Community-based palliative care and Medi-Cal SB 1004
Palliative care referrals
Refer to palliative care when a patient with serious illness has uncontrolled symptoms, repeated hospital use, or unclear goals of care, and is not ready for or not eligible for hospice. Palliative care does not require a six-month prognosis and the patient can continue disease-directed treatment. For Medi-Cal managed care members, SB 1004 sets specific eligibility criteria, summarized below.
Reviewed by our medical director, September 24, 2026
On this page (7 sections)
General referral criteria for community-based palliative care
There is no single national standard. These are common triggers:
- A serious, progressive illness such as advanced cancer, heart failure, chronic lung disease, liver or kidney disease, dementia or a neurodegenerative disease.
- Pain, dyspnea, nausea, anxiety or other symptoms that remain hard to control.
- Two or more hospitalizations or emergency visits for the illness in recent months.
- Functional decline or increasing caregiver strain.
- No advance care planning on record, or conflict and uncertainty about goals of care.
- You would not be surprised if the patient died within the next year.
Palliative care or hospice?
| Palliative care | Hospice | |
|---|---|---|
| Prognosis | Any stage of serious illness. SB 1004 uses a one-year frame | Six months or less if the illness runs its normal course, certified by a physician |
| Disease-directed treatment | Continues | Treatment to cure the terminal illness stops. Comfort treatment continues |
| Payment | Varies: Medi-Cal managed care under SB 1004, Medicare Part B for practitioner visits, plan-specific programs | Medicare hospice benefit, Medi-Cal, most private plans |
| Services | Consultation, symptom management, advance care planning, care coordination | Full interdisciplinary team, medicines, equipment and supplies related to the terminal illness, four levels of care, bereavement |
Medi-Cal SB 1004: general eligibility criteria
Under DHCS All Plan Letter 18-020, a Medi-Cal managed care member is eligible for palliative care when the member meets all of the general criteria and at least one set of disease-specific criteria. In summary, the general criteria are: the member is likely to use, or has started to use, the hospital or emergency department to manage advanced disease. The member has an advanced illness with documented continued decline and is not eligible for, or declines, hospice. Death within a year would not be unexpected. The member has received appropriate, desired medical therapy, or such therapy is no longer effective, and is not in a reversible acute decompensation. The member and, where applicable, the family agree to attempt in-home or outpatient disease management before going to the emergency department, and to take part in advance care planning.
SB 1004 disease-specific criteria
| Condition | Criteria in summary |
|---|---|
| Congestive heart failure | Hospitalized with heart failure as the primary diagnosis with no further invasive interventions planned, or NYHA class III or higher. And an ejection fraction below 30 percent for systolic failure, or significant comorbidities |
| Chronic obstructive pulmonary disease | FEV1 below 35 percent of predicted with a 24-hour oxygen requirement below 3 liters per minute, or a 24-hour oxygen requirement of 3 liters per minute or more |
| Advanced cancer | Stage III or IV solid organ cancer, lymphoma or leukemia. And a Karnofsky Performance Scale score of 70 or below, or failure of two lines of standard chemotherapy |
| Liver disease | Evidence of irreversible liver damage, serum albumin below 3.0 and INR above 1.3, with ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome or recurrent esophageal varices. Or evidence of irreversible liver damage with a MELD score above 19 |
These criteria follow DHCS All Plan Letter 18-020, which DHCS lists as its current Medi-Cal palliative care policy (it replaced APL 17-015). Plans may extend palliative care to other conditions. Pediatric criteria differ and are not covered here.
What SB 1004 palliative care includes
DHCS policy describes these services: advance care planning, palliative care assessment and consultation, a plan of care, an interdisciplinary palliative care team, care coordination, pain and symptom management, and mental health and medical social services. Plans may also authorize chaplain services and other supports. The plan, not the provider, authorizes the service, so the member's plan or medical group is usually the first call.
When palliative care becomes hospice
Patients on palliative care often reach a point where they meet hospice criteria. When the prognosis shortens or the patient decides to stop disease-directed treatment, the team discusses hospice with the patient, family and referring clinician. See eligibility guidelines. Families can read hospice vs palliative care and palliative care.
Three ways to refer
Face sheet, recent notes, medication list and an order to evaluate.
Our response commitment: A response within two hours, 24 hours a day, 7 days a week
Patients have the right to choose their hospice provider. Beta Hospice does not offer anything of value in exchange for referrals.
About this page
- Written by
- Beta Hospice care team
- Clinically reviewed by
- our medical director
- Last reviewed
- September 24, 2026
- Next review
- March 24, 2027
How we write and review this site
Sources
- DHCS: Palliative care policies (SB 1004) (opens in a new tab)
- DHCS: Medi-Cal managed care All Plan Letters (see APL 18-020, Palliative Care) (opens in a new tab)
- National Institute on Aging: What are palliative care and hospice care? (opens in a new tab)
- 42 CFR 418.20: Hospice eligibility requirements (opens in a new tab)
These sources support the general information on this page. For one person’s care and coverage, talk with the hospice team.
Refer a patient or ask a clinical question
Call any time. A nurse can talk through eligibility, timing and logistics for your patient.
Patients have the right to choose their hospice provider.