Concurrent Care For Children Who Are Enrolled In Hospice Nancy Hite Occupational Nurse Consultant Clinical Quality Care and Transformation

What is Concurrent/Curative Care? Unless otherwise specified within this billing guide, concurrent/curative treatment, related services, or related medications requested for clients age 20 and younger are subject to the Medicaid agency’s specific program rules governing those services or medications. A client age 20 and younger may voluntarily elect hospice care without waiving any rights to services that the client is entitled to under Title XIX Medicaid and Title XXI Children’s Health Insurance Program (CHIP) that are related to the treatment of the client’s condition for which a diagnosis of terminal Illness has been made.

What is covered: All medical services that would be normally covered under the child’s benefit package Medications (except for those that are the hospice agencies responsibility) All IV Fluids Blood transfusions Chemotherapy Radiation Surgery Physical Therapies Speech Therapy In Patient Stays Out Patient Procedures Other medical equipment & supplies

What is not covered under Concurrent Care The following services are to be provided by the hospice agency in accordance with current guidelines, while the client is receiving concurrent care: Services related to symptoms management: Medications for pain, nausea & vomiting Equipment & related supplies when used for the care & comfort when related to symptom management. Ancillary services such as medical transportation. Hospice covered services are described in WAC 182-551-1210

Life Prolonging and Curative Treatment Providers billing for services rendered to children 20 years old or younger receiving treatments under the concurrent care waiver, must use the expedited Prior authorization (EPA) #870001409 on their claim in order to prevent a delay in payment. If treatment, related services, or related medications appear to not covered by the Medicaid agency and exception to rule is not required for children 20 years and younger due to EPSDT Review the clients benefit package for services that require a PA, such as certain radiology procedures and scans.

Adult Palliative Care Proposal & Models Nancy Hite Occupational Nurse Consultant Clinical Quality Care and Transformation

Health Care Authority (HCA) was asked to cover   Health Care Authority (HCA) was asked to cover Palliative Care for Adults. HCA began researching the possibility of covering Adult Palliative Care. What other state Medicaid programs cover How their program was built Their provider types Services

The Department of Health (DOH) reached out to the HCA to discuss how a program like this could help our client’s in rural areas of WA State. DOH also assisted HCA in connecting with three Palliative care providers in the state who were working with DOH. These included palliative care providers at Jefferson Hospital, Yakima Memorial Hospital and the Hospice in Tri-Cities.   We appreciate the time these providers spent educating us about palliative care and the models under which they are delivering these services.

What we learned from providers: Services being delivered in the Palliative Care model are currently offered and reimbursed under Medicaid. Providers who render them are considered “eligible” providers in Medicaid. So it wasn’t necessary to try to create a new program that provided a new set of services. More importantly, those services are covered in the WA State Plan Amendment (SPA).

The State Plan Amendment (SPA) is the contract between the CMS (Federal Government) and the Health Care Authority (HCA). Under this contract, the federal government approves the services HCA provides to Medicaid covered clients and commits to paying federal funds to support those services. Getting CMS’s approval to implement this benefit is going well and there are just a few more details to work through with CMS. See this website for additional information regarding the SPA: https://www.hca.wa.gov/about-hca/apple-health-medicaid/what-state- plan.

  While these Palliative Care Services are covered as individual services under Medicaid, HCA is formalizing this as a program through Washington Administrative Code or what we refer to as the WAC. We are currently working on an addition to the WAC specifically for an Adult Palliative Program. And of course, there will be instructions on how to bill for the care coordination. Billing will be detailed in the provider guide.

Proposed addition of Adult Palliative Care as a (targeted care coordination) team Services: Skilled Nursing MSW PT OT ST Behavioral Health Pharmacy Under the direction of a MD, DO, ND or ARNP. All these services are currently available, when ordered by the client’s provider. Provider qualification: Licensed healthcare professionals trained to complete palliative care consultations or assessments.

Issue: Addition of Adult Palliative Care as a (targeted care coordination) team continued Payment for services: Providers must be enrolled Medicaid providers with a signed Core Provider agreement with HCA. Palliative Care settings: inpatient, outpatient, community based settings including but not limited to hospitals, long term care facilities, clinics, and other types of community based providers that have the staff with experience and training in Palliative Care. Palliative Care are for those with chronic life limiting conditions. The client do not need to have a life expectancy of 6 months or less. Increased quality of care will reduce ER visits & in-patient admissions

Qualified Billing Providers Home Health Agencies Hospice Agencies FQHC’S RHC’S OP Hospital Facilities SNF’S Physician office or clinics

Qualified Servicing Providers Physicians ARNP’s Medical Social Worker Pharmacists Physical Therapists Occupational Therapists Speech Therapists Respiratory therapists Behavioral Health Specialist

Examples of Adult Palliative Care Models Home Health Hospice Hospital Based Clinic/Office Model Out-patient Hospital Physician office FQHC (Public Health Clinic) Rural Health Care Clinic In any given community, there may be a different model.

How will these services be billed? Now I have a question for you: Is anyone currently billing for these services? If so, how are you billing for this service? Are you using revenue codes?

Comments, Recommendations & Questions? Nancy Hite Occupational Nurse Consultant Clinical Quality Care & Transformation nancy.hite@hca.wa.gov Tel: 360-725-1611