Purpose: The rule incorporates language from contracts with hospice care centers (HCCs) into chapter 388-551 WAC, Hospice services; clarifies and updates hospice services definitions and rules; provides a standard for medically appropriate and fiscally responsible utilization; allows stabilization of reimbursement payments for hospice services provided to medical assistance clients; adopts rules to incorporate into rule language for the pediatric palliative care (PPC) case management/coordination services program; and repeals outdated sections in chapter 388-551 WAC regarding election periods and notification requirements.

     Citation of Existing Rules Affected by this Order: Repealing WAC 388-551-1315 and 388-551-1410; and amending WAC 388-551-1000, 388-551-1010, 388-551-1200, 388-551-1210, 388-551-1300, 388-551-1310, 388-551-1320, 388-551-1330, 388-551-1340, 388-551-1350, 388-551-1360, 388-551-1400, 388-551-1500, 388-551-1510, 388-551-1520, and 388-551-1530.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.

      Adopted under notice filed as WSR 05-15-148, 05-15-149, and 05-15-150 on July 19, 2005.

     Changes Other than Editing from Proposed to Adopted Version: WAC 388-551-1010 Hospice program -- Definitions.

     "Legal representative" means an individual who has been authorized under state law 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.

WAC 388-551-1200 Client eligibility for hospice care.

     (5)(d) If the client is a Medicaid only client (i.e., not a medicaid-Medicare dual eligible client) and has a diagnosis other than cancer, the client's initial assessment has been reviewed and approved by the department (see WAC 388-551-1320).

     (5)(e)(d) The hospice agency...

WAC 388-551-1310 Hospice election periods, election statements, and the hospice certification process.

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

WAC 388-551-1320 Hospice plan of care.

     (1) ...as described in WAC 246-335-985 085, and meet the requirements in this section.

WAC 388-551-1810 Pediatric palliative care (PPC) case management/coordination services -- Client eligibility.

     (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. The client must:

     (a) Have An immediate medical needs during a time of crisis;

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

     (c) Have a A life-limiting medical condition...;

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

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

     (f) Have tTherapeutic goals that are focused on quality of life, comfort, and family stability.

WAC 388-551-1820 Pediatric palliative care (PPC) contact -- Services included and limitations to coverage.

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

WAC 388-551-1840 Pediatric palliative care (PPC) case management/coordination services -- Provider requirements.

     (1)(e) Prescribe and dDocument in the client's medical record: (1)(h)(iii) Transfer to another hospice agency for pediatric palliative care services.

     (1)(i)(iv) Specific documentations of the client's response... (e.g., would the client might have required acute care or hospital emergency room visits without the pediatric palliative care services).

     A final cost-benefit analysis is available by contacting Pam Colyar, DSHS Health and Recover Services Administration, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1582, fax (360) 586-1471, e-mail colyaps@dshs.wa.gov. (The preliminary analysis is unchanged and will be final.)

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 8, Amended 16, Repealed 2.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 8, Amended 16, Repealed 2.

     Date Adopted: August 26, 2005.

Andy Fernando, Manager

Rules and Policies Assistance Unit

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

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

     (4) Hospice care ((is ended by the client or family (revocation), the hospice agency (discharge), or death)) 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) ((Bereavement care is provided to the family of the client who chooses hospice care. It provides emotional and spiritual comfort associated with the death of a hospice client)) Hospice care includes the provision of emotional and spiritual comfort and bereavement support to the client's family member(s).

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

[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.]

     "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.

     (("CSO")) "Community services office (CSO) means ((the client's community services office of the department's economic services administration)) an office of the department that administers social and health services at the community level.

     "Discharge" means an agency ends hospice care for a client. ((See WAC 388-551-1350 for details.))

     "Election period" means the time, ninety or sixty days, that the client is certified as eligible for and chooses to receive hospice care. ((See WAC 388-551-1310 for details.))

     "Family" means ((any person(s) important to the client, as defined by the client)) 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.

     (("HCS" means the client's home and community services office of the aging and adult services administration.

     "Hospice interdisciplinary team" means the following health professionals who plan and deliver hospice care to a client as appropriate under the direction of a certified physician: Home health aides monitored by a registered nurse, therapists (physical, occupational, speech-language), registered nurses, physicians, social workers, counselors, volunteers, and others as necessary.)) "Home and community services (HCS) office" means an 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." ((See WAC 388-551-1320 for details)) means a written document based on assessment of client needs that identifies services to meet these needs.

     "Related condition(s)" means any health conditions(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 ((where the client lives for an extended period of time)) a client's home or place of living.

     "Revoke" ((and)) or "revocation" ((mean a client or family member's)) means the choice to stop receiving hospice care. ((See WAC 388-551-1220 for details.))

     "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.

[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.]

     (a) Categorically needy program (CNP);

     (b) ((General assistance - disability determination pending (GAX);

     (c))) Limited casualty program - medically needy program (LCP-MNP); ((or

     (d))) (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).

     (2) ((An eligible Medicaid client who voluntarily chooses hospice care must be certified by a physician as terminally ill before MAA pays for hospice care)) A hospice agency is responsible to verify a client's eligibility with the client or the client's home and community services (HCS) office or community services office (CSO).

     (3) ((Clients enrolled in one of MAA's healthy options managed care plans receive all hospice services directly through their plan. The managed care plan must arrange or provide all hospice services for a managed care client)) A client enrolled in one of the department's managed care plans must receive all hospice services, including facility room and board, directly through that plan. The client's managed care plan is responsible for arranging and providing all hospice services for a client enrolled in a managed care plan.

