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25-940 Updated Hospice Care Guidelines for Medi-Cal Providers

Date: 09/04/25

Key policy changes and documentation requirements from DHCS

On May 5, 2025, the California Department of Health Care Services (DHCS) issued All Plan Letter (APL) 25-008, updating  hospice guidance for Medi-Cal Managed Care Plans. This replaces APL 13-014 and aims to ensure timely, appropriate, and coordinated care for members with terminal illnesses.

Health Net, on behalf of CalViva Health, limits coverage to in-network providers, unless medically necessary services are not available in-network.

Finding an in-network hospice provider

  • Effective September 4, 2025, out-of-network (OON) coverage will not be available to members who are newly entering hospice care.
  • To find available in-network hospice providers in the service area, use the ProviderSearch tool at Health Net webpage under the Members tab, select “Find a Provider/ProviderSearch.” Select "Hospice" as the provider type.

When no in-network hospice provider is available

  • If an in-network hospice provider is unavailable, providers may request a Single Case Agreement (SCA). The request must include the initial assessment and all required documentation.
  • For Plan members currently receiving care from OON providers, the Plan will conduct a clinical review and reach out to the member directly.
  • If a transfer to an in-network hospice agency is deemed necessary, our Utilization Management team will work with the OON provider to ensure a smooth transition of care.

Submission instructions

  • Outpatient hospice services: Submit documentation via encrypted email. Prior authorization is not required.
  • Inpatient hospice services : Prior authorization is required. Follow standard procedures outlined in the Medi-Cal Provider Operations Manual >  Requesting Prior Authorization or Coordinating a PCP Referral, at Prior Authorizations. Attach all  required documentation to your request.

Required documentation

To ensure timely and accurate hospice care authorization and reimbursement, providers must submit the following documentation as part of the care coordination and compliance process:

Requirement

Guidelines

  • Certification of terminal illness (CTI)

Submit CTI, face-to-face encounter, and Medi-Cal Hospice Program Election Notice (PDF), within five calendar days of certification and election of hospice care.

 

Effective September 4, 2025, if the election form is not submitted within five calendar days, services will not be covered from the admission date to the date the completed form is received.

  • Face-to-face encounter documentation (if greater than 3 benefit periods)
  • Medi-Cal Hospice Program Election Notice
  • Initial care plan

Required for inpatient care only

  • Prior authorization
  • Written prescription
  • Request for Single Case Agreement

Only allowed when medically necessary services are unavailable in-network.

  • Revocation of hospice election

Required when applicable

  • Transfer summary

 

Hospice provider responsibilities

Hospice providers must:

  • Be contracted with the Plan or request an SCA when needed.
  • Hold all required certifications and licenses per APL-25-008.
  • Start hospice services promptly and submit election forms within five calendar days.
  • Notify the Plan of after-hours admissions by the next business day.
  • Conduct face-to-face visits starting with the third benefit period.
  • Coordinate pediatric care with the Plan and California Children’s Services.
  • Submit timely and accurate documentation.

Additional resources and information

For more on documentation and submission, see update 25-811, in the Provider Library > Select line of business > Provider Updates and Notices > Search for update numbers.

Relevant sections of provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on the provider portal.

Providers are encouraged to access the provider portal  for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at
888-893-1569.
 

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Enhanced Care Management (ECM) Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.



Last Updated: 09/04/2025