medicaid agency enrolls the client in the hospice program.

[11-14-075, recodified as 182-551-1210, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1210, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1210, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1300   Requirements for a ((department-approved)) medicaid-approved hospice agency.   (1) To become a ((department-approved)) medicaid-approved hospice agency, the ((department)) medicaid agency requires a hospice agency to provide documentation that it is medicare, Title XVIII certified by the department of health (DOH) as a hospice agency.

(2) A ((department-approved)) medicaid-approved hospice agency must at all times meet the requirements in chapter ((388-551)) 182-551 WAC, subchapter I, Hospice services, and the requirements under the Title XVIII medicare program.

(3) To ensure quality of care for medical assistance ((client's)) clients, the ((department's)) agency's clinical staff may conduct hospice agency site visits.

[11-14-075, recodified as 182-551-1300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1300, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1300, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1305   Requirements for becoming a ((department-approved)) medicaid-approved hospice care center (HCC).   (1) To apply to become a ((department-approved)) medicaid-approved hospice care center, the ((department)) medicaid agency requires a hospice agency to:

(a) Be enrolled with the ((department)) medicaid agency as ((a department)) an approved hospice agency (see WAC ((388-551-1300)) 182-551-1300);

(b) Submit a letter of request to:


Hospice Program Manager

((Division of Medical Management

Department of Social and Health Services))

P.O. Box 45506

Olympia, WA 98504-5506; and


(c) Include documentation that confirms the approved hospice agency is medicare certified by department of health (DOH) as a hospice care center and provides one or more of the following levels of hospice care (levels of care are described in WAC ((388-551-1500)) 182-551-1500):

(i) Routine home care;

(ii) Inpatient respite care; and

(iii) General inpatient care.

(2) A ((department-approved)) medicaid-approved hospice care center must at all times meet the requirements in chapter ((388-551)) 182-551 WAC, subchapter I, Hospice services, and the requirements under the Title XVIII medicare program.

(3) A hospice agency qualifies as a ((department-approved)) medicaid-approved hospice care center when:

(a) All the requirements in this section are met; and

(b) The ((department)) medicaid agency provides the hospice agency with written notification.

[11-14-075, recodified as 182-551-1305, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1305, filed 8/30/05, effective 10/1/05.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1310   Hospice election periods, election statements, and the hospice certification process.   (1) Hospice coverage is available for two ninety-day election periods followed by an unlimited number of sixty-day election periods. A client or a client's authorized representative must sign an election statement to initiate or reinitiate an election period for hospice care.

(2) The election statement must be filed in the client's hospice medical record within two calendar days following the day the hospice care begins and requires all of the following:

(a) Name and address of the hospice agency that will provide the care;

(b) Documentation that the client is fully informed and understands hospice care and waiver of other medicaid and/or medicare services;

(c) Effective date of the election; and

(d) Signature of the client or the client's authorized representative.

(3) The following describes the hospice certification process:

(a) When a client elects to receive hospice care, the ((department)) medicaid agency requires a hospice agency to:

(i) Obtain a signed written certification from a physician of the client's terminal illness; or

(ii) Document in the client's medical file that a verbal certification was obtained and follow up a documented verbal certification with a written certification signed by:

(A) The medical director of the hospice agency or a physician staff member of the interdisciplinary team; and

(B) The client's attending physician (if the client has one).

(iii) Place the signed written certification of the client's terminal illness in the client's medical file:

(A) Within sixty days following the day the hospice care begins; and

(B) Before billing the ((department)) medicaid agency for the hospice services.

(b) For subsequent election periods, the ((department)) medicaid agency requires ((the hospice agency to)):

(i) ((Obtain a signed written certification statement of the client's terminal illness; or

(ii) Document in the client's medical file that a verbal certification was obtained and follow up a documented verbal certification with a written certification signed by the medical director of the hospice agency or a physician staff member of the hospice agency; and

(iii) Place the written certification of the client's terminal illness in the client's medical file:

(A) Within two calendar days following the beginning of a subsequent election period; and

(B) Before billing the department for the hospice services.)) A hospice physician or hospice nurse practitioner to:

(A) Have a face-to-face encounter with every hospice client within thirty days prior to the one hundred eightieth-day recertification and prior to each subsequent recertification to determine continued eligibility of the client for hospice care. The medicaid agency does not pay for face-to-face encounters to recertify a hospice client; and

(B) Attest that the face-to-face encounter took place.

