• Please review AFL 21-53. This AFL notifies hospices of the chaptering of SB 664 (Chapter 494, Statutes of 2021) that establishes a moratorium on hospice licensure, prohibiting the California Department of Public Health (CDPH) from issuing a new hospice license on or after January 1, 2022, and until 365 days from the date the California State Auditor (CSA) publishes a report on hospice licensure. Applications for licensure of a multiple location of an existing hospice, a change of geographical service area, or a change of location outside of a hospice’s approved geographical service area will be subject to the moratorium.
  

• Application after January 1, 2022 – Individuals or entities interested in applying for hospice licensure after January 1, 2022, should begin by submitting an exception request. This consists of submitting a written justification and supporting documentation to demonstrate need based on geographic concentration to CAB. If CAB determines there is a need based on geographic concentration, CAB will notify the applicant that they may submit an application. 

• Applications after January 1, 2023 – Assembly Bill (AB) 2673 – Expansion of Hospice Agency Licensure Requirements Oversight, and Enforcement, in addition to Health and Safety Code (HSC) section 1749 requires a hospice agency to have an administrator,  administrator designee,  director of patient care services (DPCS),  director of patient care services designee (DPCSD), and medical director or contracted medical director. Each management personnel must submit an Applicant Individual Information - HS 215A form, a resume, and a list of hospice agencies that the individual is currently serving as management personnel. The hospice agency must submit all the above information to CDPH as part of the initial hospice application, within ten (10) business days of a change in management personnel, and currently licensed hospice agencies on a one-time basis no later than March 31, 2023. The California Department of Public Health (CDPH) must use this information to verify professional licensure status of these individuals and may verify their association with the hospice agency or their work history. Verification may include contacting hospice agency personnel or previous employers.
  

• Additionally, a hospice agency shall submit to the department information on whether its medical director, or contracted medical director, is certified as a hospice medical director according to the requirements established by the Hospice Medical Director Certification Board, or certified in hospice and palliative medicine according to the requirements established by a member board of the American Board of Medical Specialties, or by the American Osteopathic Association, or an equivalent organization as determined by the department.

Applicatio​​n Packet Forms

• ​HS 200 - Licensure and Certification Application (PDF)
• HS 215A - Applicant Individual Information (PDF)​
• ​​HS 309 - Administrative Organization and Organizational Structure (PDF) 
  
• HS 328 - Notice of Effective Date of Provider Agreement ​(PDF)
  
• DHCS 9098 - ​​​Medi-cal Provider Agreement (PDF)
  
• CMS 417 - Hospice Request for Certification in the Medicare Program​ ​(PDF)
  
• CMS 643 - Hospice Survey and Deficiencies Report​ (PDF)
  
• CMS 1561 - Health Insurance Benefits Agreement (PDF)
  
• CMS 855A - Medicare General Enrollment Health Care Provider/Supplier Application​ (PDF)
  
• HHS 690 - Assurance of Compliance (PDF)​