     (4) ((Hospice clients attain institutional status as described in WAC 388-513-1320 when they elect and are certified for hospice care. See WAC 388-513-1380 for the client's financial participation requirements)) A client who is also eligible for Medicare part A is not eligible for hospice care through the department's hospice program. The department 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.

     (5) A client who meets the requirements in this section is eligible to receive hospice care through the department'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.

     (c) The hospice agency serving the client:

     (i) Notifies the department'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 and 388-551-1305.

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

[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.]

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

     (a) ((Medically necessary for palliative care)) Related to the client's hospice diagnosis;

     (b) ((Related to the client's terminal illness)) Identified by the client's hospice interdisciplinary team;

     (c) ((Prescribed by the client's attending physician, alternate physician, or hospice medical director)) Written in the client's plan of care (POC); and

     (d) ((Supplied or arranged for by the hospice provider; and

     (e) Included in the client's plan of care)) Made available to the client by the hospice agency on a twenty-four hour basis.

     (3) ((The following intermittent services and supplies, paid by MAA's hospice daily rate, must be available from and offered by the hospice provider for the client as determined by the client's hospice interdisciplinary team:

     (a) Medical equipment and supplies that are medically necessary for palliative care;

     (b) Drugs and biologicals used primarily for the relief of pain and management of symptoms;

     (c) Home health aide services furnished by qualified aides of the hospice agency. A registered nurse must complete a home-site supervisory visit every two weeks to assess aide services provided;

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

     (e) Physician services related to administration of the plan of care;

     (f) Nursing care provided through the hospice agency by either:

     (i) A registered nurse; or

     (ii) A licensed practical nurse under the supervision of a registered nurse;

     (g) Medical social services provided through the hospice agency by a social worker under the direction of a physician;

     (h) Counseling services provided through the hospice agency to the client and his or her family members or caregivers;

     (i) Medical transportation services; and

     (j) Short-term, inpatient care, provided in a Medicare-certified hospice inpatient unit, hospital, or nursing facility)) 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), 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;

     (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;

     (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 does not pay separately for medical equipment or supplies that were previously authorized by the department and delivered on or after the date the department enrolls the client in the hospice program.

[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.]

     (a))), the department requires a hospice agency to provide documentation that it is Medicare, Title XVIII certified((; and

     (b) Enrolled with MAA as a provider of hospice care)) by the department of health (DOH) as a hospice agency.

     (2) ((All services provided through a hospice agency must be performed by qualified personnel as required through Medicare's certification process in effect as of February 1, 1999. For more information on Medicare certifications, contact:

          Department of Health

          Hospice Certification Program

          Mailstop 47852

          Olympia, Washington, 98504-7852.))

A department-approved hospice agency must at all times meet the requirements in chapter 388-551 WAC, subchapter I, Hospice services, and the requirements under the Title XVIII Medicare Program.

     (3) ((Freestanding hospice agencies licensed as hospitals by the department of health must sign an additional selective contract with MAA to receive payment from MAA)) To ensure quality of care for medical assistance client's, the department's clinical staff may conduct hospice agency site visits.

[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.]

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

     (b) Submit a letter of request to:

          Hospice Program Manager

          Division of Medical Management

          Department of Social and Health Services

          PO Box 45506

          Olympia, WA 98504-5506; and

     (c) Include documentation that confirms the 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):

     (i) Routine home care;

     (ii) Inpatient respite care; and

     (iii) General inpatient care.

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

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

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

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

[]

     (4) When a client's hospice coverage ends within an election period, the remainder of that election period is forfeited)) (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 requires a hospice agency to:

     (i) Obtain a signed written certification 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 for the hospice services.

     (b) For subsequent election periods, the department 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.

     (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.

[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.]

     (2) A registered nurse or physician must conduct an initial physical assessment of ((the)) a client and ((must)) develop the ((plan of care)) POC with at least one other member of the hospice interdisciplinary team.

     (3) ((The hospice interdisciplinary team)) At least two other hospice interdisciplinary team members must review ((in a case planning conference)) the ((plan of care,)) POC no later than two working days after it is developed.

     (4) The ((plan of care)) POC must be reviewed and updated every two weeks by at least three members of the hospice interdisciplinary team((, including)) that includes at least:

     (a) A registered nurse;

     (b) A social worker; and

     (c) One other hospice interdisciplinary team member.

     (((5) Also see WAC 246-331-135 for the department of health's plan of care requirements.))

[Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, § 388-551-1320, filed 4/9/99, effective 5/10/99.]

     (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.]

     (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.]

     (((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.]

     (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.]

     (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.

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     (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.]

     (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.]

     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
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.]

     (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.]

     (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.]

     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.

3574.4
NEW SECTION
WAC 388-551-1800   Pediatric palliative care (PPC) case management/coordination services - General.   Through a hospice agency, the department'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.

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     (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.

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     (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 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 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 program that provides similar services.

     (4) The department 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.

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

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

     (b) Submit a letter to the department's hospice/PPC program manager requesting to become a department-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 provides the hospice agency with written notification.

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

     (b) Confirm that a client meets the eligibility criteria in WAC 388-551-1810 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 13-752) to the department'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 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 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 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.

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     (2) The department makes adjustments to the reimbursement rate for PPC contacts when the legislature grants a vender rate change. New rates become effective as directed by the legislature and are effective until the next rate change.

     (3) The reimbursement rate for authorized out-of-state PPC services is the same as the in-state non-MSA rate.

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