Title of Rule:	Pediatric Hospice Waiver, Section 8.504	
Rule Number:	MSB 07-08-20-B	
Division / Contact / Phone:	Long Term Benefits / Barbara Prehmus / 303-866-2991	

SECRETARY OF STATE
RULES ACTION SUMMARY AND FILING INSTRUCTIONS

SUMMARY OF ACTION ON RULE(S)

1.	Department / Agency Name:	Health Care Policy and Financing / Medical Services Board	
2.	Title of Rule:	MSB 07-08-20-B, Pediatric Hospice Waiver, Section 8.504	
3.	This action is an adoption of:	new rules	
4.	Rule sections affected in this action (if existing rule, also give Code of Regulations number and page numbers affected): 	
Sections(s) 8.504, Colorado Department of Health Care Policy and Financing, Staff Manual Volume 8, Medical Assistance (10 CCR 2505-10).	
5.	Does this action involve any temporary or emergency rule(s)?	No	
If yes, state effective date:		
Is rule to be made permanent? (If yes, please attach notice of hearing).	Yes	

PUBLICATION INSTRUCTIONS*

Please insert new text (§8.504 [HOME AND COMMUNITY BASED SERVICES PEDIATRIC HOSPICE WAIVER] through §8.504.8.A.2) provided immediately after existing text at §8.503.210 [POST ELIGIBILITY TREATMENT OF INCOME (PETI)] and just preceding §8.506 (CHILDREN'S HOME AND COMMUNITY BASED SERVICES WAIVER PROGRAM).  This change is effective 12/30/2007.

Title of Rule:	Pediatric Hospice Waiver, Section 8.504	
Rule Number:	MSB 07-08-20-B	
Division / Contact / Phone:	Long Term Benefits / Barbara Prehmus / 303-866-2991	

STATEMENT OF BASIS AND PURPOSE

1.	Summary of the basis and purpose for the rule or rule change.  (State what the rule says or does and explain why the rule or rule change is necessary).	
This is a new rule to implement a Home and Community Based Services (HCBS) pediatric hospice waiver program approved by the federal Centers for Medicare and Medicaid Services (CMS) under the authority of Section 1915(c) of the Social Security Act.  The rule defines the population eligible for enrollment, the benefits to be provided, and the provider qualifications for the waiver program..	
2.	An emergency rule-making is imperatively necessary	
	to comply with state or federal regulation and/or	
	for the preservation of public health, safety and welfare.	
Explain:	
     	
3.	Federal authority for the Rule, if any:	
An approved Home and Commuity Based Services (HCBS) Waiver CMS Control Number 0450. 	
4.	State Authority for the Rule:	
25.5-1-301 through 25.5-1-303, C.R.S. (2006);
25.5-5-305, C.R.S. (2006)	

Title of Rule:	Pediatric Hospice Waiver, Section 8.504	
Rule Number:	MSB 07-08-20-B	
Division / Contact / Phone:	Long Term Benefits / Barbara Prehmus / 303-866-2991	

