Continuity of Care Under Cal MediConnect

 
Dual eligible enrollees in a Cal MediConnect plan will eventually be required to receive all covered services from physicians and other providers who are part of the plan’s network. However, enrollees in a Cal MediConnect plan will have continuity of care rights – the right to temporarily continue seeing an existing physician outside the Cal MediConnect network for a specified period following enrollment.

In addition to the generally applicable ability to request completion of covered services for certain conditions ([1]), enrollees may be able to continue to receive Medicare covered services from an existing primary or specialty care physician with whom they have an existing relationship for up to six months, and Medi-Cal covered services for up to 12 months.

Continuity of Care: Physicians

All of the following conditions must be met in order for a Cal MediConnect enrollee to receive this continuity of care from an out-of-network physician:

  • The enrollee, their authorized representative or their physician may request the continuity of care from the Cal MediConnect plan.
  • The plan must validate the enrollee had a preexisting relationship with the physician(s) prior to enrollment in Cal MediConnect. To demonstrate this relationship with a primary care physician, the enrollee must have seen the physician at least once in the 12 months preceding enrollment. To demonstrate a preexisting relationship with a specialist, the enrollee must have seen the physician at least twice in this 12-month period. Plans must review Medicare claims data to validate this relationship before requesting evidence from the enrollee or physician.
  • The out-of-network physician must be willing to accept the Cal MediConnect plan rate or the applicable Medicare or Medi-Cal rate, whichever is higher, and agree to receive payment from the plan. This is typically 80 percent of the Medicare fee schedule plus any copayments owed under state law.
  • The physician must enter into some type of simple agreement with the health plan and agree to follow the plan’s utilization management rules.
  • The physician has no quality of care issues or failure to meet federal or state requirements that warrant exclusion from providing care to enrollees.

 

Steps for Processing Continuity of Care Requests

Cal MediConnect plans must attempt to determine if there are continuity of care needs during the Health Risk Assessment process that takes place soon after enrollment.  Alternatively, enrollees, their authorized representatives or their physicians can make requests using the following steps:

    1. The enrollee advises the physician that s/he has enrolled in a Cal MediConnect plan, and determines whether or not the physician is part of the plan’s network. OR: The physician upon checking the enrollee’s eligibility advises the enrollee that s/he is enrolled in a Cal MediConnect plan, and informs the enrollee whether or not the physician is part of the plan’s network.
    1. If the physician is not part of the plan’s network, the enrollee, their representative or the physician contacts the Cal MediConnect plan and tells the plan that they want to continue treatment based on the preexisting relationship.
    • Plans must allow continuity of care requests by phone.
    • It is the plan’s responsibility to first attempt to validate the preexisting relationship through Medicare claims data before requesting evidence from the enrollee or provider.
    1. The Cal MediConnect plan works with the physician and makes a good faith effort to determine:
    • Whether the physician will accept the higher of the Medicare or plan rate for services, and
    • Whether there are quality issues that would prevent the physician from providing care to this enrollee.

If agreement is reached between the Cal MediConnect Plan and the physician, the enrollee can continue receiving Medicare services from the physician for up to six months. At the option of the Cal MediConnect plan, this six-month period may be extended.

 

Timeline for Processing Requests

A plan must begin to evaluate a continuity of care request within five working days, and complete the evaluation within:

  • 30 calendar days from receiving the request for general requests;
  • 15 calendar days if the enrollee’s medical condition requires more immediate attention such as upcoming appointments or other pressing care needs; or
  • 3 calendar days if there is risk of harm to the enrollee.

 

A request evaluation is completed when:

  • The plan approves the continuity of care request, or
  • The plan and physician are unable to agree on a rate, or
  • The plan has documented there are quality of care issues with the physician, or
  • The plan does not receive a response to its good faith effort to contact the physician for 30 calendar days.

Enrollees must be notified that the request evaluation has been completed within 7 calendar days of the request approval or denial.  The plan must also notify the enrollee 30 calendar days before the continuity of care period expires.

 

Retroactive Continuity of Care

Under new rules, enrollees will be able to receive retroactive continuity of care.

