ModifiedHawaii Department of Human ServicesPolicy N/A

Community Palliative Care Benefit Implementation

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Establishes a new Medicaid community palliative care benefit for non-hospital settings for QUEST Integration beneficiaries in Hawaii, describing purpose, implementation, clinical criteria, services, settings, and operational expectations for health plans and providers.

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ModifiedHawaii Department of Human ServicesPolicy N/A

Community Palliative Care Benefit Implementation

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Policy Summary

PayerHawaii Department of Human Services

PolicyCommunity Palliative Care Benefit Implementation

Policy CodePolicy N/A

Change TypeNew benefit implementation

Effective DateDec 31, 2024

Next Review DateN/A

Key ActionObtain prior approval before beginning the four-week timeline to complete the comprehensive interdisciplinary assessment.

SourceLink

POLICY UPDATE CHANGES

A new community palliative care benefit for non-hospital settings is being implemented for QUEST Integration beneficiaries.

Jan 1, 2025implementation start date

Jun 30, 2025transition deadline

24/7/365access standard

Monthly bundlepayment model

6 moreassessment interval

Coverage Criteria for Community Palliative Care

Provider Enrollment / Staffing / Operations

Providers seeking to offer community palliative care services must supply the following information and attest to requirements:

Provider Enrollment and Contact: Billing provider name, selected provider type, NPI, tax ID, Medicaid provider number, full contact information and office manager contact must be provided.

Information is required on the provider information enrollment form (Part A: Section 1).

Credentialing Information: State licensure, board certifications, and DEA numbers for the billing organization must be supplied.

Credentialing details are requested on the provider enrollment form (Part A: Section 2).

Service Location and Access: Describe service locations, whether services are provided in members' residences (including houseless members), hours of operation, and languages offered. Providers must describe how members will access symptom management services, including 24/7/365 access when applicable.

Section 3 and Section 5 of the provider form request service information and availability; providers should describe access mechanisms for symptom management and participation in care coordination with QI health plans.

Staffing Requirements: Provide staffing information including at least one physician delivering direct clinical care and providing program oversight (staff or contracted), and at least one employed full-time prescribing clinician (physician, APRN, or PA). At least one prescribing clinician on the interdisciplinary team should have specialty certification in hospice/palliative care or a related specialty when applicable, and a training plan covering required services is expected.

Staffing and training plan details are requested in Section 4 and the Interdisciplinary Team roster; provider must attest to these requirements.

Interdisciplinary Team Operations: Describe interdisciplinary team meeting frequency (requested at least bi-weekly) and provide participant contact information; commit to participating in care coordination meetings with QI health plans.

Section 5 asks whether services are available and how the team coordinates care; providers are asked to provide details on meeting frequency and coordination.

Initial eligibility and assessment

Covered when ALL of the following are met

Eligibility and enrollment assessment: Member must be assessed for eligibility prior to utilizing palliative care services; documentation must demonstrate the member meets eligibility criteria and has consented to receiving palliative care.assessment documented; consent recorded

Assessing provider must submit documentation for authorization by the billing provider for the bundled payment; verbal consent is acceptable if documented.

Assessment coding and frequency: Initial assessment must be billed using S0280 (CMS-1500) or revenue/HCPCS combination 0693 + S0280 (UB-04) with diagnosis code Z51.5 to specify a palliative care encounter.one initial assessment per member per provider per episode

An episode of care means continuous longitudinal utilization of the Palliative Care Services Benefit without member discharge or disenrollment.

Bundled payment coverage

Covered when ALL of the following are met

Monthly bundled payment coverage: All services delivered by the interdisciplinary palliative care team following the initial assessment are reimbursed via the monthly bundled payment (S0311 on CMS-1500 or 0690 + S0311 on UB-04). Providers must not bill separately for services included in the bundled payment during months the member is enrolled.one bundled payment per member per calendar month

Reimbursement duplication is prohibited; providers may track visits by provider or team while a member is enrolled. EVV is not required for services within the bundle.

