Continuity of Care
- Participating Physician Groups (PPG)
- (does not apply to HSP)
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 Cal MediConnect (CMC) members using their Medi-Cal benefits are given the option to continue routine care treatment with an out-of-network provider, including a primary care physician (PCP) for up to 12 months if all requirements noted below are met. Even if their providers do not participate in Cal MediConnect plans and are not contracting with the participating physician group (PPG).
Members must have a pre-existing relationship with the requested provider. A pre-existing relationship means the member has seen an out-of-network PCP or specialist at least once during the 12 months prior to the date of their initial enrollment into CMC for a non-emergency visit.
- The requested provider is willing to accept the higher of contracted rates or Medi-Cal fee-for-service (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 Medi-Cal or Medicare services not covered for Cal MediConnect 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 documented quality-of-care issues with the provider, the member will be offered another in-network provider.
If a member opts out or disenrolls from Cal MediConnect and later re-enrolls in Cal MediConnect, the member has the right to a 12 month COC period, regardless of whether the member received COC in the past.
Health Net accepts retroactive COC requests that are submitted more than 30 days after the first service if the provider can document the reason for the delay. Refer to the Cal MediConnect Member Services Department for assistance.
Health Net begins to process the non clinical COC request within five days of receipt of the request. For delegated 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 time frame 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 Public Program Specialist follows up with the out-of-network provider and the member to confirm they have received authorization from the PPG, and both understand the process for further authorization requests.
In addition to the non clinical criteria above, current CMC members who meet the following clinical criteria may be eligible for COC when they currently are undergoing care with a provider 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 are serious in nature and do 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 for the duration of the terminal illness.
- Newborn care between birth and age 36 months – Coverage may not exceed 12 months 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.
Upon completion of the COC review, the provider and the member will be notified of the decision within seven calendar days.
Health Net also notifies members 30 calendar days before the end of the COC period about the process to transition at the end of the COC period.
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.