PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 98-01-189.
Title of Rule: WAC 388-86-047 Hospice services (repeal) and new chapter 388-551 WAC, Alternative to hospital services, subchapter: I Hospice services.
Purpose: The department originally intended to amend WAC 388-86-047 Hospice services; instead, new chapter 388-551 WAC, will be established. The department is changing the hospice election periods (i.e. when a client can choose hospice coverage) for its medical assistance clients, to match the Medicare hospice election periods, which were changed October 1, 1997. The department is also requiring hospice providers to notify the department of hospice status changes within five days of such changes.
Statutory Authority for Adoption: RCW 74.09.520 and 74.08.090.
Statute Being Implemented: RCW 74.09.520 and 74.08.090, 42 CFR 418.22 and .24.
Summary: Certain Medicaid clients who are certified as terminally ill may elect to receive hospice benefits. The rule describes the services that hospice providers must make available to these clients; the client's hospice interdisciplinary team determines the services needed. The rule also describes hospice provider record retention requirements, hospice agency notification requirements, methods of payment to hospice providers, and client eligibility requirements.
Reasons Supporting Proposal: Congress and the state legislature authorized the department to offer these services.
Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Sue White, DSHS/MAA/DHSQS, 805 Plum Street S.E., Olympia, WA 98501, (360) 586-5305.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: Certain Medicaid clients who are certified as terminally ill may elect to receive hospice benefits. The rule describes the services that hospice providers must make available to these clients; the client's hospice interdisciplinary team determines the services. The rule also describes requirements for hospice provider record retention, hospice agency notification, methods of payment to hospice providers, and client eligibility requirements.
Proposal Changes the Following Existing Rules: WAC 388-86-047 is to be repealed. The rule is being incorporated into new chapter 388-551 WAC being established.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department prepared a cost-benefit analysis (CBA) which includes a description of why a small business economic impact statement is unnecessary. The CBA is available from the staff person named above.
RCW 34.05.328 applies to this rule adoption. These rules meet the definition of significant legislative rules. As such, a cost-benefit analysis (CBA) has been prepared. The CBA is available from the staff person named above.
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on March 23, 1999, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Paige Wall by March 12, 1999, phone (360) 902-7540, TTY (360) 902-8324, e-mail pwall@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by March 23, 1999.
Date of Intended Adoption: March 26, 1999.
February 12, 1999
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2505.9ALTERNATIVES TO HOSPITAL SERVICES
SUBCHAPTER I--HOSPICE SERVICES
(1) Hospice is a twenty-four hour program coordinated by a hospice interdisciplinary team. The Hospice program allows the terminally ill client to choose physical, pastoral/spiritual, and psychosocial comfort rather than cure. Hospitalization is used only for acute symptom management.
(2) Hospice care may be in a client's temporary or permanent place of residence.
(3) 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.
(4) Hospice care is initiated by the choice of client, family, or physician. The client's physician must certify a client as appropriate for hospice care.
(5) Hospice care is ended by the client or family (revocation), the hospice agency (discharge), or death.
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The following definitions and those found in WAC 388-500-0005, Medical definitions have the following meanings for this subchapter. Defined words and phrases are bolded in the text.
"Biologicals" means medicinal preparations including serum, vaccine autotoxins, and biotechnological drugs made from living organisms and their products.
"Brief period" means five days or less.
"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.
"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, and others as necessary.
"Palliative" means medical treatment designed to reduce pain or increase comfort, rather than cure.
"Plan of care." See WAC 388-551-1320 for details.
"Residence" means where the client lives for an extended period of time.
"Revoke" and "revocation" mean a client or family member's 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.
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HOSPICE--COVERAGE(1) A client must be eligible for one of the following Medicaid programs to receive hospice care:
(a) Categorically needy program (CNP);
(b) General assistance -- disability determination pending (GAX);
(c) Limited casualty program - medically needy program (LCP -MNP); or
(d) Children's health (V).
(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.
(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.
(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.
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(1) In the client's individual plan of care, the hospice interdisciplinary team identifies the specific Hospice services and supplies to be provided to the client.
(2) The services must be all of the following:
(a) Medically necessary for palliative care;
(b) Related to the client's terminal illness;
(c) Prescribed by the client's attending physician, alternate physician, or hospice medical director;
(d) Supplied or arranged for by the hospice provider; and
(e) Included in the client's plan of care.
(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.
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HOSPICE--PROVIDER REQUIREMENTS(1) To be reimbursed by MAA, a hospice agency must be:
(a) Medicare, Title XVIII certified; and
(b) Enrolled with MAA as a provider of hospice care.
(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.
(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.
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A client chooses to receive Hospice care through a series of time-limited periods, called "election periods." An example of this process is WAC 388-551-1315. Hospice providers are responsible for obtaining physician certifications for these election periods.
(1) A client's hospice coverage must be available for two initial ninety-day election periods followed by an unlimited number of succeeding sixty-day election periods.
(2) The hospice provider must document the client's medical prognosis of a specific terminal illness in the client's hospice record. This written certification must be filed in the client's hospice record for each election period. The certification must meet all of the following criteria:
(a) For the initial election period, signatures of the hospice medical director and the client's attending physician;
(b) For subsequent election periods, signature of the hospice medical director; and
(c) Verbal certifications for subsequent election periods by the hospice medical director or the client's attending physician must be documented in writing no later than two calendar days after hospice care is initiated or renewed.
