DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
Center for Medicaid, CHIP and Survey & Certification 
 
SMD # 10-018 
ACA # 8 
 
 
September 9, 2010 
 
Re:  Hospice Care for Children in Medicaid and CHIP 
 
Dear State Health Official: 
Dear State Medicaid Director: 
 
This letter is one of a series intended to provide guidance on the implementation of the 
Affordable Care Act (Pub. L. No. 111-148 as amended by the Health Care and Education 
Reconciliation Act of 2010 (Pub. L. No. 111-152)), together known as the Affordable Care Act. 
 
Specifically, this letter provides guidance to States on the implementation of section 2302 of the 
Affordable Care Act, entitled Concurrent Care for Children.  Section 2302 of the law amends 
sections 1905(o)(1) and 2110(a)(23) of the Social Security Act to remove the prohibition of 
receiving curative treatment upon the election of the hospice benefit by or on behalf of a 
Medicaid or Childrens Health Insurance Program (CHIP) eligible child. 
 
Hospice services are covered under the Medicaid and CHIP programs as an optional benefit. 
However, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provision 
requires Medicaid and CHIP programs operating as Medicaid expansions to provide all 
medically necessary services, including hospice services, to individuals under age 21.  In order to 
qualify for the hospice service in either Medicaid or CHIP, a physician must certify that the 
eligible person is within the last 6 months of life. 
 
The Affordable Care Act does not change the criteria for receiving hospice services; however, 
prior to enactment of the new law, curative treatment of the terminal illness ceased upon election 
of the hospice benefit.  This new provision requires States to make hospice services available to 
children eligible for Medicaid and children eligible for Medicaid-expansion CHIP programs 
without forgoing any other service to which the child is entitled under Medicaid  for treatment of 
the terminal condition. These services and supports may include pain and symptom management 
and family counseling provided by specially-trained hospice staff.   States with stand-alone CHIP 
programs continue to have the option to provide hospice services, but if they cover hospice 
services they must comply with the new requirements under the Affordable Care Act. 
 
We believe implementation of this new provision is vitally important for children and their 
families seeking a blended package of curative and palliative services.  This provision will 
increase utilization of hospice services since parents and children will no longer be required to 
forego curative treatment. 
 
 
 
   
Page 2  State Health Official/State Medicaid Director 
 
This provision was effective upon enactment of the Affordable Care Act on March 23, 2010  
Therefore, under Medicaid, including CHIP programs operating as Medicaid expansions, we 
expect States will continue the provision of medically necessary curative services, even after 
election of the hospice benefit by or on behalf of children receiving services.  States operating 
stand-alone CHIP programs that offer the optional hospice benefit must now provide it 
concurrently with medically necessary curative services. 
 
Implementation 
 
Medicaid 
 
The Centers for Medicare & Medicaid Services (CMS) is revising the Medicaid State plan 
hospice preprint page of Attachment 3.1-A and 3.1-B to reflect this new feature of the hospice 
benefit.  Once approved, CMS will release the new preprint page for States use.  States will 
need to submit the revised preprint page to indicate that hospice is provided to children 
concurrently with curative treatment.  States are not required to submit any needed revisions to 
their State plan coverage language until the preprint page is made available but are expected, in 
the interim, to be providing these services consistent with the requirements described in this 
guidance. 
 
CHIP 
 
As noted above, the Medicaid guidance also applies to CHIP programs operating as a Medicaid 
expansion. States with separate CHIP programs that currently cover hospice services do not need 
to submit a State Plan amendment (SPA) to modify this definition, but States are expected to 
implement these services in compliance with the Affordable Care Act. We are, however, happy 
to work with States that are interested in submitting SPAs to explicitly modify the definition of 
hospice services. States with separate CHIP programs that do not currently cover hospice 
services and would like to extend this benefit to children do need to submit a SPA indicating this 
intention and confirming that hospice services will be offered concurrently with curative 
treatment. 
 
We are ready to work with States to provide assistance in implementing this new requirement, 
and we look forward to our continuing collaboration.  If you have any questions, please contact 
Ms. Barbara Edwards, Director of the Disabled and Elderly Health Programs Group, at 
410-786-7089, or at Barbara.Edwards@cms.hhs.gov.  If you have any questions on 
implementing this provision in the CHIP program, please contact Ms. Victoria Wachino, 
Director of the Family and Childrens Health Programs Group, at 410-786-9535, or at 
Victoria.Wachino@cms.hhs.gov. 
 
Sincerely, 
 
/s/ 
 
Cindy Mann 
Director 
 
 
cc:  CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Children's Health 
 
Richard Fenton 
Acting Director 
Health Services Division 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Carol Steckel 
President 
National Association of Medicaid Directors 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Christine Evans, M.P.H. 
Director, Government Relations  
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy