Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a)
Hospice care, as defined in Section
51180 is covered to the extent
specified in this section.
(b) Of
the four levels of care described in subsection (j), only general inpatient
care is subject to prior authorization. Authorization for general inpatient
care shall be granted only when all applicable requirements, as set forth in
the Criteria for Authorization of Hospice Care section of the Department's
Manual of Criteria for Medi-Cal Authorization, are met.
(c) Services shall be limited to individuals
who have been certified as terminally ill in accordance with the procedures
specified in Title 42, Code of Federal Regulations, Part 418, Subpart B, and
who directly or through their representative voluntarily elect to receive such
benefits in lieu of other care as specified.
(d) An individual who elects to receive
hospice care, or that individual's representative as defined in Section
51180.7 must file an election
statement with the hospice providing the care. The election statement shall
include:
(1) Identification of the
hospice.
(2) The individual's or
representative's acknowledgement that:
(A)
Hospice care provided to adults shall be palliative rather than curative in
nature, or
(B) Hospice care
provided to a child, under the age of 21, may be palliative and curative at the
discretion of the treating physician.
(C) For adults, certain Medi-Cal benefits as
specified in subsection (f) are waived by the election.
(3) The effective date of the
election.
(4) The signature of the
individual or representative.
(e) Elections, as specified under subsection
(d), may be made for up to two periods of 90 days each and for an unlimited
number of subsequent periods of 60 days each.
(1) Payment shall be made for hospice care on
behalf of an individual who voluntarily elects such care only during the two
periods of 90 days each and during the unlimited number of subsequent periods
of 60 days each during the individual's lifetime.
(2) An election period shall be considered to
continue through the initial election period and through subsequent election
periods as long as the hospice provider agrees to renew the election and as
long as the individual:
(A) Remains in the
care of the hospice; and
(B) Does
not revoke the election.
(3) An individual's voluntary election may be
revoked or modified at any time. To revoke the election of hospice care, the
individual or representative must file a statement with the hospice that
includes the following information:
(A) A
signed statement that the individual or representative revokes the individual
election for Medi-Cal coverage for the remainder of the election
period.
(B) The effective date,
which may not be earlier than the date the revocation is
made.
(4) Revocation
shall constitute a waiver of the right to hospice care during the remainder of
the current 90 or subsequent 60-day election periods.
(5) An individual may at any time after
revocation execute a new election for any remaining entitled election
period.
(6) An individual may once
in each election period elect to receive services through a hospice program
different than the hospice with which the election was made. Such change shall
not be considered a revocation pursuant to subparagraph (A). Such change shall
be made in accordance with the procedure specified in 42 Code of Federal
Regulations, Part 418, Subpart B.
(f) An individual who voluntarily elects
hospice care under subsection (c) shall waive the right to payment on his or
her behalf for all Medi-Cal services related to the terminal condition for
which hospice care was elected, except for:
(1) Services provided by the designated
hospice.
(2) Services provided by
another hospice through arrangement made by the designated hospice.
(3) Services provided by the individual's
attending physician if that physician is not employed by the designated hospice
or receiving compensation from the hospice for those
services.
(g) A plan of
care shall be established by the hospice for each individual before services
are provided. Services must be consistent with the plan of care. The plan of
care shall conform to the standards specified in 42 Code of Federal
Regulations, Part 418, Subpart C.
(h) The following services, when reasonable
and necessary for the palliation or management of a terminal illness and
related conditions are covered when provided by qualified personnel:
(1) Nursing services when provided by or
under the supervision of a registered nurse.
(2) Physician services when provided by any
Medi-Cal enrolled physician except that the services of the hospice medical
director or the physician member of the interdisciplinary group, as required
under 42 Code of Federal Regulations, Part 418, Subpart C shall be performed by
a doctor of medicine or osteopathy.
(3) Medical social services when provided by
a social worker with at least a Bachelor's degree in social work, from a school
approved or accredited by the council on Social Work Education, under the
direction of a physician.