(ii) The hospice agency to:

(A) Document in the client's medical file that a verbal certification was obtained and follow up a documented verbal certification with a written certification signed by the medical director of the hospice agency or a physician staff member of the hospice agency;

(B) Place the written certification of the client's terminal illness in the client's medical file:

(I) Within two calendar days following the beginning of a subsequent election period; and

(II) Before billing the medicaid agency for the hospice services; and

(C) Fax a completed medicaid hospice notification form (HCA 13-746) to the medicaid agency certifying the face-to-face encounter with the client, including date and name of the hospice physician or hospice nurse practitioner. To ensure payment for hospice services, the medicaid agency must receive the notification form no later than seven days following the one hundred eightieth-day recertification and each subsequent recertification.

(4) When a client's hospice coverage ends within an election period (e.g., the client revokes hospice care), the remainder of that election period is forfeited. The client may reinstate the hospice benefit at any time by providing an election statement and meeting the certification process requirements.

[11-14-075, recodified as 182-551-1310, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1310, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1310, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1330   Hospice -- Client care and responsibilities of hospice agencies.   (1) A hospice agency must facilitate a client's continuity of care with nonhospice providers to ensure that medically necessary care, both related and not related to the terminal illness, is met. This includes:

(a) Determining if the ((department)) medicaid agency has approved a request for prescribed medical equipment, such as a wheelchair. If the prescribed item is not delivered to the client before the client becomes covered by a hospice agency, the ((department)) medicaid agency will rescind the approval. See WAC ((388-543-1500)) 182-543-9100(7).

(b) Communicating with other ((department)) medicaid programs and documenting the services a client is receiving in order to prevent duplication of payment and to ensure continuity of care. Other ((department)) medicaid programs include, but are not limited to, programs administered by the department of social and health services aging and disability services administration (ADSA).

(c) Documenting each contact with nonhospice providers.

(2) When a client resides in a nursing facility, the hospice agency must:

(a) Coordinate the client's care with all providers, including pharmacies and medical vendors; and

(b) Provide the same level of hospice care the hospice agency provides to a client residing in their home.

(3) Once a client chooses hospice care, hospice agency staff must notify and inform the client of the following:

(a) By choosing hospice care from a hospice agency, the client gives up the right to:

(i) Covered medicaid hospice service and supplies received at the same time from another hospice agency; and

(ii) Any covered medicaid services and supplies received from any other provider that are necessary for the palliation and management of the terminal illness and related medical conditions.

(b) Services and supplies are not paid through the hospice daily rate if they are:

(i) Proven to be clinically unrelated to the palliation and management of the client's terminal illness and related medical conditions (see WAC ((388-551-1210(3))) 182-551-1210(3));

(ii) Not covered by the hospice daily rate;

(iii) Provided under a Title XIX medicaid program when the services are similar or duplicate the hospice care services; or

(iv) Not necessary for the palliation and management of the client's terminal illness and related medical conditions.

(4) A hospice agency must have written agreements with all contracted providers.

[11-14-075, recodified as 182-551-1330, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1330, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1330, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1340   When a client leaves hospice without notice.   When a client chooses to leave hospice care or refuses hospice care without giving the hospice agency a revocation statement, as required by WAC ((388-551-1360)) 182-551-1360, the hospice agency must do all of the following:

(1) Within five working days of becoming aware of the client's decision, inform and notify in writing the ((department's)) medicaid hospice program manager (see WAC ((388-551-1400)) 182-551-1400 for further requirements);

(2) Complete a medicaid hospice ((5-day)) notification form (((DSHS)) HCA 13-746) and forward a copy to the appropriate department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO) to notify that the client is discharging from the program;

(3) Notify the client, or the client's authorized representative, that the client's discharge has been reported to the ((department)) medicaid agency; and

(4) Document the effective date and details of the discharge in the client's hospice record.