REGULATORY ANALYSIS

1.	Describe the classes of persons who will be affected by the proposed rule, including classes that will bear the costs of the proposed rule and classes that will benefit from the proposed rule.
The classes of persons directly benefiting from the program that will be implemented in accordance with the proposed rule are Medicaid-eligible children aged 0 through 18 who have a life-limiting diagnosis.  Parents and/or legal guardians of such children will also benefit indirectly from the additional services allowable under this new waiver program.
2.	To the extent practicable, describe the probable quantitative and qualitative impact of the proposed rule, economic or otherwise, upon affected classes of persons.
The qualitative impact of the proposed rule will be enhanced quality of life for enrolled children diagnosed with a life-limited, or terminal, illness for the time the child has remaining.  Legislative fiscal analysis for the authorizing legislation (Senate Bill 04-206) showed cost savings of an estimated $10,283 per year per child, associated with receiving home-based care as an alternative to institutional inpatient hospital care.
3.	Discuss the probable costs to the Department and to any other agency of the implementation and enforcement of the proposed rule and any anticipated effect on state revenues.
The following information dates back to when the original fiscal note was completed for this legislative proposal (2004).  The department has not completed a revised fiscal analysis however the department plans to complete a revised analysis during the regular budget process. 
The legislative fiscal analysis estimated $75 in prior authorization requests for each qualifying child and an additional $225,000 in Medicaid Management Information System (MMIS) costs for the Department of Health Care Policy and Financing.  However, implementation of the waiver program itself is estimated to save $10,283 per year per child.  Based upon full waiver capacity of 200 children, the savings to cost ratio is $8.57 in cost avoidance for each $1 of investment.
4.	Compare the probable costs and benefits of the proposed rule to the probable costs and benefits of inaction.
Inaction would result in violation of state statute, unnecessary additional reduction in quality of life for the eligible children and their families, and higher Medicaid expenditures in institutional inpatient hospital settings.
5.	Determine whether there are less costly methods or less intrusive methods for achieving the purpose of the proposed rule.
No other method was considered
6.	Describe any alternative methods for achieving the purpose for the proposed rule that were seriously considered by the Department and the reasons why they were rejected in favor of the proposed rule.
No alternative method to achieve the implementation of this new Medicaid waiver program was considered.

8.504	HOME AND COMMUNITY BASED SERVICES PEDIATRIC HOSPICE WAIVER
8.504.1	DEFINITIONS
Assessment means a comprehensive face-to-face evaluation using the ULTC 100.2 conducted by the case manager with the client, family and appropriate collaterals, with supporting diagnostic information from the individual’s medical professional(s), to determine the applicant’s level of functioning, service needs, available resources, and potential funding sources.
Case Management means the Assessment of the client’s needs, the development and implementation of the Service Plan, coordination and monitoring of service delivery, the evaluation of service effectiveness and periodic reassessment of the client’s needs.
Client/Family/Caregiver Counseling means grief/loss or anticipatory grief counseling and bereavement counseling that assist the client, family or caregiver to decrease emotional suffering due to the client’s health status, to decrease feelings of isolation or to cope with the client’s life-limiting diagnosis.
Continued Stay Review (CSR) means a reassessment by the Single Entry Point case manager to determine the client’s continued eligibility and functional level of care.
Continuous Nursing means line of sight, face-to-face skilled nursing that is more individualized and continuous, as opposed to visits or intermittent nursing care that is available under the State Plan home health benefit or is routinely provided in a hospital or nursing facility as described at 10 CCR 25050-10 Section 8.540.
Cost Containment means the determination that, on an average aggregate basis, the cost of providing care in the community is less than or the same as the cost of providing care in a hospital.

