ALW and Hospice Coordination Guide

Yes, a participant in California's Assisted Living Waiver (ALW) can elect hospice, it happens often, and it can work well. What doesn't happen is automatic. Someone has to decide, for this patient, which medications and equipment are hospice's, which personal care stays with the facility under the ALW plan, and who calls whom at 2 a.m.

Coordinate a Current Case

Important: This general guide does not establish whether hospice is clinically appropriate, covered or coordinated correctly for a particular person; qualified clinical, benefits and compliance review is still needed for the individual situation. Hospice and ALW do not automatically work together. The participant chooses any qualified hospice; no facility or Care Coordination Agency (CCA) may condition ALW services or placement on choosing an affiliated hospice. Beta also operates a hospice program. ALW care coordination and hospice are separate services with separate eligibility; you choose your hospice provider, and Beta's ALW team does not steer that choice.

What is confirmed

Medicaid and Medicare hospice benefits have defined eligibility, election and service scopes; room and board stays with the residential agreement.
Medicare generally does not pay room and board simply because someone receives hospice in a residential facility, except for limited covered inpatient/respite circumstances. ALW itself does not pay room and board.
The CCA keeps its ALW assessment, care-plan (Individualized Service Plan, or ISP) and monitoring responsibilities; hospice election does not end ALW coordination.
The facility (licensed as an RCFE or ARF) keeps its licensed residential responsibilities and must meet California Department of Social Services (CDSS) licensing requirements for residents receiving hospice.

What requires case-specific determination

Hospice eligibility and payer; which conditions are related to the terminal illness; which medications, supplies and durable medical equipment (DME) are hospice's responsibility; which services remain under ALW or another benefit, and whether any duplicate; the facility's hospice waiver or exception and ability to retain the resident; and whether the ISP must change, including after a hospitalization or hospice discharge.

Responsibility matrix

The matrix is educational; the actual benefit, license and plan documents control.

Area	Hospice	CCA (Beta)	Facility (RCFE/ARF)	Other provider or payer
Hospice eligibility and election	Leads under the benefit	Is informed and coordinates	Supports the resident	Payer applies coverage
Terminal-illness plan of care	Leads	Aligns with the ALW ISP	Implements the facility role	Attending physician
ALW ISP and routine residential care	Supplies information	Leads, updates and monitors	Implements ALW and residential services	Contributes as needed
Terminal-related medications, DME and supplies	Determines and supplies under the benefit	Coordinates to avoid gaps or overlap	Administers and assists within scope	Other payer if unrelated

Medications, DME and billing

Keep one written responsibility list each for medications and equipment, updated at every change. The hospice decides relatedness and coverage under the applicable rules, subject to beneficiary rights and payer processes; don't assume every medication becomes hospice-covered, or that every existing medication stays with the prior payer.

Cover the same ground for equipment and supplies, and avoid duplicate orders and gaps during the transition. For each overlapping service, including hospice-aide and facility personal care, write down its relationship to the terminal diagnosis, the responsible provider and payer, why it is not a duplicate, and the escalation contact; don't rely on industry custom.

Facility requirements, the CCA's role, and transitions

The facility verifies the applicable hospice waiver, exception or licensing condition; whether it can retain the resident safely; staff training; fire-clearance implications; the after-hours process; and the hospice–facility agreement, under current CDSS licensing guidance.

The CCA documents hospice involvement, updates the ISP, continues required monitoring and reassessment, checks that participant choice is respected, and stays in communication with the facility and hospice.

Before an avoidable transfer, everyone should know whom to call first, the hospice goals, the participant's wishes and what the facility can manage in place. After a hospitalization, reassess hospice status, the facility's ability to readmit, new equipment and medications, and ISP implications.

Coordination checklist

Use this one list for the whole case.

Participant or representative authorization documented
Hospice election and payer verified; CCA notified
Facility licensing condition and care capability verified
Terminal plan of care and ALW ISP aligned
Medication and DME responsibility lists written
Service overlap, billing and nonduplication checked
Emergency plan, after-hours contacts and reassessment triggers agreed
Hospice choice documented as the participant's own

Your next step

Start the coordination request for this patient, or open the facility's working reference.

Coordinate a Current Case

Read the Facility Operations Guide