For additional information, see below.

Health Net follows state of California regulations on certification that states a member whose prognosis indicates a life expectancy of six months or less is considered terminally ill. The physician certification must contain the qualifying clause, "the individual's prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course." Neither Health Net nor its delegated participating physician groups (PPGs) may deny hospice care to a Medi-Cal member certified as terminally ill. Each certification period needs to be authorized and consists of two 90-day periods followed by an unlimited number of 60-day periods. The hospice provider is required to obtain written certification of terminal illness for each hospice benefit period.

Hospice care options for children do not fit the traditional adult hospice model. Effective January 1, 2019, pediatric palliative care is authorized and managed by the health plan through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. This applies to members who meet the eligibility criteria.

Policy guidelines and directions for authorization of medically necessary services (PDF) related to a CCS life-limiting condition for children who have elected hospice is available on the DHCS website.

Health Net and its delegated participating physician groups (PPGs) work with CCS to help with continuity of medical care. This includes keeping the current relationship between patient and provider. If elected, hospice care for children with terminal diseases requires working closely with Health Net, the PPG, the local CCS program, and other caregivers. Hospice counseling, including grief, bereavement and spiritual services, may be needed during this transition.

A member under age 21 may be eligible for palliative care and hospice services concurrently with curative care under the Patient Protection and Affordable Care Act (ACA) Section 2302 as detailed in CMS Letter #10-018. Information regarding the concurrent care policy is available in Policy Letter (PL) 11-004, titled "The Implementation of Section 2302 of the Affordable Care Act, titled "Concurrent Care for Children"; APL 13-014; and the appropriate California Children's Services (CCS) Numbered Letter (NL), including any future iterations of these letters.

Palliative care CCS NL 16-1218 (PDF) provides additional palliative care information on the DHCS website.

Note: Palliative care services may be authorized by CCS if they are part of a plan of care of a CCS special care center (SCC). CCS is financially responsible for the palliative care services and not the medical plan.

Upon the Medi-Cal member's election of hospice care services, Health Net and its delegated participating physician groups (PPGs) must ensure provision of, and payment for, hospice care services (listed below) provided by a hospice provider.

Hospice care services include, but are not limited to, the following:

Physician services include general supervisory services of the hospice medical director and participation in establishing the member's plan of care, supervision of care and services, periodic review and updating plan of care, and establishing governing policies by the physician of the hospice interdisciplinary team. Other physician services not related to hospice services are covered separately.

Interdisciplinary hospice services, may be provided to patients with serious illnesses, as determined by the physician and surgeon in charge of their care, and patients who continue to receive curative treatment from other licensed health care professionals.

Due to the highly specialized services provided by hospice providers, federal law mandates the hospice provider designate an interdisciplinary group to plan, provide and supervise the care and services offered by the hospice provider. A written plan of care must be established by the attending physician, the medical director or designated physician, and the interdisciplinary hospice group prior to providing care. The plan of care is then reviewed and updated as specified in the plan of care by the attending physician, medical director or designated physician and interdisciplinary hospice group.

Health Net and its delegated PPG or primary care physician (PCP) coordinate the care between Health Net, the member's PPG and hospice care providers, and allow for the interdisciplinary hospice group to manage the Medi-Cal member's care.

Each hospice agency designs its own election statement, which should include the following:

The member is required to elect hospice care and the attending physician is required to establish a plan of care before services are provided.

The following information applies to participating physician groups (PPGs) and ancillary providers only.

Hospice physicians or hospice nurse practitioners (NPs) must have a face-to-face encounter with every hospice patient to determine continued hospice eligibility. To satisfy this requirement, the following criteria must be met:

In cases where a hospice newly admits a patient in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period (as described in criteria 1). For example, if the patient is an emergency admission on a weekend, it may be impossible for a hospice physician or NP to see the patient until the following Monday, or the hospice may be unaware that the member is in the third benefit period. In such documented cases, a face-to-face encounter within two days after admission is considered timely. If the patient dies within two days of admission without a face-to-face encounter, a face-to-face encounter can be deemed as completed.

The hospice must retain the certification statements and have them available for Health Net's audit purposes.

