Coordinating hospice for an ALW participant

Nothing is automatic when a participant in California's Assisted Living Waiver (ALW) elects hospice. Roles, medications, equipment and after-hours cover are worked out case by case by the hospice, Beta as the Care Coordination Agency (CCA), the facility and the payer. This guide says what a written source settles, what your team settles, and who to call.

Coordinate care with the ALW team

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, and Beta's ALW team does not steer that choice. Beta's ALW care coordination is a separate service from any hospice, with its own eligibility. In an emergency, call 911.

Starting points

What a written source settles:

• Medicare covers hospice care but not room and board, except during hospice-arranged short inpatient or respite stays. Medi-Cal pays hospice room and board only in a certified nursing facility or ICF. Neither pays room and board in an RCFE or ARF. ALW does not pay it either.
• The CCA keeps the ALW assessment, the care plan (the Individualized Service Plan, or ISP) and the monthly visit. DHCS requires its case management to be independent of the services it arranges.
• The participant chooses providers, including any hospice (DHCS Freedom of Choice form), and keeps the rights on the ALW patient rights form.
• Under a CDSS hospice care waiver (22 CCR 87632 and 87633), a licensed RCFE may accept or keep a resident who receives hospice care, up to the facility's own approved maximum. Keeping a bedridden resident needs fire clearance (Health and Safety Code 1569.72). The licensee helps residents get hospice care and keeps observing them between visits (CDSS PIN 22-24-ASC). ARF rules are not covered here.

What your team settles for this participant

Settle each of these in writing:

• Hospice eligibility and the payer.
• Which conditions relate to the terminal illness. The hospice and the payer decide this under their own rules.
• Which medications, supplies and durable medical equipment (DME) the hospice supplies.
• Which services stay under ALW or another benefit, and whether any duplicate.
• Whether the facility holds the hospice care waiver and can keep the resident safely.
• Whether the ISP must change, including after a hospital stay or a hospice discharge.

Medications, equipment and billing

Keep one written responsibility list for medications and one for equipment and supplies. Update both at every change. The hospice and the payer decide, under their own rules, which items relate to the terminal illness and which are covered. Do not assume that every medication becomes hospice-covered. For each service that could overlap, write down the responsible provider, the payer, why it is not a duplicate and the escalation contact.

The facility, the CCA and transitions

The facility confirms its hospice care waiver and whether it can keep the resident safely. That includes fire clearance, staff training, the after-hours process and its agreement with the hospice. The CCA records the hospice involvement, updates the ISP and checks that the participant's choice is respected.

Before any 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 hospital stay, check the hospice status, whether the facility can readmit, any new equipment or medications, and whether the ISP changes.

Coordination checklist

One list for the whole case. Ticks on this page are not saved: print the page or copy the list into your own record.

• Participant or representative authorization documented
• Hospice election and payer verified, CCA notified
• Facility hospice care waiver 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

Send the coordination request for this participant, or call. It takes your professional details and a short note, with no participant names, health details or identifiers. Beta's ALW team names the route for records once you are in touch.

The Facility Operations Guide covers the facility's side, and Your rights in ALW covers the participant's rights and complaint route.

Beta Hospice Care, a separate program of the same company, explains the hospice side for families on its own site: how hospice and the Assisted Living Waiver fit together ↗. Choosing Beta for one program never affects the other, and the participant chooses any hospice.