All Medi-Cal managed care plans are required to coordinate the care and placement of beneficiaries who need long term care services.  Plans in non-COHS counties are responsible for all medically necessary long term care services provided from the time of admission into a long term care facility and up to one month after the month of admission.  For beneficiaries requiring a longer LTC stay, plans must submit a disenrollment request to DHCS to be effective the first day of the second month after admission.  Non-COHS plans are required to coordinate transfer to the Medi-Cal Fee for Service program and notify the beneficiary of the change.  The request cannot be submitted before a beneficiary is placed into long term care, and plans are still responsible for coordinating care, including coordinating placement in the LTC facility.

Plans in COHS counties are required to covered all medically necessary LTC services regardless of length of stay in the facility.  LTC is a contractual obligation for these plans.

People who become Medi-Cal eligible while in long term care are not eligible for plan enrollment.

DHCS APL 17-017 (October 27, 2017)

Under Welfare and Institutions Code section 14132.75, the Medi-Cal program covers palliative care for non-dual eligible beneficiaries.  Palliative care is defined as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.  The services available for palliative care can be similar to those available under hospice care, which is intended for pain and symptom management for those with a life expectancy of six months or less.  A non-child beneficiary may not concurrently receive hospice and palliative care, but palliative care may be provided concurrently with curative care.

To be eligible for palliative care, a Medi-Cal beneficiary must meet general eligibility requirements and disease-specific eligibility requirements.  In general:

1. A beneficiary needs to be likely to or have started to use the hospital or emergency room to manage advanced disease on a non-elective manner.
2. The beneficiary must have an advanced illness with decline in health and not participating in hospice care.
3. The beneficiary’s death within a year would not be unexpected.
4. The beneficiary has received appropriate medical care or the medical therapy is no longer effective
5. The beneficiary agrees to try alternatives to emergency room care and participate in advance care planning discussions

There are disease-specific requirements for congestive heart failure, chronic obstructive pulmonary disease, advanced cancer, and liver disease.  As long as beneficiaries meet these criteria, they will continue to have access to palliative and curative care until the condition improves, stabilizes, or results in death.  The managed care plan can terminate palliative care if it is no longer medically necessary.

Starting January 1, 2018, managed care plans must authorize palliative care when a beneficiary, regardless of age, meets the minimum criteria.  Services must be medically necessary and reasonable for the patient’s condition, and can include: advance care planning, palliative care assessment and consultation, plan of care, palliative care team, care coordination, pain and symptom management, and mental health and medical social services.  Plans may offer additional palliative care services, and may authorize them to be provided in a variety of settings by appropriate providers.

DHCS APL 17-015 (October 19, 2017).