[11-14-075, recodified as 182-551-1340, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1340, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1340, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1350   Discharges from hospice care.   (1) A hospice agency may discharge a client from hospice care when the client:

(a) Is no longer certified for hospice care;

(b) Is no longer appropriate for hospice care; or

(c) The hospice agency's medical director determines the client is seeking treatment for the terminal illness outside the plan of care (POC).

(2) At the time of a client's discharge, a hospice agency must:

(a) Within five working days, complete a medicaid hospice ((5-day)) notification form (((DSHS)) HCA 13-746) and forward the form to the ((department's)) medicaid hospice program manager (see WAC ((388-551-1400)) 182-551-1400 for additional requirements), and a copy to the appropriate DSHS home and community services office (HCS) or community services office (CSO);

(b) Keep the discharge statement in the client's hospice record;

(c) Provide the client with a copy of the discharge statement; and

(d) Inform the client that the discharge statement must be:

(i) Presented with the client's current services card when obtaining medicaid covered ((healthcare)) health care services or supplies, or both; and

(ii) Used until the ((department)) medicaid agency removes the hospice restriction from the client's information available online at https://www.waproviderone.org.

[11-14-075, recodified as 182-551-1350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-19-057, 388-551-1350, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1350, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1350, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1360   Ending hospice care (revocations).   (1) A client or a client's authorized representative may choose to stop hospice care at any time by signing a revocation statement.

(2) The revocation statement documents the client's choice to stop medicaid hospice care. The revocation statement must include all of the following:

(a) Client's signature (or the client's authorized representative's signature if the client is unable to sign);

(b) Date the revocation was signed; and

(c) Actual date that the client chose to stop receiving hospice care.

(3) The hospice agency must keep any explanation supporting any difference in the signature and revocation dates in the client's hospice records.

(4) When a client revokes hospice care, the hospice agency must:

(a) Inform and notify in writing the medicaid agency's hospice program manager, within five working days of becoming aware of the client's decision((, inform and notify in writing the department's hospice program manager)) (see WAC ((388-551-1400)) 182-551-1400 for additional requirements);

(b) Notify the appropriate department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO) of the revocation by completing and forwarding a copy of the medicaid hospice ((5-day)) notification form (((DSHS)) HCA 13-746) to the appropriate DSHS home and community services (HCS) office or community services office (CSO);

(c) Keep the revocation statement in the client's hospice record;

(d) Provide the client with a copy of the revocation statement; and

(e) Inform the client that the revocation statement must be:

(i) Presented with the client's current ((medical identification (medical ID))) services card when obtaining medicaid covered ((healthcare)) health care services or supplies, or both; and

(ii) Used until the ((department)) medicaid agency issues a new ((medical ID)) services card that identifies that the client is no longer a hospice client.

(5) After a client revokes hospice care, the remaining days within the current election period are forfeited. The client may immediately enter the next consecutive election period. The client does not have to wait for the forfeited days to pass before entering the next consecutive election period.

[11-14-075, recodified as 182-551-1360, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1360, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1360, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1370   When a hospice client dies.   When a client dies, the hospice agency must:

(1) Within five working days, inform and notify in writing the ((department's)) medicaid agency's hospice program manager; and

(2) Notify the appropriate department of social and health services (DSHS) home and community services (HCS) office or community services office (CSO) of the client's date of death by completing and forwarding a copy of the medicaid hospice ((5-day)) notification form (((DSHS)) HCA 13-746) to the appropriate DSHS HCS office or CSO.

[11-14-075, recodified as 182-551-1370, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1370, filed 8/30/05, effective 10/1/05.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1400   Notification requirements for hospice agencies.   (1) To be reimbursed for providing hospice services, the hospice agency must complete a medicaid hospice ((5-day)) notification form (((DSHS)) HCA 13-746) and forward the form to the ((department's)) medicaid agency's hospice program manager within five working days from when a medical assistance client begins the first day of hospice care, or has a change in hospice status. The hospice agency must notify the ((department's)) medicaid hospice program of:

(a) The name and address of the hospice agency;

(b) The date of the client's first day of hospice care;

(c) A change in the client's primary physician;

(d) A client's revocation of the hospice benefit (home or institutional);

(e) The date a client leaves hospice without notice;

(f) A client's discharge from hospice care;

(g) A client who admits to a nursing facility (this does not apply to an admit for inpatient respite care or general inpatient care);

(h) A client who discharges from a nursing facility (this does not apply to an admit for inpatient respite care or general inpatient care.);

(i) A client who is eligible for or becomes eligible for medicare or third party liability (TPL) insurance;

(j) A client who dies; or

(k) A client who transfers to another hospice agency. Both the former agency and current agency must provide the ((department)) medicaid agency with:

(i) The client's name, the name of the former hospice agency servicing the client, and the effective date of the client's discharge; and

(ii) The name of the current hospice agency serving the client, the hospice agency's provider number, and the effective date of the client's admission.