Curative Care means medical care or active treatment of a medical condition seeking to affect a cure.
Expressive Therapy means creative art, music or play therapy which provides children the ability to creatively and kinesthetically express their medical situation for the purpose of allowing the client to express feelings of isolation, to improve communication skills, to decrease emotional suffering due to health status, and to develop coping skills.
Intake/Screening/Referral means the SEP’s initial contact with the individual and shall include, but not be limited to, a determination of the need for a comprehensive client Assessment, referral to other waivers or services and long term care services.
Life Limiting Illness means a medical condition that, in the opinion of the medical specialist involved, has a prognosis of death that is highly probably before the child reaches adulthood.
Palliative/Supportive Care means hospice-like care provided to manage, control, and alleviate symptoms such as pain, nausea, discomfort and anxiety related to a life-limiting diagnosis that may be provided at the same time as curative treatments.
Personal Care means services needed to meet a client’s physical requirements and functional needs when such services are provided by a personal care attendant and do not require the supervision of a nurse or physician, such as assistance with activities of daily living.
Private Duty Nursing means continuous nursing different in nature and scope from the private duty nursing services in the State Plan, and does not include a requirement for the client to be technology-dependent.
Respite Care means services provided to an eligible client who is unable to care for himself/herself on a short term basis because of the absence or the need for relief of those persons normally providing care.  Respite Care is provided in the client’s residence and may be provided by different levels of providers depending upon the needs of the client.  
Service Plan means the document used to identify the client’s needs and sets forth the services to be provided to the client including the funding source, amount, scope, duration, frequency, provider of each services, and the expected outcome or purpose of such services.
Uniform Long Term Care 100.2 Form (ULTC 100.2) means the tool used to assess the functional needs of an applicant.
Utilization Review means approving or denying admission or continued stay in the waiver based on level of care needs, clinical necessity, amount and scope, appropriateness, efficacy or efficiency of health care services, procedures or settings.
8.504.2	BENEFITS
8.504.2.A.	Home and Community Based Services under the Pediatric Hospice Waiver (HCBS-PHW) benefits shall be provided within Cost Containment.
8.504.2.B.	Benefits shall be available to eligible clients from the date of diagnosis of a life-limiting illness or condition.
8.504.2.C.	Client/Family/Caregiver Counseling shall be provided in individual or group setting.
1.	Client/Family/Caregiver Counseling shall only be a benefit if it is not available under Medicaid EPSDT coverage, Medicaid State Plan benefits, third party liability coverage or by other means.
2.	Client/Family/Caregiver Counseling shall be limited to 98 hours per every 365 days based on the date the client entered the program.
3.	Family/Caregiver Counseling shall be available to family members for bereavement counseling for up to one year following the death of the client.
8.504.2.D.	Expressive therapy includes, but is not limited to, book writing, painting, music therapy and scrapbook making.  
1.	Expressive therapy is limited to 39 hours per every 365 days based on the date the client entered the program.
8.504.2.E.	Respite Care shall be provided in the home of an eligible client on a short term basis, not to exceed 30 days per every 365 days based on the date the client entered the program.  Respite Care shall not be duplicated on the same date of service as state plan Home Health or Palliative/Supportive Care services.  
1.	Respite Care services include any of the following in any combination necessary according to the Service Plan.
a.	Skilled nursing.
b.	Home health aide
c.	Personal Care
d.	Private duty nursing
8.504.2.F  Palliative/Supportive Care shall not require a six month terminal prognosis for the client.	
	1.  Palliative/Supportive Care includes, but is not limited to:
a.	Skilled nursing
b.	Home health aide
c.	Physical therapy
d.	Occupational therapy
e.	Speech/language pathology
f.	Alternative therapies
g.	Dietary/nutritional counseling or therapy

