Cal. Code Regs. Tit. 22, § 51349 - Hospice Care

(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.

Notes

Cal. Code Regs. Tit. 22, § 51349

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.

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 -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).