(2) The ((department)) medicaid agency does not require a hospice agency to notify the hospice program manager when a hospice client is admitted to a hospital for palliative care.

(3) When a hospice agency does not notify the ((department's)) medicaid agency's hospice program within five working days of the date of the client's first day of hospice care as required in subsection (1)(c) of this section, the ((department)) medicaid agency authorizes the hospice daily rate reimbursement effective the fifth working day prior to the date of notification.

[11-14-075, recodified as 182-551-1400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1400, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1400, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1500   Hospice daily rate -- Four levels of hospice care.   All services, supplies and equipment related to the client's terminal illness and related conditions are included in the hospice daily rate. The ((department)) medicaid agency pays for only one of the following four levels of hospice care per day (see WAC 388-551-1510 for payment methods):

(1) Routine home care. Routine home care includes daily care administered to the client at the client's residence. The services are not restricted in length or frequency of visits, are dependent on the client's needs, and are provided to achieve palliation or management of acute symptoms.

(2) Continuous home care. Continuous home care includes acute skilled care provided to an unstable client during a brief period of medical crisis in order to maintain the client in the client's residence and is limited to:

(a) A minimum of eight hours of acute care provided during a twenty-four-hour day;

(b) Nursing care that must be provided by a registered or licensed practical nurse for more than half the period of care;

(c) Homemaker, home health aide, and attendant services that may be provided as supplements to the nursing care; and

(d) In home care only (not care in a nursing facility or a hospice care center).

(3) Inpatient respite care. Inpatient respite care includes room and board services provided to a client in a ((department-approved)) medicaid-approved hospice care center, nursing facility, or hospital. Respite care is intended to provide relief to the client's primary caregiver and is limited to:

(a) No more than six consecutive days; and

(b) A client not currently residing in a hospice care center, nursing facility, or hospital.

(4) General inpatient hospice care. General inpatient hospice care includes services administered to a client for pain control or management of acute symptoms. In addition:

(a) The services must conform to the client's written plan of care (POC).

(b) This benefit is limited to brief periods of care in ((department-approved)) medicaid agency-approved:

(i) Hospitals;

(ii) Nursing facilities; or

(iii) Hospice care centers.

(((b))) (c) There must be documentation in the client's medical record to support the need for general inpatient level of hospice care.

[11-14-075, recodified as 182-551-1500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1500, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1500, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1510   Rates methodology and payment method for hospice agencies.   This section describes rates methodology and payment methods for hospice care provided to hospice clients.

(1) The ((department)) medicaid agency uses the same rates methodology as medicare uses for the four levels of hospice care identified in WAC 388-551-1500.

(2) Each of the four levels of hospice care has the following three rate components:

(a) Wage component;

(b) Wage index; and

(c) Unweighted amount.

(3) To allow hospice payment rates to be adjusted for regional differences in wages, the department bases payment rates on the metropolitan statistical area (MSA) county location. MSAs are identified in the department's current published billing instructions.

(4) Payment rates for:

(a) Routine and continuous home care services are based on the county location of the client's residence.

(b) Inpatient respite and general inpatient care services are based on the MSA county location of the providing hospice agency.

(5) The ((department)) medicaid agency pays hospice agencies for services (not room and board) at a daily rate calculated as follows:

(a) Payments for services delivered in a client's residence (routine and continuous home care) are based on the county location of the client's residence; or

(b) Payments for respite and general inpatient care are based on the county location of the providing hospice agency.

(6) The ((department)) medicaid agency:

(a) Pays for routine hospice care, continuous home care, respite care, or general inpatient care for the day of death;

(b) Does not pay room and board for the day of death; and

(c) Does not pay hospice agencies for the client's last day of hospice care when the last day is for the client's discharge, revocation, or transfer.

