26-594 Medi‑Cal Hospice Prior Authorization Update for Hospice Providers
Date: 05/01/26
Outpatient hospice services will require prior authorization starting July 9, 2026
Effective July 9, 2026, prior authorization requirements will be implemented for outpatient hospice services in accordance with Assembly Bill (AB) 116 (2025). This update affects how outpatient hospice services are administered under Health Net Medi‑Cal managed care, on behalf of Community Health Plan of Imperial Valley.
What is changing on July 9, 2026
Under existing law, Medi-Cal managed care plans are restricted from applying prior authorization to outpatient hospice services.
Effective July 9, 2026, this restriction will no longer apply, and Medi‑Cal managed care plans may implement utilization controls, including prior authorization, for hospice services consistent with Medicare hospice requirements.
What hospice providers need to know and do
- Effective July 9, 2026, the Plan will require prior authorization for outpatient hospice services, as permitted by law.
- Hospice services will continue to be covered when all hospice eligibility, certification, and documentation requirements are met.
- Hospice providers must submit a prior authorization request with the required documentation to support medical necessity.
What is not changing
- Hospice services will remain a covered Medi‑Cal benefit.
- Hospice eligibility criteria are not changing.
- Certification and documentation requirements remain the same, including:
- A Certificate of Terminal Illness (CTI), completed from written certification statements from the hospice medical director and, if applicable, the attending physician confirming a terminal illness with a life expectancy of six months or less.
- If written certification cannot be obtained within two calendar days after a benefit period begins, a verbal certification must be obtained within two calendar days and the written certification secured before claim submission, consistent with 42 CFR § 418.22.
- A Medi-Cal Hospice Program Election Notice signed by both the member (or authorized representative) and hospice provider.
- An individualized written care plan outlining the hospice services the patient will receive.
- Transfer summaries, discharge summaries and/or prior revocation of hospice elections forms, as applicable.
- A Certificate of Terminal Illness (CTI), completed from written certification statements from the hospice medical director and, if applicable, the attending physician confirming a terminal illness with a life expectancy of six months or less.
For purposes of this notice, ‘outpatient hospice services’ refers to routine home care, continuous home care and respite care provided outside an inpatient hospice setting; inpatient hospice services remain subject to prior authorization as under current policy.
Need help? Contact us
If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral health providers can call 844-966-0298.
This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Imperial County.