WSR 05-15-150

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed July 19, 2005, 4:26 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 04-07-114.

Title of Rule and Other Identifying Information: Part 2 of 3, amending WAC 388-551-1330 Hospice coordination of care, 388-551-1340 When a client leaves hospice without notice, 388-551-1350 Discharges from hospice care, 388-551-1360 Ending hospice care (revocations), 388-551-1370 When a hospice client dies, 388-551-1400 Hospice providers must notify the department, 388-551-1500 Availability requirements for hospice care, 388-551-1510 Payment method for hospice providers, 388-551-1520 Payment method for nonhospice providers, 388-551-1530 Payment method for Medicaid-Medicare dual eligible clients; and repealing WAC 388-551-1315 Example of how hospices client certifications (election periods) work and 388-551-1410 Hospice providers must notify institutional providers.

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on August 23, 2005, at 10:00 a.m.

Date of Intended Adoption: Not earlier than August 24, 2005.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., August 23, 2005.

Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by August 19, 2005, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: DSHS is amending these rules to incorporate language from contracts with hospice care centers (HCCs) into chapter 388-551 WAC, Hospice services; to clarify and update hospice services definitions and rules; to provide a standard for medically appropriate and fiscally responsible utilization; and to allow stabilization of reimbursement payments for hospice services provided to medical assistance clients. Also, to repeal outdated sections in chapter 388-551 WAC regarding election periods and notification requirements.

Reasons Supporting Proposal: See Purpose above.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Statute Being Implemented: RCW 74.08.090, 74.09.520, and 42 C.F.R. 418.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of Social and Health Services, governmental.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1342; Implementation and Enforcement: Pam Colyar, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1582.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendment and concludes that it will impose no new costs on small businesses. The preparation of a comprehensive small business economic impact statement is not required.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Pam Colyar, Health and Recovery Services Administration, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1582, fax (360) 586-1471, e-mail colyaps@dshs.wa.gov.

July 15, 2005

Andy Fernando, Manager

Rules and Policies Assistance Unit

3575.2
AMENDATORY SECTION(Amending WSR 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1330   Hospice ((coordination of care)) - Client care and responsibilities of hospice agencies.   (1) ((Once a client chooses hospice care from a hospice agency, that client gives up the right to:

(a) Covered Medicaid hospice services and supplies received at the same time from another hospice agency; and

(b) Any covered Medicaid services and supplies received from any other provider and which are related to the terminal illness.

(2) Services and supplies not covered by the Medicaid hospice benefit are paid separately, if covered under the client's Medicaid eligibility. These services include but are not limited to:

(a) COPES (community options program entry system) as determined and paid by the department's aging and adult services administration (AASA); and

(b) Medically intensive home care program (MIHCP) as determined by the department's division of developmentally disabled.

(3) Clients eligible for coordinated community aids services alternatives (CCASA) are not eligible for hospice coverage.

(4) The hospice provider must coordinate all the client's medical management for the terminal illness.

(5) All of the client's providers, including the hospice provider, must coordinate:

(a) The client's health care; and

(b) Services available from other department programs, such as COPES)) 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 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 will rescind the approval. See WAC 388-543-1500.

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

(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.

[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.]

Hospice - Discharges and Notification
AMENDATORY SECTION(Amending WSR 99-09-007, filed 4/9/99, effective 5/10/99)

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

(1) ((Notify MAA's hospice coordinator)) 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 for further requirements);

(2) ((Stop billing MAA for hospice payment)) Complete a Medicaid Hospice 5-Day Notification form (DSHS 13-746) and forward a copy to the appropriate 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 ((MAA)) the department; and

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

[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 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1350   Discharges from hospice care.   (1) A hospice ((provider)) agency may discharge a client from hospice care when the client:

(((1))) (a) Is no longer certified for hospice care;

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

(((3) Seeks)) (c) The hospice agency's medical director determines the client is seeking treatment for the terminal illness ((from)) outside the plan of care (POC) ((as defined by the hospice interdisciplinary team)).

(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 13-746) and forward to the department's hospice program manager (see WAC 388-551-1400 for additional requirements), and a copy to the appropriate 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 medical identification (medical ID) card when obtaining Medicaid covered healthcare services or supplies, or both; and

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

[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 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1360   Ending hospice care (revocations).   (1) A client or a ((family member)) 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 ((keep the revocation statement in the client's hospice record)):

(a) 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 for additional requirements);

(b) Notify the appropriate 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 13-746) to the appropriate 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) card when obtaining Medicaid covered healthcare services or supplies, or both; and

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

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

[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.]

((Hospice--Notification))
NEW SECTION
WAC 388-551-1370   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 hospice program manager; and

(2) Notify the appropriate 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 13-746) to the appropriate HCS office or CSO.

[]


AMENDATORY SECTION(Amending WSR 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1400   ((Hospice providers must notify the department)) Notification requirements for hospice agencies.   (1) ((Notification within five working days avoids duplicative payments for services related to a client's terminal illness. Hospice providers must notify the MAA hospice coordinator, and either the client's CSO or HCS as appropriate.