(4)
Counseling services when provided to the terminally ill individual and the
family member or other persons caring for the individual at home. Counseling
shall, as appropriate, be provided for the purpose of training the individual's
family or other care giver to provide care and to help the individual and those
caring for him or her to adjust to the individual's approaching death and to
cope with feelings of grief and loss.
(5) Short-term inpatient care when provided
in a hospice inpatient unit or in a hospital or a skilled nursing
facility/Level B, that meets the standards specified in 42 Code of Federal
Regulations, Part 418, Subpart E regarding staffing and patient
areas.
(6) Drugs and Biologicals
when used primarily for the relief of pain and symptom control related to the
individual's terminal illness.
(7)
Medical supplies and appliances.
(8) Home health aide services and homemaker
services when provided under the general supervision of a registered nurse.
Services may include personal care services and such household services as may
be necessary to maintain a safe and sanitary environment in the areas of the
home used by the patient.
(9)
Physical therapy, occupational therapy and speech-language pathology when
provided for the purpose of symptom control, or to enable the patient to
maintain activities of daily living and basic functional
skills.
(i) Bereavement
counseling as necessary shall be made available to the patient's immediate
family or significant other for up to one year after death, however bereavement
counseling is not reimbursable through the Medi-Cal program.
(j) Reimbursement for covered services, with
the exception of physician services, shall be made at one of the four levels
specified below and in Section
51544. Coinsurance on behalf of
Medicare eligible beneficiaries and room and board for residents of skilled
nursing/Level B or intermediate care facilities/Level A shall be paid to the
hospice as specified in Section
51544.
(1) Routine home care shall be covered for
each day the recipient is at home and is not receiving continuous
care.
(2) Continuous home care
shall be covered only during periods of crisis when skilled nursing care is
necessary on a continuous basis to achieve palliation or management of the
patient's pain or symptoms in order to maintain the recipient in his/her
residence. Continuous care may include homemaker and/or home health aide
services but must be predominantly nursing in nature.
(3) Respite care shall be covered only when
provided in an inpatient facility, on an occasional, intermittent and
nonroutine basis and only when necessary to relieve family members or other
persons caring for the terminally ill individual.
(4) General inpatient care shall be covered
only when the patient requires and receives general inpatient care in an
inpatient facility for pain control or chronic symptom management which cannot
be managed in the patient's residence.
1. New
section filed 10-27-87 as an emergency; operative 10-27-87 (Register 87, No.
44). A Certificate of Compliance must be transmitted to OAL within 120 days or
emergency will be repealed on 2-24-88.
2. Certificate of Compliance
transmitted to OAL 2-24-88 and filed 3-22-88 (Register 88, No.
15).
3. Amendment of section and NOTE filed 3-27-2000 as an
emergency; operative 3-30-2000 (Register
2000,
No. 13). A Certificate of Compliance must be transmitted to OAL by 7-28-2000 or
emergency language will be repealed by operation of law on the following
day.
4. Certificate of Compliance as to 3-27-2000 order transmitted
to OAL 7-17-2000 and filed 8-28-2000 (Register 2000, No. 35).
5.
Amendment of subsections (d) and (d)(2)(A), new subsection (d)(2)(B),
subsection relettering, amendment of newly designated subsection (d)(2)(C) and
subsections (e), (e)(1) and (e)(4) and amendment of NOTE filed 1-5-2016;
operative 4-1-2016 (Register 2016, No. 2).
Note: Authority cited: Section
20, Health and Safety Code; and
Sections
10725,
14105
and
14124.5,
Welfare and Institutions Code. Reference: Sections
14053,
14132,
14132.74
and
14133.85,
Welfare and Institutions Code;
42 U.S.C. Sections
1395d(a)(4),
1395d(d)(1),
1396d(o) and
1397jj(a)(23);
and 42 CFR Section
418.21.
