Effective January 1, 2025, Community Palliative Care Services is a state Medicaid benefit that provides specialized medical care to eligible QUEST members living with a serious illness. This benefit replaces HMSA’s Supportive Care program benefit which was discontinued on June 30, 2025. Community Palliative Care aims to address the holistic needs of the member and their family or caregiver(s), with a focus on relieving pain and symptoms associated with serious illness. A serious illness is defined as a health condition that carries a high risk of mortality and negatively impacts daily functioning, or quality of life, or excessively strains caregivers.
HMSA contracts with community providers with HMSA’s QUEST plan who have received approval from HMSA to provide palliative care services. Services are delivered by the interdisciplinary team (IDT), which consist of a specialty trained team of physicians, nurses, social workers, and others that work together with the member’s other providers to assess member and family needs, coordinate care and provide an added layer of support.
To be eligible for Community Palliative Care, HMSA members require a diagnosis of a qualifying health condition and evidence of ongoing functional decline. HMSA members who are receiving hospice care or enrolled in the State of Hawai‘i Organ and Tissue Transplant (SHOTT) program are ineligible for this benefit. Services under this benefit can be delivered in any non-hospital setting. For policy criteria and a list of qualifying conditions, please refer to HMSA’s Palliative Care medical policy. Precertification is not required.
Service Provider Requirements
Providers are responsible for determining community palliative care eligibility and obtaining documented member consent prior to delivering services. Providers will also be required to complete the Community Palliative Care Provider Attestation Form before being approved to provide services. Every five years, providers that have been approved to deliver community palliative care services shall renew their approval by resubmitting an updated attestation form.
Additional Service Provider Requirements:
- Shall have at least one physician that delivers direct clinical care and program oversight;
- Shall have at least one employed, full-time prescribing clinician;
- Shall have at least one prescribing clinician with a specialty certification in hospice or palliative care;
- Shall have a training plan in place that includes the services required under the benefit;
- Shall have the following required members as part of the interdisciplinary team (IDT) who are registered with Hawaii’s Online Kahu Utility (HOKU) as a Medicaid provider:
- Physician (Medical Doctor, MD and Doctor of Osteopathy, DO)
- Registered Nurse (RN)
- Licensed Clinical Social Worker (LCSW)
- Grief Counselor
- Child Life Specialist (CLS)
Claim Coding Guidelines
Claims must be billed with the appropriate revenue, HCPCS, and applicable modifier codes to be eligible for reimbursement.
|
REV CODE (UB04 only) |
HCPCS CODE (UB04 or CMS1500) |
MODIFIER CODE | DIAGNOSIS | |
|---|---|---|---|---|
| Initial Assessment | 0693 | S0280 – Medical home program, comprehensive care coordination and planning, initial plan | Z51.51 – Encounter for Palliative Care | |
| Reassessment | 0693 | S0281 – Medical home program, comprehensive care coordination and planning, ongoing maintenance | Z51.51 – Encounter for Palliative Care | |
| Palliative Care Services | 0690 | S0311 – Comprehensive management and care coordination for advanced illness, per calendar month |
HB2 (for dual eligible members) HC2(for non-dual eligible members) |
1Must be documented on the claim but shall not be the primary diagnosis for the member.
2Claims with missing or invalid modifier codes will be denied.
Community Palliative Care Forms
The following forms were created by Med-QUEST and are designed to aid in the eligibility screening, assessment and administration of this benefit. All forms can be accessed via the appendices of Med-QUEST Memo QI-2430A/CCS-2410A/FFS 24-12A [PDF].
- Community Palliative Care Provider Attestation Form (Appendix H)
- Comprehensive Community Palliative Care Action Plan Supplement (Appendix D)
- Comprehensive Community Palliative Care Assessment Supplement (Appendix D)
- Palliative Care Program Eligibility Screening Tool (Appendix E)
Requirements for Community Palliative Care were provided through Memo QI-2430A/CCS-2410A/FFS 24-12A.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|