Billing limitations and exceptions: Services unrelated to palliative care or outside the bundled payment scope (e.g., certain behavioral health, annual wellness visits, or Medicare-covered home health services for duals) may be billed separately when not included in Appendices D and E.N/A

Dual-eligible members may have certain services billed in addition to the bundled payment; MQD may develop tiered or partial-month bundled rates in the future.

Reassessment and care plan updates

Covered when ALL of the following are met

Reassessment requirement: Member must be reassessed at least every six (6) months or when the member's goals of care change; reassessments should result in a revised care plan based on assessment outcomes.reassessment every 6 months

Use S0281 (CMS-1500) or 0693 + S0281 (UB-04) with diagnosis code Z51.5 for reassessments; reassessments cannot be reimbursed more than once per month.

Continuity and discharge planning: Reassessments are expected to support continued utilization for members who continue to qualify and consent, or to trigger discharge and transition to higher-level care or other benefits (for example, hospice) when appropriate.N/A

Community palliative care providers must ensure continuity across care transitions and may continue limited billing to support timely transition back to the community when frequency criteria for minimum services are met.

Members who become eligible for and accept hospice or transplant services must be discharged from the community palliative care benefit and transitioned to the appropriate benefit or program. MCOs are required to document the reason for discharge as part of the member's record. The community palliative care monthly bundled payment does not apply while a member is enrolled in hospice or receiving transplant services; transition and discharge documentation must reflect this change in benefit.

The monthly bundled payment for community palliative care excludes durable medical equipment (DME), supplies, prescription medications, and personal assistance services. These items may be provided separately if approved by the member's health plan; health plans are expected to expedite prior authorization requests for such items (for example, home oxygen, hospital beds, comfort medications, or DME that aids ambulation/ADLs). Clinicians may continue to bill fee-for-service for services that are explicitly not included in the bundle, and certain non-palliative services (e.g., behavioral health by licensed clinical social workers, annual wellness visits) may also be billed outside the bundle in accordance with applicable code sets and plan rules.

Providers must complete the required provider attestation accurately. The attestation explicitly warns that false or misleading information on the form may result in termination of the provider's ability to deliver community palliative care services; providers should ensure submissions are complete and truthful before signing.

When a member is enrolled in the community palliative care benefit, services included in the monthly bundled payment (S0311) must not be billed separately. Separate billing for services that are factored into the bundled rate is prohibited because it would duplicate reimbursement. Providers are encouraged to track visits and services performed while a member is enrolled to ensure billing outside the bundle is limited to services explicitly excluded from the bundle or otherwise permitted by the health plan.

Coding, Billing & Payment Model

Assessment, Reassessment, and Bundled Payment Codesmixed

S0280	Medical home program, comprehensive care coordination and planning, initial plan
S0281	Medical home program, comprehensive care coordination and planning, ongoing maintenance
S0311	Comprehensive management and care coordination for advanced illness, per calendar month
Z51.5	Palliative Care Encounter (ICD-10 diagnosis code)
0693	Revenue category used on UB-04 for Pre-hospice/Palliative Care Services (associated with S0280/S0281)
0690	Revenue category used on UB-04 for Pre-hospice/Palliative Care Services (associated with S0311)

Appendix D - CPT Codes (Medicaid-only)CPTCovered

98966	Telephone assessment and management service by qualified nonphysician; 5-10 minutes
98967	Telephone assessment and management service by qualified nonphysician; 11-20 minutes
98968	Telephone assessment and management service by qualified nonphysician; 21-30 minutes
99201	Office/outpatient E/M for new patient; typically 10 minutes
99202	Office/outpatient E/M for new patient; typically 20 minutes
99203	Office/outpatient E/M for new patient; typically 30 minutes
99204	Office/outpatient E/M for new patient; typically 45 minutes
99205	Office/outpatient E/M for new patient; typically 60 minutes
99211	Office/outpatient E/M for established patient; typically 5 minutes
99212	Office/outpatient E/M for established patient; typically 10 minutes

1–10 of 13

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Appendix D - Home/Domiciliary and Prolonged Service CodesCPTCovered

