Hospice Services
Notification requirements noted on this page are effective November 1, 2025. Hospice notification is not required prior to this date. Prior authorization requirements for inpatient hospice care remains in place.
San Francisco Health Plan (SFHP) covers hospice care for children and adults, which help reduce physical, emotional, social, and spiritual discomforts. Adults ages 21 years or older may not get hospice care and curative (healing) care services at the same time.
Hospice Provider Notification Requirements
In alignment with Department of Healthcare Services (DHCS) All Plan Letter (APL) 25-008, SFHP requires all Hospice Providers to provide timely notification to SFHP of member’s election of hospice services.
SFHP will enforce these notification requirements effective November 1, 2025. Failure to provide SFHP with timely notification will result in denied claims.
Hospice Provider Responsibilities
- Hospice providers must notify SFHP within five (5) calendar days of both the certification of terminal illness and the member’s election of hospice care.
- For general inpatient care placements that occur outside of normal business hours, notification must be submitted by the next business day.
- Submit the documentation indicated in grid below.
- Note: SFHP may request additional documentation to verify medical necessity, ensure appropriateness of services, and confirm that claims are accurate and not based on fraudulent or incomplete submissions.
- Submission Method: Fax all notifications and documentation to SFHP at 1(415) 943-9711 or through the SFHP Provider Portal.
Hospice Provider Notification Requirements
SFHP requires members receive hospice care from an in-network provider unless medically necessary services are not available in-network. Non-contracted Hospice providers should seek a Letter of Agreement (LOA) or single case agreement with SFHP in addition to the listed required documents.
| Scenario | Notification Timeframe | Required Documentation |
|---|---|---|
| Initial Hospice Election | 5 calendar days |
|
| Recertification for Continued Hospice Care | 5 calendar days |
|
| Inpatient Hospice Care (Requires Prior Authorization) | 24 hours |
|
| Transfer between Hospice agencies | 5 calendar days |
|
| Member Revocation of Hospice | 5 calendar days |
|
Hospice Care Eligibility
Individuals may be eligible for hospice care if they meet the following criteria:
- A physician certifies that the member has a life expectancy of six (6) months or less due to a terminal illness.
- The member (or their authorized representative) voluntarily elects hospice care by signing an election statement with a licensed hospice provider.
- Hospice services are focused on comfort, pain relief, and emotional support, rather than curative treatment.
- Certain benefits related to the terminal condition are waived during the hospice election period.
- The member understands that hospice care is provided in lieu of standard coverage for services directly related to the terminal illness.
By electing hospice care, the member acknowledges the following:
There are Four Levels of Hospice Care
- Routine Home Care: Standard hospice services provided in the Member’s home or residential setting. Includes nursing, social work, counseling, and aide services.
- Continuous Home Care: Time-limited, intensive nursing care provided during a crisis to manage acute symptoms at home. Must be provided for at least 8 hours in a 24-hour period.
- Respite Care: Short-term inpatient care provided to relieve family or caregivers. Typically limited to 5 consecutive days per occurrence.
- General Inpatient Care: Short-term inpatient care for pain control or symptom management that cannot be managed in other settings. Provided in a contracted facility.
Hospice Benefit Periods
Hospice services are delivered in distinct benefit periods: two initial 90-day periods, which are followed by 60-day periods. Each period requires physician certification, with face-to-face recertification starting before the third period.
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