24-734m Ensure D-SNP Members Have Timely Access to Continuity of Care

Date: 07/26/24

New guidelines for dual eligible special needs plans (D-SNPs) effective January 1, 2024

On January 1, 2024, the Department of Health Care Services (DHCS) provided new guidelines to help Plan administrators and Medicare physicians and other providers inform members about continuity of care. The new guidelines are intended to ensure continued access to Medicare physicians and other providers and covered services for members joining a D-SNP. These guidelines are included in the 2024 CalAIM Dual Eligible Special Needs Plans Policy Guide (PDF).

Continuity of care for Medicare primary and specialty providers

Upon a member, authorized representative, or a physician or other provider’s request, Wellcare By Health Net (Health Net) Dual Special Needs Plan (D-SNP) must offer continuity of care with out-of-network Medicare physicians or other providers to all members if all the following circumstances exist:

• Member has an existing relationship with a primary or specialty care physician or other provider.
• The physician or other provider is willing to accept, at a minimum, payment from the D-SNP based on the current Medicare fee schedule, as applicable; and
• The physician or other provider does not have any documented quality of care concerns that would cause the D-SNP to exclude the provider from its network.
• If member leaves the D-SNP and later rejoins the D-SNP; then, the 
  D-SNP must offer the member a 12-month continuity of care period based on the date of re-enrollment, regardless of whether the member received continuity of care in the past.
• If a member changes D-SNPs, the continuity of care period may start over one time. If the member changes D-SNPs a second time (or more), the continuity of care period does not start over, meaning the D-SNP is not required to offer the member a new 12-month period.

Request continuity of care

Members, their authorized representatives, or their physicians or other providers may make a direct request to the D-SNP for continuity of care. The D-SNP must accept and approve retroactive requests for continuity of care and pay claims that meet all continuity of care requirements noted above, with the exception of the requirement to follow the Plan’s utilization management policies.

Services that are the subject of the request must have occurred after the member’s enrollment into the D-SNP, and the  D-SNP may require the member, their authorized representative, or their physician or other provider to demonstrate that there was an existing relationship between the member and physician or other provider prior to the member’s enrollment into the D-SNP. Member or physician or other provider may not attest to a preexisting relationship (instead, actual documentation must be provided) unless the D-SNP makes this option available to them. Once a pre-existing relationship is confirmed, the D-SNP must contact the physician or other provider and make a good faith effort to enter into a contract, letter of agreement, single-case agreement or other form of agreement in order to establish a continuity of care relationship for the member.

Completion timeline for request received

When a request for continuity of care is submitted:

The D-SNP must process the request within five working days after receipt of the request. The request must be completed in three calendar days if there is a risk of harm to the member.

The D-SNP must approve any retroactive requests that:

Have dates of services within 30 calendar days of the first date of service for which the physician or other provider is requesting, or has previously requested, continuity of care retroactive reimbursement; and Are submitted within 30 calendar days of the first service for which retroactive continuity of care is being requested or denial from another entity when the claim was incorrectly submitted. Are submitted more than 30 days after the first service if the physician or other provider can document that the reason for the delay is that the physician or other provider sent the request to the incorrect entity and the request is sent within 30 days of the denial from the other entity.

 

Primary Care Physicians (PCPs) and Delegated Entities

• When a member transitions into a D-SNP and has an existing relationship with a PCP that is in the D-SNP’s network, the D-SNP must assign the member to the PCP, unless the member chooses a different PCP.
• If the D-SNP contracts with delegated entities, it must assign the member to a delegated entity that has the member’s preferred PCP in its network.
• When a member transitions into a D-SNP, has an existing relationship with a PCP and at least one specialist that is in the D-SNP’s network, and the member wishes to continue to seek treatment from each of these physicians and specialists, the D-SNP must allow the member to continue treatment with each of these physicians and specialists for the continuity of care period. This is regardless of whether these physicians and specialists are, or are not, in the network of the primary plan’s delegated entity to which the member is assigned, as long as the continuity of care requirements are met.

Additional information

If you have questions regarding the information contained in this update, contact the Provider Services Center by email, by phone 800-929-9224 or through the provider portal.

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary Providers.