99324	Domiciliary/rest home visit E/M for new patient; typically 20 minutes
99325	Domiciliary/rest home visit E/M for new patient; typically 30 minutes
99326	Domiciliary/rest home visit E/M for new patient; typically 45 minutes
99327	Domiciliary/rest home visit E/M for new patient; typically 60 minutes
99334	Domiciliary/rest home visit E/M for new patient; typically 75 minutes
99335	Domiciliary/rest home visit E/M for established patient; typically 15 minutes
99336	Domiciliary/rest home visit E/M for established patient; typically 25 minutes
99337	Home visit E/M for new patient; typically 20 minutes
99341	Home visit E/M for new patient; typically 30 minutes
99342	Home visit E/M for new patient; typically 30 minutes

1–10 of 19

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Appendix D - Telephone, CCM, TCM, Advance Care Planning, and Hospice Service CodesmixedCovered

99441	Telephone E/M; 5-10 minutes of medical discussion
99442	Telephone E/M; 11-20 minutes of medical discussion
99443	Telephone E/M; 21-30 minutes of medical discussion
99490	Chronic care management services; at least 20 minutes of clinical staff time per calendar month
99495	Transitional care management; moderate complexity; face-to-face within 14 days of discharge
99496	Transitional care management; high complexity; face-to-face within 7 days of discharge
99497	Advance care planning; first 30 minutes
99498	Advance care planning; each additional 30 minutes
G0155	Services of clinical social worker in home health or hospice settings, each 15 minutes
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes

1–10 of 11

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Appendix D - HCPCS/Q and S CodesHCPCSCovered

Q5001	Hospice or home health care provided in patient's home/residence
Q5002	Hospice or home health care provided in assisted living facility
Q5003	Hospice care provided in nursing long-term care facility
Q5004	Hospice care provided in skilled nursing facility
Q5007	Hospice care provided in long-term care facility
Q5009	Hospice or home health care provided in place not otherwise specified
Q5010	Hospice home care provided in a hospice facility
S9122	Home health aide or certified nurse assistant providing care in the home; per hour
S9123	Nursing care in the home; by registered nurse, per hour
S9124	Nursing care in the home; by licensed practical nurse, per hour

Appendix E - CPT Codes (Dual Eligible)CPTCovered

98966	Telephone assessment and management service by qualified nonphysician; 5-10 minutes
98967	Telephone assessment and management service by qualified nonphysician; 11-20 minutes
98968	Telephone assessment and management service by qualified nonphysician; 21-30 minutes
99201	Office/outpatient E/M for new patient; typically 10 minutes
99213	Office/outpatient E/M for established patient; typically 15 minutes
99214	Office/outpatient E/M for established patient; typically 25 minutes
99215	Office/outpatient E/M for established patient; typically 40 minutes

Appendix E - Home Visit, Telephone, TCM, CCM, and Advance Care Planning Codes (Dual Eligible)mixedCovered

99324	Domiciliary/rest home visit E/M for new patient; typically 20 minutes
99325	Domiciliary/rest home visit E/M for new patient; typically 30 minutes
99326	Domiciliary/rest home visit E/M for new patient; typically 45 minutes
99327	Domiciliary/rest home visit E/M for new patient; typically 60 minutes
99334	Domiciliary/rest home visit E/M for new patient; typically 75 minutes
99337	Home visit/prolonged home visit minutes as listed
99341	Home visit E/M for new patient; typically 30 minutes
99342	Home visit E/M for new patient; typically 30 minutes
99343	Home visit E/M for new patient; typically 45 minutes
99344	Home visit E/M for new patient; typically 60 minutes

1–10 of 24

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Reassessment interval

Minimum reassessment frequencyEvery 6 months; reassessments must be completed every six (6) months or when member goals of care change

Reimbursement limit for reassessmentsRe-assessments cannot be reimbursed more than one time per month

Required reassessment code and diagnosisUse S0281 for reassessment and diagnosis code Z51.5 (Palliative Care Encounter) to specify palliative care reassessment

Bundled payment frequency

Bundled payment frequencyOne monthly bundled payment per member: S0311 billed per calendar month; providers cannot be reimbursed more than one time per month

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Prior approval required before 4‑week assessment timeline

Prior approval from the member's health plan is required before the four-week timeline to complete the comprehensive interdisciplinary assessment begins; the assessment must be completed within four (4) weeks of receiving prior approval. Services provided must be consistent with any prior approvals/authorizations.