  • Plans will retroactively approve and reimburse physicians for continuity of care for services that were already provided if requirements are met.
  • All physician continuity of care requirements continue to apply, including a validated preexisting relationship between the enrollee and physician
  • The enrollee, authorized representative or physician providing continuity of care must request the continuity of care within 30 calendar days of the first service provided after the enrollee joins the Cal MediConnect plan.
  • The physician can continue to treat the patient for those 30 days and will be reimbursed if all continuity of care requirements are met.
  • Once the plan and physician have agreed to terms, the physician must agree to follow the Cal MediConnect plan’s utilization management requirements.

 
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Out-of-Network Referrals

An out-of-network physician providing Medicare services under the extended continuity of care provisions applicable to Cal MediConnect enrollees cannot refer the enrollee to another out-of-network provider without prior authorization from the Cal MediConnect plan.

 

There may be some instances when the dual eligible enrollee must receive services outside the network if adequate coverage for a specific specialty is unavailable in the Cal MediConnect plan.  The Cal MediConnect plan will make that determination.

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Continuity of Care: Other Providers and Services

Authorized Services

Cal MediConnect plans are required to honor Medi-Cal (including State-issued Treatment Authorization Requests, TARs) and Medicare service authorizations for all services for up to 6 months for Medicare services and 12 months for Medi-Cal services.

 

Nursing Facilities

Cal MediConnect enrollees who are long-term residents of nursing facilities will not have to change facilities even if their nursing facility is not in the health plan’s contracted network unless there are quality concerns during the period of the Cal MediConnect pilot.

 

The facility must come to payment agreements with the health plans.  Payments will be based on the Medicare and Medi-Cal rates unless otherwise agreed to by the parties.

 

Other Long-Term Services and Supports

Cal MediConnect enrollees will not have to change their In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS), or Multipurpose Senior Services Program (MSSP) providers.

 

Enrollees who receive IHSS will see no change in their IHSS care under Cal MediConnect.  The county still approves hours. The enrollee still has the right to hire, fire, and manage their IHSS workers.  The enrollee also keeps the right to file an appeal with the state for issues related to IHSS.

 

Medicare Part D Prescription Drugs

Existing Medicare Part D continuity of care rules apply to enrollees in Cal MediConnect plans.  Plans must provide a supply of up to 30 days of any existing Medicare Part D prescription.  After that, enrollees must either switch to drugs on the Cal MediConnect plan’s formulary (list of covered medications) or obtain an exception from the plan.  This may require switching between brand names and generic prescriptions.

 

Hospitals

Hospitals are not included in continuity of care.  Generally, if an enrollee is in a hospital during their transition to a Cal MediConnect plan, their previous form of Medicare coverage (Original/ fee-for-service Medicare or Medicare Advantage plan) will be responsible for the Part A services for that entire hospital stay.  The Cal MediConnect plan will be responsible for Part B physician services starting the first day of enrollment. Physicians providing those Part B services who are not in the Cal MediConnect network should request continuity of care as described above.

 

Providers Not Covered by Continuity of Care

Enrollees in a Cal MediConnect plan must use in-network providers for most non-physician services such as transportation, durable medical equipment, and medical supplies.  Enrollees will also have to use home health or physical therapy providers who are in their plan’s network upon enrollment.

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Multiple Continuity of Care Periods

If a Cal MediConnect enrollee changes enrollment to another Cal MediConnect plan, the 6- or 12-month continuity of care period may start over one time. If the enrollee changes plans a second time (or more), the continuity of care period does not start over. If an enrollee returns to fee-for-service Medicare and later re-enrolls in a Cal MediConnect plan, the continuity of care period does not start over.

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Contracting with Cal MediConnect Plans

If you are a provider and want to find out more about how to join the network of Cal MediConnect plans in your county, please contact the plans – you can find their contact information here.

Please note that most health plans contract with IPAs and medical groups. In these instances, physicians may have to join the health plan network by contracting with those groups. Each plan can provide a list of its Cal MediConnect contracted IPAs and medical groups.

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[1] Acute or serious chronic conditions, pregnancy, terminal illness, care of newborn child from birth to 36 months, or performance of surgery or other procedure authorized by the plan as part of a documented course of treatment. (California Health and Safety Code, Section 1373.96)

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