8.504.2.G.	HCBS-PHW clients are eligible for all other Medicaid state plan benefits, including Curative Care and Home Health. 
8.504.3	NON-BENEFIT
8.504.3.A.	Case Management shall not be a benefit of the HCBS-PHW but shall be provided as an administrative activity through the SEP.
8.504.4	CLIENT ELIGIBILITY
8.504.4.A.	An eligible client shall:
1.	Be determined financially eligible.
2.	Be at risk of institutionalization into a hospital as determined by the SEP case manager using the ULTC 100.2 and physician’s statement.
3.	Meet the target population criteria as follows:
a.	Have a life-limiting diagnosis, as certified in writing by a physician,. 
b.	Have not yet reached 19 years.
4.	A client shall receive at least one HCBS-PHW waiver benefit per month to maintain enrollment in the waiver.  
5.	A client who has not received at least one HCBS-PHW waiver benefit during a month shall be discontinued from the waiver.
6.	Case Management shall not satisfy the requirement to receive at least one benefit per month on the HCBS-PHW waiver.
8.504.5	WAIT LIST
8.504.5.A.	The number of clients who may be served through the waiver at any one time during a year shall be limited to 200.
8.504.5.B.	Applicants who are determined eligible for benefits under the HCBS-PHW waiver, who cannot be served within the 200 client limit, shall be eligible for placement on a wait list maintained by the Department.
8.504.5.C.	The SEP case manager shall ensure the applicant meets all criteria as set forth in Section 8.504.4 prior to notifying the Department to place the applicant on the wait list.
8.504.5.D.	The SEP case manager shall notify the Department by entering the ULTC 100.2 Form and Professional Medical Information Page data in the Benefits Utilization System (BUS).
8.504.5.E.	The date and time of notification from the SEP case manager shall be used to establish the order of an applicant’s place on the wait list.
8.504.5.F.	Within five working days of notification from the Department that an opening for the HCBS-PHW waiver is available the SEP shall:
	1.	Reassess the applicant for functional level of care using the ULTC 100.2 Form if the date of the last Assessment is more than six months old.
	2.	Update the existing ULTC 100.2 Form data if the date is less than six months old.
	3.	Reassess for the target population criteria.
	4.	Notify the Department of the applicant’s eligibility status.
8.504.6	PROVIDER ELIGIBILITY
8.504.6.A.	Providers shall conform to all federal and state established standards for the specific service they provide under the HCBS-PHW waiver and enter into an agreement with the Department as set forth in 10 CCR 2505-10, Section 8.130.
8.504.6.B.	Licensure and required certification for providers shall be in accordance with their specific specialty practice act and with current state licensure status and regulations.
8.504.6.C.	Expressive Therapy or Client/Family/Caregiver Counseling Providers shall enroll individually with the fiscal agent or be employed by a qualified Medicaid home health or hospice agency.
8.504.6.D.	Client/Family/Caregiver Counseling Providers shall be one of the  following:
1.	Licensed Clinical Social Worker (LCSW) 
2.	Licensed Professional Counselor (LPC)
3.	Licensed Social Worker (LSW) 
4.	Licensed Independent Social Worker (LISW)
5.	Licensed Psychologist; or
6.	Non-denominational Spiritual Counselor, if employed by a qualified Medicaid home health or hospice agency.
8.504.6.E.	Expressive therapy providers shall meet any of the requirements for Client/Family/Caregiver Counseling providers and shall have at least one year of experience in the provision of Art, Music or Play therapy to pediatric/adolescent clients.
8.504.6.F.	Nurses, home health aides, personal care providers, physical therapists, occupational therapists, and speech/language pathologists shall:
1.	be employed by a qualified Medicaid personal care, home health or hospice provider agency pursuant to the rules for those provider types; and
2.	shall meet the required license or certification standards in accordance with their specific specialty practice act and current state licensure status and regulations.
8.504.6.G.	Palliative/Supportive Care Providers shall be employed by or working under a formal affiliation agreement with a qualified Medicaid hospice agency.
8.504.6.H.	Respite Providers shall be employed by a qualified Medicaid home health, hospice or personal care agency.
8.504.7	PRIOR AUTHORIZATION REQUESTS
8.504.7.A.	The SEP shall complete and submit a PAR form within one calendar month of determination of eligibility for the HCBS-PHW waiver.
8.504.7.B.	All units of service requested shall be listed on the Service Plan form.
8.504.7.C.	The first date for which services can be authorized shall be the later of any of the following:
	1.	The financial eligibility start date, as determined by the financial eligibility site.
	2.	The assigned start date on the certification page of the ULTC 100.2 Form.
	3.	The date, on which the client’s parent(s) and/or legal guardian signs the Service Plan form or Intake form, as prescribed by the Department, agreeing to receive services.
8.504.7.D.	The PAR shall not cover a period of time longer than the certification period assigned on the certification page of the UTLC 100.2 Form.
8.504.7.E.	The SEP shall submit a revised PAR if a change in the Service Plan results in a change in services.
8.504.7.F.	The revised Service Plan shall list the service being changed and state the reason for the change.  Services on the Revised Service Plan, plus all services on the original Service Plan, shall be entered on the revised PAR.
8.504.7.G.	Revisions to the Service Plan requested by providers after the end date on a PAR shall be disapproved.
8.504.7.H.	A revised PAR shall not be submitted if services on the Service Plan are decreased, unless the services are being eliminated or reduced in order to add other services while maintaining cost-effectiveness.
8.504.7.I.	If services are decreased without the client’s parent(s) and/or legal guardian agreement, the SEP case manager shall notify the client’s parent(s) and/or legal guardian of the adverse action and appeal rights using the LTC 803 form in accordance with the 10 day advance notice period.
8.504.8	REIMBURSEMENT
8.504.8.A.	Providers shall be reimbursed at the lower of:
	1.	Submitted charges; or
	2.	A fee scheduled as determined by the Department.