California Code of Regulations (CCR), Title 22, Section 51349 describes four levels of hospice care, which are routine home care, continuous home care, respite care, and inpatient care. Only general inpatient care (HCPCS code Z7106¹) is subject to prior authorization (PDF). Providers must submit the following to request prior authorization:

Health Net does not require prior authorization for:

Hospice providers must notify the Health Net Hospital Notification Department and the member's participating physician group (PPG) or primary care physician (PCP) on the next business day when a member is admitted for inpatient care after normal business hours.

For more information on hospice care rates, refer to the Department of Health Care Services (DHCS) website at www.dhcs.ca.gov/services/medi-cal/Pages/Hospice.aspx.

Hospice services are covered and are not categorized as long-term care (LTC) services regardless of the member's expected or actual length of stay in a nursing facility (NF) while also receiving hospice care. Section 1905(o)(1)(A) of the Social Security Act (SSA) allows for the provision of hospice care while an individual is a resident of a skilled nursing facility (SNF) or intermediate care facility (ICF).

Health Net and its PPGs should not require authorization for room and board as described in Code of  Federal Regulations (CFR), Title 42, Section 418.112 and Section 1902(a)(13)(B) of the SSA.

In accordance with the Centers for Medicare and Medicaid Services (CMS), the hospice provider reimburses the NF for the room and board at the rate negotiated between the hospice and SNF. Payment for the room and board component must be equal to at least 95 percent of the reimbursement the NF/SNF would have been reimbursed by fee-for-service (FFS) Medi-Cal or Health Net less the member's share of cost, if applicable. Payments by a hospice provider to a nursing home for room and board are not to exceed what would have been received directly from FFS Medi-Cal or Health Net if the member had not been enrolled in a hospice. ¹ HCPCS codes were taken from the Centers for Medicare and Medicaid Services (CMS) HCPCS website.

Members that elect hospice may revoke or modify their decision at any time during an election period. To revoke the election of hospice care, the member or the member's authorized representative must file a signed statement with the hospice revoking the individual election for the remainder of the election period. The effective date may not be retroactive. At any time after revocation, the member may execute a new election, which starts the 90-day/90-day/unlimited 60-day certification periods of care. A member or their representative may change the designation of a hospice provider once per benefit period. The member's change from one designated hospice to another is not considered a revocation of the hospice election.

If a Medi-Cal member wishes to elect a hospice provider that is not contracting with Health Net or the delegated participating physician group (PPG), the PPG must consider each member's case individually. The PPG has the option to immediately initiate a contract (one-time or ongoing) with the chosen hospice provider or refer the patient to a participating hospice for hospice care. In some cases, members receiving hospice at the time they become Health Net Medi-Cal members may not be able to change their hospice provider due to limitations on the number of times the member can change a hospice provider during an election period. Health Net or the PPG may also determine that such a change is disruptive to the member's care or is not in their best interest. PPGs must consider a one-time or ongoing contract with the established hospice provider until the new benefit period, or until the end of hospice services.

Hospice care services may be initiated or continued in a home or clinical setting. Health Net and its delegated PPGs remain responsible for the provision of, and payment for, all fee-for-service (FFS) Medi-Cal-covered services not related to the terminal illness, including those of the member's primary care physician (PCP).

A period of crisis is time during which the member requires continuous primary nursing care to achieve palliation or to manage acute medical symptoms. Nursing care may be covered for up to 24 hours a day during periods of crisis if necessary to allow the member to remain at home. Care during such a period must be predominantly nursing care.

Health Net emphasizes the importance of timely recognition of a member's eligibility for hospice care services and their election of these services.

Once a member has elected hospice care services, participating providers and case management staff work closely with hospice providers to facilitate the transfer of member services from those directed towards cure and/or prolongation of life to those directed towards palliation. Ongoing care coordination ensures that services necessary to diagnose, treat and follow-up on conditions not related to the terminal illness continue or are initiated as necessary (Code of Federal Regulations (CFR), Title 42, CFR, Section 438.208).

Neither Health Net nor delegated participating physician groups (PPGs) may restrict access to hospice care services (Code of Federal Regulations (CFR), Title 42, Section 438.210(a)). The Medi-Cal fee-for-service (FFS) program does not require prior authorization of hospice services except for inpatient admissions; therefore, Health Net and PPGs only require prior authorization for inpatient admission.