(7) Hospice agencies must bill the ((department)) medicaid agency for their services using hospice-specific revenue codes.

(8) For hospice clients in a nursing facility:

(a) The ((department)) medicaid agency pays nursing facility room and board payments at a daily rate directly to the hospice agency at ninety-five percent of the nursing facility's current medicaid daily rate in effect on the date the services were provided; and

(b) The hospice agency pays the nursing facility at a daily rate no greater than the nursing facility's current medicaid daily rate.

(9) The ((department)) medicaid agency:

(a) Pays a hospice care center a daily rate for room and board based on the average room and board rate for all nursing facilities in effect on the date the services were provided.

(b) Does not pay hospice agencies or hospice care centers a nursing facility room and board payment for:

(i) A client's last day of hospice care (e.g., client's discharge, revocation, or transfer); or

(ii) The day of death.

(10) The daily rate for authorized out-of-state hospice services is the same as for in-state non-MSA hospice services.

(11) The client's notice of action (award) letter states the amount of participation the client is responsible to pay each month towards the total cost of hospice care. The hospice agency receives a copy of the award letter and:

(a) Is responsible to collect the correct amount of the client's participation if the client has any; and

(b) Must show the client's monthly participation on the hospice claim. (Hospice providers may refer to the ((department's)) medicaid agency's current published billing instructions for how to bill a hospice claim.) If a client has a participation amount that is not reflected on the claim and the ((department)) medicaid agency reimburses the amount to the hospice agency, the amount is subject to recoupment by the ((department)) medicaid agency.

[11-14-075, recodified as 182-551-1510, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1510, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1510, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1520   Payment method for nonhospice providers.   (1) The ((department)) medicaid agency pays for hospitals that provide inpatient care to clients in the hospice program for medical conditions not related to their terminal illness according to chapter ((388-550)) 182-550 WAC, Hospital services.

(2) The ((department)) medicaid agency pays providers who are attending physicians and not employed by the hospice agency, the usual amount through the resource based relative value scale (RBRVS) fee schedule:

(a) For direct physician care services provided to a hospice client;

(b) When the provided services are not related to the terminal illness; and

(c) When the client's providers, including the hospice agency, coordinate the health care provided.

(3) The ((department's)) department of social and health services (DSHS) aging and disability services administration (ADSA) pays for services provided to a client eligible under the community options program entry system (COPES) directly to the COPES provider.

(a) The client's monthly participation amount, if there is one, for services provided under COPES is paid separately to the COPES provider; and

(b) Hospice agencies must bill the ((department's)) medicaid agency's hospice program directly for hospice services, not the COPES program.

[11-14-075, recodified as 182-551-1520, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1520, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1520, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1530   Payment method for medicaid-medicare dual eligible clients.   (1) The ((department does not)) medicaid agency will not pay for ((any)) hospice care ((provided to)) for a client ((covered by)) who is also eligible for payment of medicare hospice under part A (hospital insurance).

(2) The ((department)) medicaid agency may pay for hospice care provided to a client:

(a) Covered by medicaid part B (medical insurance); and

(b) Not covered by medicare part A.

(3) For hospice care provided to a medicaid-medicare dual eligible client, hospice agencies are responsible to bill:

(a) Medicare before billing the ((department)) medicaid agency;

(b) The ((department)) medicaid agency for hospice nursing facility room and board;

(c) The ((department)) medicaid agency for hospice care center room and board; and

(d) Medicare for general inpatient care or inpatient respite care.

(4) All the limitations and requirements related to hospice care described in this subchapter apply to the payments described in this section.

[11-14-075, recodified as 182-551-1530, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1530, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520 and 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, 388-551-1530, filed 4/9/99, effective 5/10/99.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1800   Pediatric palliative care (PPC) case management/coordination services -- General.   Through a hospice agency, the ((department's)) medicaid agency's pediatric palliative care (PPC) case management/coordination services provide the care coordination and skilled care services to clients who have life-limiting medical conditions. Family members and caregivers of clients eligible for pediatric palliative care services may also receive support through care coordination when the services are related to the client's medical needs.