(2) Hospice providers must report any changes in the client's hospice status within five working days from when a MAA client:

(a) Begins the first day of hospice care;

(b) Changes hospice agencies. Clients may change hospice agencies only once per election period. Both the old and new hospice providers must supply the department as described in subsection (1) of this section with:

(i) The effective date of discharge from the old agency; and

(ii) The effective date of the admit to, the name of, and the provider number of the new agency;

(c) Revokes the hospice benefit (home or institutional);

(d) Discharges from hospice care;

(e) Becomes an institutional facility resident;

(f) Leaves an institutional facility as a resident; or

(g) Dies.

(3) A hospice agency must submit a client's assessment to MAA within five working days of MAA's request for that assessment)) To be reimbursed for providing hospice services, the hospice agency must complete a Medicaid Hospice 5-Day Notification form (DSHS 13-746) and forward to the department'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 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 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 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 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 authorizes the hospice daily rate reimbursement effective the fifth working day prior to the date of notification.

[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 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1500   ((Availability requirements for)) 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 ((through)). The department 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 ((for each day the client is at their residence, with no restriction on length or frequency of visits,)). 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 ((is acute episodic care received by the client to maintain the client at home and addresses a brief period of medical crisis. Continuous care consists predominately of nursing care. This benefit)). 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; ((and))

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

(a) No more than ((five)) six consecutive days; and

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

(4) General inpatient hospice care ((is)). General inpatient hospice care includes services administered to a client for pain ((and symptom management that cannot be provided in other settings)) 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 ((MAA))department-approved:

(i) Hospitals;

(ii) Nursing facilities; or

(iii) Hospice ((inpatient facilities)) care centers.

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

[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 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1510   Rates methodology and payment method for hospice ((providers)) agencies.   This section describes rates methodology and payment methods for hospice care provided ((under WAC 388-551-1500)) to hospice clients.

(1) ((Prior to submitting a claim to MAA, the hospice provider must file written certification in the client's hospice record per WAC 388-551-1310)) The department uses the same rates methodology as Medicare uses for the four levels of hospice care identified in WAC 388-551-1500.

(2) ((MAA may pay for Hospice care provided to clients in one of the following settings:

(a) A client's residence;

(b) Inpatient respite services; or

(c) General inpatient as follows:

DAY OF PAID AT
Admit General Inpatient
Brief Period General Inpatient
Death General Inpatient
Other Discharge Routine
)) 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 be paid by MAA, the hospice provider must provide and/or coordinate MAA covered:

(a) Medicaid hospice services; and

(b) Services that relate to the client's terminal illness at the time of the hospice admit)) 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) ((MAA does not pay hospice providers for the client's last day, except for the day of death)) 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) ((Hospice providers must bill MAA for their services using hospice-specific revenue codes)) The department 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) ((MAA pays hospice providers for services (not room and board) at a daily rate calculated by one of the following methods and adjusted for current wages:

(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 for that particular client; or

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

(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) ((MAA pays nursing facility room and board payments to hospice agencies, not licensed as hospitals, at a day rate as follows:

(a) Directly to the hospice provider at ninety-five percent of the nursing facility's lowest current Medicaid day rate;

(b) The hospice agency pays the nursing facility at a day rate no greater than the nursing facility's lowest current Medicaid daily rate; and

(c) The correct amount of the patient's participation must be:

(i) Collected by the hospice agency as directed by the department each month; and

(ii) Forwarded to the nursing facility)) Hospice agencies must bill the department for their services using hospice-specific revenue codes.

(8) For hospice clients in a nursing facility:

(a) ((MAA)) The department pays nursing facility room and board payments ((to free-standing hospice agencies licensed as hospitals by using MAA's administrative statewide average day rate in effect at the time the contract is signed)) 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 pays for COPES services clients directly to the COPES provider.

(a) Patient participation in that case is paid separately to the COPES provider.

(b) Hospice providers bill MAA directly for hospice services, not the COPES program)) The department:

(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 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 reimburses the amount to the hospice agency, the amount is subject to recoupment by the department.

[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 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1520   Payment method for nonhospice providers.   (1) ((Hospitals which provide inpatient care to clients in the hospice program for medical conditions not related to their terminal illness may be paid)) The department 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 WAC, Hospital services.

(2) ((MAA)) The department pays providers who are attending physicians ((who are)) and not employed by the hospice agency ((at their)), 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 ((provider)) agency, coordinate the health care provided.

(3) The department's 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 hospice program directly for hospice services, not the COPES program.

[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 99-09-007, filed 4/9/99, effective 5/10/99)

WAC 388-551-1530   Payment method for Medicaid-Medicare dual eligible clients.   (1) ((MAA)) The department does not pay for any hospice care provided to a client covered by ((part A)) Medicare part A (hospital insurance).

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

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

(b) Not covered by ((part A)) Medicare part A.

(3) For hospice care provided to a Medicaid-Medicare dual eligible client, hospice ((providers must)) agencies are responsible to bill:

(a) Medicare before billing ((Medicaid, except for hospice nursing facility room and board)) the department;

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

(c) The department 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 ((chapter)) subchapter apply to the payments described in this section.

[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.]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-551-1315 Example of how hospice client certifications (election periods) work.
WAC 388-551-1410 Hospice providers must notify institutional providers.

Washington State Code Reviser's Office