Medi-Cal Provider Manual, Part 2, Hospice Care, Hospice Service Restrictions

Services Related to Primary/Terminal Hospice Illness

For Medi-Cal members who elect to receive hospice services, hospice providers will receive

a response from Medi-Cal’s eligibility verification system that reads: “Primary

diagnosis/limited to hospice.” Medi-Cal members will not be eligible to receive curative or

other services related to their terminal illness from providers other than their hospice

provider or attending physician. Accordingly, whenever this response is returned from the

eligibility verification system for Medi-Cal members who have elected to receive hospice

services, other providers should inform the Medi-Cal members’ hospice provider that they

are seeking other curative or other services related to the terminal illness.

Services Unrelated to Primary/Terminal Hospice Illness

For Medi-Cal members who elect to receive hospice services, the special response from

Medi-Cal’s eligibility verification system (for example, “Primary diagnosis/limited to hospice”)

does not mean that Medi-Cal members are prohibited from receiving other services that are

unrelated to the terminal illness, such as physician examinations, drugs, or other medical

care.

For example, if Medi-Cal members receiving hospice services suffer an injury or have a

pre-existing condition, such as diabetes, all necessary medical care would be covered in the

usual manner subject to applicable Medi-Cal coverage policies.

Note: If other providers determine that Medi-Cal members have revoked their hospice

election, but the eligibility verification system response continues to return the special

response indicating they are receiving hospice services (for example, “Primary

diagnosis/limited to hospice”), any medically necessary services may be rendered in

the usual manner, subject to applicable Medi-Cal coverage policies.››