For the first time, the U.S. Centers for Medicare and Medicaid Services (CMS) has approved a Medicaid state plan amendment (SPA) to establish palliative care services provided in non-hospital settings as a Medicaid covered service. By adding community palliative care as a preventive service in its Medicaid state plan, Hawaii is the first state to be able to comprehensively cover these palliative care services for its Medicaid beneficiaries.
The state has been working toward a community palliative care Medicaid benefit for many years, and NASHP has tracked and supported this work. We talked with Judy Mohr Peterson, Med-QUEST administrator (Medicaid director) in Hawaii to learn about the newly approved SPA and its significance.
What is community palliative care, and why did Hawaii create a community palliative care Medicaid benefit?
“We created a community palliative care benefit because we wanted individuals with serious illness to have access to the valuable services and team-based approach available under the hospice benefit without the requirement for a certain prognosis or having to forgo any curative treatment options,” Mohr Peterson said.
Approved on May 7, 2024, the SPA adds “Community Palliative Care” to the list of services in the “Preventive Services” benefit covered by Medicaid in Hawaii. Because Hawaii Medicaid (Med-QUEST) added palliative care services in non-hospital settings as a preventive service, the community palliative care services can now be offered to anyone who qualifies for services.
Palliative care, including its purpose and use, is clearly defined in the SPA under “Preventive Services”: “Palliative care is defined as patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and other needs and to facilitate patient autonomy, access to information, and choice in accordance with the Preventative Services benefit. Services furnished to the beneficiary’s family or other collaterals are for the direct benefit of the beneficiary.”
Services under “Community Palliative Care” include, but are not limited to:
- Plan development and implementation that is aligned with patient and family goals
- Clinical services provided through an interdisciplinary team
- Comprehensive management
- Care coordination and communication
Specific services are provided based on medical necessity, and specific conditions and clinical criteria are determined by Hawaii.
Who will provide community palliative care to Medicaid beneficiaries, and how will they be paid?
“Our health care system can be fragmented and challenging, especially for individuals and families facing serious illness. Palliative care helps bring in a team approach, with a diverse range of professionals, to support the mental and physical health of those with serious illness,” Mohr Peterson said.
The SPA specifies the required and optional members of a palliative care interdisciplinary team for both adult and pediatric care teams. A physician, registered nurse, licensed clinical social worker, and grief counselor are required team members for adult care, with the addition of a child life specialist for pediatric care. Seven other professionals are listed as optional team members.
As outlined in the SPA, community palliative care services are paid for through a bundled payment reimbursement methodology called the “Community Palliative Care Service Bundle.” The bundled rate(s) and billing codes are in the Hawaii Medicaid Fee Schedule.
What does the SPA’s approval mean for Hawaii?
“Providing palliative care as a preventive service can help in preventing worse outcomes such as hospitalizations, increased emergency room use, or progression of mental health issues,” Mohr Peterson said.
The SPA is significant for Med-QUEST because the state does not need to go back to CMS to request renewals for community palliative care, as the services are now embedded in its state plan. Hawaii will now look to implementation. In consultation and collaboration with palliative care providers and others in the palliative care community, Med-QUEST will soon release a memo with additional details on billing, reimbursement, and other implementation considerations.
Mohr Peterson credits Hawaii’s success to the dedicated work of a large team, including Med-QUEST’s Joy Soares and the program and policy team, community members and groups, national experts, CMS, and the generous support of the Stupski Foundation.
What does Hawaii’s new palliative care coverage mean for other states?
“We are leading the way, not only for our state but for the country’s Medicaid programs, to improve the continuum of care for individuals suffering from serious illness,” Mohr Peterson said.
With Hawaii as a model, there is a clearer pathway for states to work with CMS on similar ways to cover palliative care services in their Medicaid programs. While no two state Medicaid programs are the same, Hawaii’s SPA approval and implementation of community palliative care can provide insights for other states.
Learn More
NASHP is hosting a webinar on Hawaii’s Community Palliative Care SPA on August 5, 2024, from 3:30 to 4:30 p.m. ET. Register here to attend and hear from the leaders in Hawaii who championed this work. Subscribe to NASHP’s palliative care newsletter for this announcement and to stay in the loop on Hawaii’s progress and developments in other states. Visit NASHP’s Palliative Care Resource Center to learn more about state work to expand awareness of and access to palliative care.
Acknowledgments
This work is made possible by a generous grant from The John A. Hartford Foundation.
