Medi-Cal palliative care: who qualifies and what it covers

Palliative care helps people with a serious illness feel better and live better, at any stage, alongside the treatment they’re getting. In California, Medi-Cal managed care plans are required to offer it. Many families with Medi-Cal have never heard that, and so they never ask. This note explains who qualifies, what the plan must cover and how to ask for it, using the state’s own rules.

The short answer

• The California Department of Health Care Services requires Medi-Cal managed care plans to have palliative care programs for their members.¹
• Palliative care can be given at the same time as treatment meant to cure the illness.²
• A member qualifies by meeting five general criteria and the criteria for one of four illnesses: heart failure, COPD, advanced cancer or liver disease.²
• Every plan must cover seven services, from advance care planning to pain and symptom management.²
• Since January 2024, Medicare Dual Eligible Special Needs Plans must also have palliative care programs for people with both Medicare and Medi-Cal.¹

Who qualifies: the general criteria

A member must meet all five of these.²

• They’re likely to use the hospital or emergency room for their illness, or they’ve started to.
• They have an advanced illness that keeps getting worse, and they don’t qualify for hospice or have chosen not to use it.
• Their doctor wouldn’t be surprised if they died within a year.
• They’ve had the treatment they want, or it has stopped working, and they aren’t in a short-term crisis that’s expected to reverse.
• The member and their family or support person agree to try care at home or in the community first and to take part in advance care planning.

Who qualifies: the four illnesses

A member must also meet the criteria for one of these.²

• Heart failure: a hospital stay for heart failure with no further invasive treatment planned, or heart failure of class III or higher on the New York Heart Association scale, together with an ejection fraction under 30% or other serious conditions.
• COPD: lung function, measured as FEV1, below 35% of predicted with oxygen needed around the clock, or a need for 3 liters a minute of oxygen or more around the clock.
• Advanced cancer: a stage III or IV solid tumor, lymphoma or leukemia, with significantly limited day-to-day function or after two lines of standard treatment have failed.
• Liver disease: irreversible liver damage with low albumin and a raised INR together with complications like ascites or hepatic encephalopathy, or irreversible damage with a MELD score above 19.

These are the state’s minimum. A plan can ask the state to approve broader criteria of its own.²

Children and young adults

Palliative care is available at any age when the criteria are met, and plans must authorize it without regard to age.² Members under 21 who don’t fit the adult criteria can qualify under broader criteria for children, and they can get palliative care and hospice at the same time as treatment meant to cure the illness.²

The seven services every plan must cover

When they’re medically necessary and reasonable, palliative care under Medi-Cal must include at least:²

• Advance care planning: conversations about what matters to the person and what care they want, with the documents to match
• Palliative care assessment and consultation: a full look at symptoms, needs and goals
• A plan of care: written with the person and family
• A palliative care team: doctors, nurses and social workers who work together
• Care coordination: one team keeping the doctors, specialists and services connected
• Pain and symptom management: for pain, breathlessness, nausea, fatigue, anxiety and more
• Mental health and medical social services: support for the emotional and practical weight of serious illness

What it looks like at home

Palliative care meets people where they live. A nurse, a doctor or nurse practitioner, and a social worker come to the home, or see the person by video, on a schedule that fits their needs. They ask about symptoms, adjust medicines with the person’s doctors, and make sure everyone is working from the same plan. They help the family talk through what matters most and put the person’s wishes in writing. And they’re the people to call when something changes, so a bad night is more likely to end with a phone call and a plan than with a trip to the emergency room.

Palliative care and hospice

The two are related but different. Palliative care can start at any stage and continues alongside treatment. Hospice is for the last months of life, when treatment meant to cure has stopped. Under Medi-Cal, a member on palliative care can move to hospice if they meet the hospice criteria, and adults 21 and older can’t be enrolled in both at the same time.²

When one organization provides both, the move can happen without starting over somewhere new. HealthView provides both.

How to ask for it

Start with the person’s doctor or the Medi-Cal plan’s member services line. Ask whether the person qualifies for the plan’s palliative care program, and ask which palliative care providers the plan works with. If the person doesn’t qualify yet, ask what would change that, and ask again when their illness changes.

You can also call us. HealthView provides palliative care and hospice across Los Angeles, Orange, Riverside and San Bernardino counties, and we work with Medi-Cal plans, including CalOptima. Our team can look at the criteria with you and reach out to the plan.