Assessment timeline (complete within 4 weeks) starts only after health plan prior approval.
Health plans monitor that required standards of care are met to receive the bundled payment.

Prior Authorization

Prior authorization may be required for the monthly bundled payment

Health plans may require prior authorization for the monthly bundled payment (S0311) and are permitted to incorporate utilization controls such as preauthorization per the QI contract; plans shall only prior authorize one provider at a time to deliver palliative care services for a member.

Monthly bundled payment (S0311) may be subject to plan-level prior authorization and utilization controls.

Background and Purpose

Palliative care is specialized, patient- and family-centered care for people with serious illness that focuses on relief of symptoms, management of distress, and improvement of quality of life. It is appropriate at any age and stage of illness and can be provided alongside curative treatment. The community palliative care benefit was developed to fill identified gaps in palliative services for members in home and community settings who do not meet hospice criteria, by offering interdisciplinary team-based management, care coordination, and support for members and caregivers.

Clinical eligibility for the benefit requires a diagnosis of a qualifying health condition and evidence of ongoing functional decline; members who no longer meet eligibility or who accept hospice or transplant services are expected to be discharged from the palliative care benefit and transitioned to the appropriate program, with MCOs documenting the reason for discharge.

Key Definitions

Palliative care; Serious illness

Palliative care definitionSpecialized medical, patient- and family-centered care focused on relief of symptoms and stress of serious illness, appropriate at any age and stage and can be provided alongside curative treatment

Serious illness definitionA health condition that carries a high risk of mortality and negatively impacts daily functioning, quality of life, or excessively strains caregivers

Team-based deliveryProvided by a specialty-trained team of physicians, nurses, social workers, and others working with the member's other providers

Comfort care

Comfort care definitionA patient care plan focused on symptom control, pain relief, and quality of life; considered medical necessity

Typical context

Policy Summary

PayerHawaii Department of Human Services

PolicyCommunity Palliative Care Benefit Implementation

Policy CodePolicy N/A

Change TypeNew benefit implementation

Effective DateDec 31, 2024

Next Review DateN/A

Key ActionObtain prior approval before beginning the four-week timeline to complete the comprehensive interdisciplinary assessment.

SourceLink

On This Page

Billing guidanceS0311 used on CMS-1500; 0690 with HCPCS S0311 used on UB-04 for bundled monthly payment

Prohibition on duplicate billingWhile enrolled in the benefit, providers must not bill separately for services included in the bundled payment; separate billing that duplicates the bundle is not permitted

Chronic care management monthly time

CCM monthly time requirement>= 20 minutes of clinical staff time per calendar month required for Chronic Care Management (CPT 99490)

Relevant code99490: Chronic care management services; at least 20 minutes of clinical staff time per calendar month

Inclusion99490 is listed in Appendices D and E as included in the bundle code sets for palliative services

Transitional care management follow-up timing

TCM face-to-face timing requirements99495: face-to-face within 14 calendar days of discharge; 99496: face-to-face within 7 calendar days of discharge

Relevant codes99495 (moderate complexity TCM) and 99496 (high complexity TCM)

Appendix listingTransitional care management codes 99495 and 99496 are listed in Appendices D and E as included code categories

Only one provider may be prior authorized at a time for palliative care services for any member.

Assessment documentation may serve as justification for prior authorization.

Billing Rule

CPT/HCPCS codes included in the bundled payment (Appendices D & E)

Appendices D and E list the CPT/HCPCS procedure codes that are included as part of the bundled payment rate for palliative care services for Medicaid-only and dual-eligible members; these code lists define services that are part of the bundle and should not be billed separately during months the member is enrolled.

See Appendix D (Medicaid-only) and Appendix E (Dual-eligible) for included CPT/HCPCS codes.
Do not separately bill services that are included in the bundled monthly payment during enrollment.

