Continuity of Care
- Participating Physician Groups (PPG)
Under Health Net’s continuity of care (COC) policy, there are two types of COC, non clinical and clinical COC.
Non Clinical COC
All new Medi-Cal members who have been receiving care that meets certain criteria may continue with their existing out-of-network providers for up to 12 months. An existing relationship means the member has seen the non-participating provider at least once during the previous 12 months for non-emergency condition prior to the date of their initial enrollment with Health Net.
Member must have a pre-existing relationship with the requested provider. A pre-existing relationship means the member has seen an out-of-network primary care provider (PCP) or specialist at least once during the 12 months prior to the date of their initial enrollment into Medi Cal for a non-emergency visit.
The health plan or the delegated entity determines if a relationship exists through use of data provided by the Department of Health Care Services (DHCS), such as Medi-Cal fee-for-service (FFS) utilization data. A member or their provider may also provide information to the health plan or the delegated entity that demonstrates a pre-existing relationship with the provider.
Following identification of a pre-existing relationship, the health plan or the delegated entity determines if the provider is an in-network provider. If the provider is not an in-network provider, the health plan or the delegated entity contacts the provider and makes a good faith effort to enter into a contract, letter of agreement, single-case agreement, or other form of relationship to establish a COC relationship for the member.
- The requested provider is willing to accept the higher of contracted rates or Medi-Cal FFS rates.
- The requested provider has no quality-of-care concerns. Health Net does not exclude the provider from its provider network unless there are documented quality-of-care concerns, or state or federal exclusion requirements.
- The requested provider is a California State Plan-approved provider.
- The requested provider supplies all relevant treatment information to determine medical necessity, as well as current treatment plan.
COC services not covered for Medi-Cal members
- Durable medical equipment (DME) providers or other ancillary services, such as transportation or carved-out services.
- Out-of-network providers who do not agree to abide by Health Net's utilization management UM policies.
If the out-of-network provider does not agree to a rate, or Health Net has a documented quality-of-care issue with the provider, the member will be offered an in-network alternative, and assigned to another in-network provider.
COC for mental health services is provided by MHN. MHN provides COC with an out-of-network specialty mental health service provider where a member's mental health condition has stabilized and the member no longer qualifies to receive specialty mental health services (SMHS) from the county mental health plan (MHP). The member then becomes eligible to receive non-specialty mental health services from MHN. In this situation, the COC requirement only applies to psychiatrists and/or outpatient mental health providers approved to provide Medi-Cal services.
Health Homes Program
COC with out-of-network providers is not available for Health Homes Program (HHP) services.
Health Net begins to process the non clinical COC request within five days of receiving the request. For delegated participating physician groups (PPGs), the Public Program Specialist’s team forwards the COC request to the PPG's utilization management (UM) department.
Staff from the PPG UM works with the out-of-network provider to secure a care plan for the member. They also issue the decision and explain the process for requesting continued services beyond the first authorization and, if warranted, how to continue out-of-network services up to the allowable timeframe of 12 months.
Necessary authorizations must be processed within 30 calendar days for regular requests and 15 calendar days for more immediate cases.
The PPG is also responsible to:
- Notify the member about the transition to a new provider 30 calendar days prior to the end of the COC period, and coordinates the transition with the out-of-network provider.
- Work with the out-of-network provider to make sure they are willing to work with the PPG and Health Net. Out-of-network providers cannot refer the member to another out-of-network provider without authorization from Health Net or a delegated PPG.
- The PPG follows up with the out-of-network provider and member to confirm they have received authorization from the PPG, and both understand the process for further authorization requests.
A current Medi-Cal member may also be approved to complete care with a departing Health Net provider after that provider leaves Health Net's network. Completion of covered services are provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by Health Net in consultation with the member and terminated provider or non-participating provider and consistent with good professional practice and:
- The provider contract is terminated with Health Net for a reason other than medical discipline, fraud or crime.
- Had a PPG change due to provider contract termination or provider leaving assigned PPG.
- Are new members in treatment for conditions listed below.
Types of clinical criteria where a member may be eligible for COC:
- Acute conditions, which include medical conditions that involve a sudden onset of symptoms due to an illness, injury or other medical problem requiring prompt medical attention with a limited duration. Services must be provided for the duration of the acute condition.
- Services for a serious chronic condition must be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by Health Net in consultation with the member and the provider and consistent with good professional practice. Coverage may not exceed 12 months from the contract termination date. Serious chronic conditions include medical conditions due to a disease, illness or other medical problem or medical disorder that is serious in nature and does either of the following:
- Persists without full cure or worsens over an extended period of time.
- Requires ongoing treatment to maintain remission or prevent deterioration.
- Documented pregnancies – Completion of covered pregnancy services and the immediate postpartum period.
- A maternal mental health condition is a mental health condition that can impact a woman during pregnancy, peri- or post-partum, or that arises during pregnancy, in the peri- or post-partum period, up to one year after delivery.
- Terminal illness – Services are provided for the duration of the terminal illness.
- Newborn care between birth and age 36 months – Coverage may not exceed 12 moths from the contract termination date or 12 months from the effective date of coverage for a new member.
- Performance of a surgery or other procedure that is authorized by the plan as part of a documented course of treatment and had been recommended and documented by the provider to occur within 180 days.
- Medically necessary behavioral health treatment for children under age 21. These services include applied behavioral analysis (ABA) – for up to 12 months.
Requesting Continuity of Care
Medi Cal members, their authorized representatives on file with Medi-Cal or their providers may initiate a request for continuity of care directly from Health Net. Health Net accepts verbal or written COC requests. Refer to the Member Services Department (Medi-Cal) (CalViva Health) for assistance.
Health Net completes continuity of care requests within:
- 30 calendar days from the date of receipt
- 15 calendar days if the member's medical condition requires more immediate attention, or
- Three calendar days if there is risk of harm to the member. Risk of harm is defined as an imminent and serious threat to the member’s health.
Upon completion of the COC review, the provider and the member will be notified of decision within seven calendar days.
- If a member changes Medi-Cal managed care plans, the COC period may start over one time.
- If the member changes Medi-Cal managed care plans a second time (or more), the COC does not start over, meaning the member does not have the right to a new 12 months of COC by the non-participating provider.
- If the member returns to Medi-Cal fee-for-service (FFS) and later re-enrolls in a Medi-Cal managed care plan, the COC period does not start over.
- If a member changes managed care plans, COC assistance does not extend to participating providers the member accessed through their previous managed care plan.
A request for COC is complete when:
- The member is informed of their right to continued access.
- Health Net and the non-participating FFS provider are unable to agree to a compensation rate.
- Health Net has documented quality-of-care issues, or
- Health Net makes a good faith effort to contact the provider and the provider has not responded to Health Net within 30 calendar days of Health Net's effort to contact the provider.
At any time, Health Net members may change their providers regardless of whether a COC relationship has been secured.