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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health



​Application Request for a Hospice Provider

These instructions are to assist you in preparing a hospice provider licensing and/or certification (for Medi-Cal Title 19 and/or Medicare Title 18 reimbursement) application package to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. When preparing your application package, please use the following applicable checklist(s):


Licensing Requirements
A state license is required to operate as a hospice provider in California, pursuant to Health and Safety (H&S) Code Sections 1745(a) and 1747(a), unless it meets any of the following:

  • It was established as a hospice before January 1, 1991, pursuant to H&S Code Section 1747(a).
  • It is a "volunteer hospice," pursuant to H&S Code Section 1747(c).
  • It is a small and rural hospice which is exempt from licensure, pursuant to H&S Code Sections 1745(c) and 1747(d).
  • It is a hospice certified in accordance with federal Medicare hospice conditions of participation covered under the licensed home health agency (HHA), pursuant to H&S Code Section 1747.1.

Note:  A "certified" hospice provider needs to be separately licensed as a freestanding hospice provider or separately certified under a licensed HHA as a service (refer to the Application Request for a Home Health Agency webpage).


A hospice is defined as:

Hospice means "a specialized form of multidisciplinary health care which is designated to provide palliative care, alleviate the physical, emotional, social and spiritual discomforts of an individual who is experiencing the last phases of life due to the existence of a terminal disease, and to provide supportive care for the primary care giver and the family of the hospice patient," pursuant to H&S Code Section 1746(b).

Hospice services, required by H&S Code Section 1749(b), shall be provided in compliance with the "Standards for Quality Hospice Care (SQHC)," as available from the 2005 California Hospice and Palliative Care Association (CHAPCA), until the CDPH adopts regulations establishing alternative standards pursuant to H&S Code Section 1749(c). The SQHC is available at the California Hospice and Palliative website.

An application is required for: (1) a new (initial) hospice (whether it is a parent or an additional hospice site of a parent), (2) whenever a CHOW occurs, and (3) other changes beside a CHOW. 

  • "CHOW" applications: A CHOW is the only "change" requiring a new application.
  • "Other" changes (besides a CHOW): Changes (change of name, mailing address, location, administrator, etc.) must be requested.

Note: The "other" changes do not require submittal of an entirely "new" application package, but will require specific forms depending on the type of change being made (change of name, mailing address, location, administrator, etc.). The Centralized Applications Branch (CAB) will assist you on which forms must be submitted for the specific change.


Completion of Applications

For your convenience, each checklist has instructions to complete the forms required for licensing and certification of a hospice provider. The checklist provides specific item numbers that applicants typically have encountered problems in submitting incorrect or missing information. Please make sure that all item numbers in each form are completely filled out. For example: (1) the applicant’s formal name must be consistently the same throughout all the documents in the application package; or (2) in some instances, a specific attachment may need to be submitted with a specific form. All forms are required to be signed by the "licensee," owners, or officers, unless otherwise stated.

Please read each required application package form carefully and provide all requested supplemental documents. Use the guidance below:

  • Do not leave any items blank.
  • If a question does not apply, please respond with "Not Applicable" or "N/A."
  • Do not make changes to these forms.
  • Use "blue" ink to sign all forms.
  • Do not use white out/correction fluid to make corrections.
  • To correct an error, place a single line through the entry and enter the correct information. The individual responsible for making the correction must initial and date the correction.
  • There are some differences between documents required for a CHOW and "initial" applications that are noted on the checklist. 

You should retain a photocopy of the completed documents for your files. We may need to contact you in the future and we will be referring to the information in the documents you provided.

 

Submission of Applications

 All completed application packages must be submitted via regular mail to:

California Department of Public Health
Licensing and Certification Program
Centralized Applications Branch
P.O. Box 997377, MS 3207
Sacramento, CA 95899-7377

CAB will review the application package for completion. Once the application package has been given a recommendation of "approved" by CAB and all required surveys have been performed, CAB will issue the license accordingly.

In addition, a check or money order made payable to the "California Department of Public Health" for the licensing fee, determined pursuant to H&S Code Section 1266, must accompany the required forms before your application will be processed. The licensing fees change annually; therefore, please check the current licensing fee for a hospice which is posted on the L&C Facility Fee website.

The application fee will not be returned if the application is withdrawn or denied.

The application package review process will consider the applicant’s and associates’ (i.e., board members, LLC members, managers, etc.) past compliance history. This will be based on a review of all facilities and agencies operated by those individuals in California and nationally. The applicant and associates must demonstrate substantial compliance with state and federal requirements for all facilities that they operate, pursuant to H&S Code Section 1755.

Failure to demonstrate substantial compliance history may result in the denial of your application package. You will be notified in writing of L&C’s intent to deny the application.

 
Choice of Fiscal Intermediary

The fiscal intermediaries are available from the Federal Department of Health and Human Services website.

To apply for National Provider Identifier (NPI), go to the National Plan and Provider Enumeration System website.


Certification

Certification status will allow the hospice provider to provide services to Medicare beneficiaries (under Title 18). Once the hospice has become Medicare certified, they may also provide services to Medi-Cal beneficiaries (Title 19), if requested. The hospice provider is required to be licensed prior to seeking certification status.

Many applicants, including hospice, have the option of becoming certified on the basis of accreditation by the Centers for Medicare & Medicaid Services’ (CMS) approved accreditation organizations (listed below) instead of a survey by L&C.

Once approved by the accreditation organization, submit the approval letter from the accreditation organization to the appropriate district office (DO). Since the Medicare certification forms listed on the attached checklist are submitted with your "initial" application package, if there are any changes to the forms, the DO will request amended forms after they receive the approval letter from the accreditation organization.

If you do not choose to go through one of these accreditation organizations, it will be several years before L&C will be able to perform a certification survey since "initial" certification surveys for hospices have been categorized as a low priority; however, if you still want the L&C DO to consider conducting the "initial" certification survey, you will need to submit justification to the DO for CMS approval. The burden will be on the hospice to provide data and other evidence that effectively establishes the probability of serious, adverse beneficiary health care access consequences if the hospice is NOT enrolled to participate in Medicare.

In addition, you must be in compliance with state licensing laws and federal conditions of participation, located in the CMS website. It is the applicant’s responsibility to obtain the Code of Federal Regulations and to understand the hospice provider Conditions of Participation, which are located on the United States Government Publishing Office website


Initial Licensing Survey

An initial licensing survey is part of the application process for "new" hospice provider applications. The initial licensing survey is a scheduled survey conducted by L&C DOs.

Except for the Los Angeles (LA) facilities, the DO will notify you (via letter) when the application has been approved by CAB and will schedule an "initial" licensing survey. For the LA facilities, the CAU will notify you (via letter) when the application has been approved and will schedule an "initial" licensing survey.

Note: You must be ready for the initial licensing survey upon notification. It is L&C’s policy that, except for very unusual circumstances, only one inspection visit will be made. Failure of the hospice provider to be in substantial compliance, at the time of the visit, will result in the "denial" of the application. Any further activity regarding your request, after such denial, will require a new application, and license fee.

Please note: An "initial" license will not be issued until the application is approved and, if required, a successful licensing survey is conducted.


If you have any questions, please contact the CAB, at (916) 552-8632 or by e-mail at CAB@cdph.ca.gov.

 


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