[11-14-075, recodified as 182-551-1800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1800, filed 8/30/05, effective 10/1/05.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1810   Pediatric palliative care (PPC) case management/coordination services -- Client eligibility.   To receive pediatric palliative care (PPC) case management/coordination services, a person must:

(1) Be twenty years of age or younger;

(2) Be a current recipient of the:

(a) Categorically needy program (CNP);

(b) Limited casualty program - Medically needy program (LCP-MNP);

(c) CNP(( -- )) - Alien emergency medical;

(d) LCP-MNP(( -- )) - Alien emergency medical;

(e) Children's health insurance program (SCHIP); and

(3) Have a life-limiting medical condition that requires case management and coordination of medical services due to at least three of the following circumstances:

(a) An immediate medical need during a time of crisis;

(b) Coordination with family member(s) and providers required in more than one setting (i.e., school, home, and multiple medical offices or clinics);

(c) A life-limiting medical condition that impacts cognitive, social, and physical development;

(d) A medical condition with which the family is unable to cope;

(e) A family member(s) and/or caregiver who needs additional knowledge or assistance with the client's medical needs; and

(f) Therapeutic goals focused on quality of life, comfort, and family stability.

(4) See WAC 182-551-1860 for concurrent palliative and curative care for hospice clients twenty years of age and younger.

[11-14-075, recodified as 182-551-1810, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1810, filed 8/30/05, effective 10/1/05.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1820   Pediatric palliative care (PPC) contact -- Services included and limitations to coverage.   (1) The ((department's)) medicaid agency's pediatric palliative care (PPC) case management/coordination services cover up to six pediatric palliative care contacts per client, per calendar month, subject to the limitations in this section and other applicable WAC.

(2) One pediatric palliative care contact consists of:

(a) One visit with a registered nurse, social worker, or therapist (for the purpose of this section, the ((department)) medicaid agency defines therapist as a licensed physical therapist, occupational therapist, or speech/language therapist) with the client in the client's residence to address:

(i) Pain and symptom management;

(ii) Psychosocial counseling; or

(iii) Education/training.

(b) Two hours or more per month of case management or coordination services to include any combination of the following:

(i) Psychosocial counseling services (includes grief support provided to the client, client's family member(s), or client's caregiver prior to the client's death);

(ii) Establishing or implementing care conferences;

(iii) Arranging, planning, coordinating, and evaluating community resources to meet the client's needs;

(iv) Visits lasting twenty minutes or less (for example, visits to give injections, drop off supplies, or make appointments for other PPC-related services.); and

(v) Visits not provided in the client's home.

(3) The ((department)) medicaid agency does not pay for a pediatric palliative care contact described in subsection (2) of this section when a client is receiving services from any of the following:

(a) Home health program;

(b) Hospice program;

(c) Private duty nursing (private duty nursing can subcontract with PPC to provide services)/medical intensive care;

(d) Disease case management program; or

(e) Any other ((department)) medicaid program that provides similar services.

(4) The ((department)) medicaid agency does not pay for a pediatric palliative care contact that includes providing counseling services to a client's family member or the client's caregiver for grief or bereavement for dates of service after a client's death.

[11-14-075, recodified as 182-551-1820, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1820, filed 8/30/05, effective 10/1/05.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1830   How to become a ((department-approved)) medicaid-approved pediatric palliative care (PPC) case management/coordination services provider.   This section applies to ((department-enrolled)) medicaid-approved providers who currently do not provide pediatric palliative care (PPC) services to medical assistance clients.

(1) To apply to become a ((department-approved)) medicaid-approved provider of PPC services, a provider must:

(a) Be a ((department-approved)) medicaid-approved hospice agency (see WAC ((388-551-1300)) 182-551-1300 and ((388-551-1305)) 182-551-1305); and

(b) Submit a letter to the ((department's)) medicaid agency's hospice/PPC program manager requesting to become a ((department-approved)) medicaid-approved provider of PPC and include a copy of the provider's policies and position descriptions with minimum qualifications specific to pediatric palliative care.

(2) A hospice agency qualifies to provide PPC services when:

(a) All the requirements in this section are met; and

(b) The ((department)) medicaid agency provides the hospice agency with written notification.