(3) The provider must file election statements in the client’s hospice medical record. This election statement must include:
(a) Name and address of the hospice;
(b) Proof that client was fully informed about hospice care and waiver of other services;
(c) Effective date of the election; and
(d) Signature of the client or their representative.
(4) When a client’s hospice coverage ends within an election period, the remainder of that election period is forfeited.
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This is an example of how election periods, as described in WAC 388-551-1310, work:
(1) Client chooses hospice care, physician certifies the client;
(2) Client is on hospice care for the first ninety-day period;
(3) Physician recertifies the client for the second ninety-day period;
(4) Client revokes hospice care, on the sixty-third day of the second ninety-day period (one hundred and fifty-three days since original certification);
(5) Hospice care for the client stops on the sixty-third day of the second ninety-day period (one hundred and fifty-three days since original certification);
(6) Client decides to re-elect hospice care, eleven days later, the seventy-fourth day of the second ninety-day period (the one hundred and sixty-fourth day since original certification);
(7) Client forfeits the right to the remaining sixteen days of the second ninety-day period; and
(8) Does the physician re-certify the client for hospice care?:
(a) If yes, the client may immediately begin a new sixty-day election period; or
(b) If no, the client no longer is eligible to receive hospice care.
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(1) The hospice agency must establish the client's hospice plan of care in accordance with Medicare requirements before hospice services are delivered. Hospice services delivered must be consistent with that plan of care.
(2) A registered nurse or physician must conduct an initial assessment of the client and must develop the plan of care with at least one other member of the hospice interdisciplinary team.
(3) The hospice interdisciplinary team must meet in person or by phone to discuss the plan of care no later than two working days after it is developed.
(4) The plan of care must be reviewed and updated every two weeks by at least three members of the hospice interdisciplinary team, including 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.
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(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.
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When a client chooses to leave hospice care or refuses hospice care without giving the hospice provider a revocation statement, as required by WAC 388-551-1360, the hospice provider must do all of the following:
(1) Notify MAA's hospice coordinator within five working days of becoming aware of the client's decision;
(2) Stop billing MAA for hospice payment;
(3) Notify the client, or the client's representative, that the client's discharge has been reported to MAA; and
(4) Document the effective date and details of the discharge in the client's hospice record.
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A hospice provider may discharge a client from hospice care when the client:
(1) Is no longer certified for hospice care;
(2) Is no longer appropriate for hospice care; or
(3) Seeks treatment for the terminal illness from outside the plan of care as defined by the hospice interdisciplinary team.
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(1) A client or a family member may choose to stop receiving 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;
(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) The hospice agency must keep the revocation statement in the client's hospice record.
(5) After a client revokes hospice care, the remaining days on the current election period are forfeited. The client may 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.
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HOSPICE--NOTIFICATIONTo avoid double payments for services related to a client's terminal illness, hospice providers must notify the MAA Hospice Coordinator of any changes in the client's hospice status within five working days from when a MAA client:
(1) Begins the first day of hospice care;
(2) Changes hospice agencies. Clients may change hospice agencies only once per election period. Both the old and new hospice agencies must provide MAA with:
(a) The effective date of discharge from the old agency; and
(b) The effective date of the admit to, the name of, and the provider number of the new agency;
(3) Revokes the hospice benefit;
(4) Discharges from hospice care;
(5) Becomes a nursing home resident;
(6) Leaves a nursing home as a resident; or
(7) Dies.
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Hospice providers must notify a client’s institutional provider of the changes described in WAC 388-551-1400.
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HOSPICE--PAYMENTAll services related to the client's terminal illness are included in the daily rate through one of the following four levels of hospice care:
(1) Routine care for each day the client is at their residence, with no restriction on length or frequency of visits, dependent on the client's needs.
(2) Continuous 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 is limited to:
(a) A minimum of eight hours of 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.
(3) Inpatient respite care is care received in an approved nursing facility or hospital to relieve the primary caregiver. This benefit is limited:
(a) To no more than five consecutive days; and
(b) The client's residence may not be a nursing facility.
(4) General inpatient hospice care is for pain and symptom management that cannot be provided in other settings.
(a) The services must conform to the client's written plan of care.
(b) This benefit is limited to brief periods of care in MAA-approved:
(i) Hospitals;
(ii) Nursing facilities; or
(iii) Hospice inpatient facilities.
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This section describes 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.
(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 |
(a) Medicaid hospice services; and
(b) Services that relate to the client's terminal illness at the time of the hospice admit.
(4) MAA does not pay hospice providers for the client’s last day, except for the day of death.
(5) Hospice providers must bill MAA for their services using hospice-specific revenue codes.
(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.
(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.
(8) MAA 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.
(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.
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(1) Hospitals which provide inpatient care to clients in the hospice program for medical conditions not related to their terminal illness may be paid according to chapter 388-550 WAC, Hospital services.
(2) MAA pays attending physicians who are not employed by the hospice agency at their 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 hospice provider, coordinate the health care provided.
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(1) MAA does not pay for any hospice care provided to a client covered by part A Medicare (hospital insurance).
(2) MAA may pay for hospice care provided to a client:
(a) Covered by part B Medicaid (medical insurance); and
(b) Not covered by part A Medicare.
(3) Hospice providers must bill Medicare before billing Medicaid, except for hospice nursing facility room and board.
(4) All the limitations and requirements related to hospice care described in this chapter apply to the payments described in this section.
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The following section of the Washington Administrative Code is repealed:
| WAC 388-86-047 | Hospice services. |