Step Therapy

Discharge required when member accepts hospice or transplant

Members who are eligible for and accept hospice or transplant services must be discharged from the community palliative care benefit and transitioned to the appropriate benefit or program; MCOs must document the reason for discharge.

Discharge is required when a member accepts hospice or transplant services.
MCOs must document reason for discharge as part of services.

Documentation Required

MCOs must document discharges and monitor required services

Managed care organizations and health plans must document reasons for member discharge from the palliative care benefit and monitor that required standards and services are provided; monitoring supports eligibility for the bundled payment.

Health plans are required to monitor palliative care services to ensure all required services are provided in order to receive the bundled payment.
MCOs must document reasons for discharge from the palliative care benefit.

Documentation Required

Assessing providers must document eligibility and consent

Assessing providers must document that the member meets eligibility criteria for the benefit and that the member has consented to receiving palliative care services; consent may be verbal if documented. Assessment documentation can be used to support prior authorization requests.

Documentation must demonstrate member meets eligibility criteria and has consented to services.
Verbal consent is acceptable if recorded in documentation.
Assessment documentation may justify prior authorization by the billing provider.

Documentation Required

Provide billing and contact information for enrollment

Providers must supply required provider documentation including billing provider name, provider type, NPI, tax ID, Medicaid provider number, full contact information, and office manager/primary contact details as part of enrollment/operational information.

Provide billing provider name, provider type selection, NPI, Tax ID, and Medicaid provider number.
Provide full contact information (address, phone, fax, email) and office manager/primary contact name and contact details.

Documentation Required

Document transition and reason for discharge when member exits benefit

When members are no longer eligible or appropriate for palliative care they must be discharged from the benefit and transitioned; MCOs must document the transition and the reason for discharge.

Discharge and transition must be documented when eligibility ends or member accepts another benefit (e.g., hospice, transplant).
Documentation of reason for discharge is required by MCOs.

Prior Authorization

Only one provider may hold prior authorization for palliative services at a time

Only one provider may be prior authorized at a time to deliver palliative care services for a member; providers and referring clinicians should consult the member's health plan about referral and prior authorization pathways.

Plans shall only prior authorize one provider at a time for palliative care services for any member.
Referring providers should consult the member's health plan on referral and PA processes.

Denial Risk

Attestation accuracy risk: false or misleading information may lead to termination

The provider attestation must be accurate and complete; false or misleading information on the attestation may result in termination of the provider's ability to provide community palliative care services.

Complete and accurate attestation is required on the provider attestation form.
False or misleading attestation may lead to termination of provider ability to offer community palliative care services.

Note

Appendices D & E: Code tables (source rendered)

Interdisciplinary team and appendix content as provided in the source: Appendix D and Appendix E list CPT/HCPCS codes included as part of the bundled payment rate for Medicaid-only and dual-eligible members (see source appendices for full tables).

Appendix D: CPT codes included for Medicaid-only members.
Appendix E: CPT codes included for dual-eligible members.

Note

Provider attestation text (source rendered)

Provider attestation form text as provided in the source: The attestation states that the signer attests information is accurate and complete to the best of their knowledge and that false or misleading information may result in termination of ability to provide community palliative care services.

Bill Provider Organization Name, Billing Provider Name, Billing Provider Title, Signature, Date are required on the attestation.

Often administered to patients hospitalized several times where further medical treatment is unlikely to alter prognosis

Symptoms addressedPain, breathing problems, skin irritation, digestive problems, temperature sensitivity, fatigue, and other illness-related issues

Interdisciplinary Team — composition and requirements

Required core membersAt least one physician delivering direct clinical care and program oversight (staff or contracted) and at least one employed full-time prescribing clinician (physician, APRN, or PA)

CertificationsAt least one prescribing clinician on the interdisciplinary team should have specialty certification in hospice/palliative care or a related specialty, if applicable; providers must describe certification and certifying entity

Team documentation fieldsProvider roster fields must indicate specialty, whether member is a prescribing clinician, and certification in palliative care or related specialty

Operational expectationsTeams are expected to hold interdisciplinary team meetings (e.g., bi-weekly) and provide staffing/training plan information to health plans