[11-14-075, recodified as 182-551-1830, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1830, filed 8/30/05, effective 10/1/05.]


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-551-1840   Pediatric palliative care (PPC) case management/coordination services -- Provider requirements.   (1) An eligible provider of pediatric palliative care (PPC) case management/coordination services must do all of the following:

(a) Meet the conditions in WAC ((388-551-1300)) 182-551-1300;

(b) Confirm that a client meets the eligibility criteria in WAC ((388-551-1810)) 182-551-1810 prior to providing the pediatric palliative care services;

(c) Place in the client's medical record a written order for PPC from the client's physician;

(d) Determine and document in the client's medical record the medical necessity for the initial and ongoing care coordination of pediatric palliative care services;

(e) Document in the client's medical record:

(i) A palliative plan of care (POC) (a written document based on assessment of a client's individual needs that identifies services to meet those needs).

(ii) The medical necessity for those services to be provided in the client's residence; and

(iii) Discharge planning.

(f) Provide medically necessary skilled interventions and psychosocial counseling services by qualified interdisciplinary hospice team members;

(g) Assign and make available a PPC case manager (nurse, social worker or therapist) to implement care coordination with community-based providers to assure clarity, effectiveness, and safety of the client's POC;

(h) Complete and fax the pediatric palliative care (PPC) referral and 5-day notification form (((DSHS)) HCA 13-752) to the ((department's)) medicaid agency's PPC program manager within five working days from date of occurrence of the client's:

(i) Date of enrollment in PPC.

(ii) Discharge from the hospice agency or PPC program when the client:

(A) No longer meets PPC criteria;

(B) Is able to receive all care in the community;

(C) Does not require any services for sixty days; or

(D) Discharges from the PPC program and enrolls in the ((department's)) medicaid hospice program.

(iii) Transfer to another hospice agency for pediatric palliative care services.

(iv) Death.

(i) Maintain the client's file which includes the POC, visit notes, and all of the following:

(i) The client's start of care date and dates of service;

(ii) Discipline and services provided (in-home or place of service);

(iii) Case management activity and documentation of hours of work; and

(iv) Specific documentation of the client's response to the palliative care and the client's and/or client's family's response to the effectiveness of the palliative care (e.g., the client might have required acute care or hospital emergency room visits without the pediatric palliative care services).

(j) Provide when requested by the ((department's)) medicaid agency's PPC program manager, a copy of the client's POC, visit notes, and any other documents listing the information identified in subsection (1)(i) of this section.

(2) If the ((department)) medicaid agency determines the POC, visit notes, and/or other required information do not meet the criteria for a client's PPC eligibility or does not justify the billed amount, any payment to the provider is subject to recoupment by the ((department)) medicaid agency.

[11-14-075, recodified as 182-551-1840, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, 388-551-1840, filed 8/30/05, effective 10/1/05.]


NEW SECTION
WAC 182-551-1860   Concurrent care for hospice clients twenty years of age and younger.   (1) In accordance with Section 2302 of the Patient Protection and Affordable Care Act of 2010 and Section 1814 (a)(7) of the Social Security Act, hospice palliative services are available to clients twenty years of age and younger without forgoing curative services which the client is entitled to under Title XIX Medicaid and Title XXI Children's Health Insurance Program (CHIP) for treatment of the terminal condition.

(2) Unless otherwise specified within this section, curative treatment, related services, or related medications requested for clients twenty years of age and younger are subject to the medicaid agency's specific program rules governing those services or medications.

(3) Health care professionals must request prior authorization from the agency in accordance with WAC 182-501-0050 for all curative treatment including treatment planning and actual treatment, all related services and related medications for a hospice client twenty years of age and younger. Prior authorization requests for curative treatment or medications are subject to medical necessity review under WAC 182-501-0165.

(4) If the curative treatment, related services, or related medications are not covered by the medicaid agency, the provider must request an exception to rule in accordance with WAC 182-501-0160. Exception to rule requests are subject to medical necessity review under WAC 182-501-0165.

(5) If the medicaid agency denies a request for a covered service, refer to WAC 182-502-0160 when a provider or a client may be responsible to pay for a covered service.

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Washington State Code Reviser's Office