Continuity of Care (COC) provides continuous care for chronic or acute medical and behavioral health conditions. COC helps Alliance members maintain care that has been established in one setting, as they transition to a new setting, such as a facility to home, facility to facility, providers, service areas, managed care plans or state programs.

Through COC, the Alliance also provides the continuity of covered services to be completEd by a terminated or out-of-network/non-participating provider (NPP) of any type at the member’s request. In accordance with Health and Safety Code Section 1373.96, including medical and mental health service providers.

Current and Newly Enrolled Group Care and Medi-Cal Members

Upon their request, current Alliance members or newly enrolled members with certain conditions may continue to receive an active course of treatment and health care services from a terminated or non-contracted provider for a specific condition and time frame as noted below:

Acute Condition – A medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.

Diagnosed Maternal Mental Health Condition – A mental health condition that impacts a woman during pregnancy, peri- or postpartum, or that arises during pregnancy, in the peri- or postpartum period, up to 12 months after delivery.

Newborn childcare – The care of a newborn child between birth and 36 months. Completion of covered services shall not go past 12 months from the end of the contract or 12 months from when the coverage started for a newly covered member.

Pediatric Palliative Care – A patient and family centered care that optimizes quality of life by anticipating, preventing, and treating suffering for children. For members currently enrolled in the Alliance or transitioning from Medi-Cal FFS, the Alliance will allow, at the request of the member, the provider, or the member’s authorized representative, up to 12 months continuity of care with the out-of-network provider. The Alliance will not provide continuity of care for services that are excluded by the PPC Waiver Program and that are not also covered by Medi-Cal under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) per the California Department of Health Care Services (DHCS) requirements.

Pregnancy – The three (3) trimesters of pregnancy and the immediate postpartum period. Services shall be covered for the duration of the pregnancy and the immediate postpartum period. Immediate postpartum is defined as up to six (6) weeks after birth.

Serious Chronic Condition – A medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time, or requires ongoing treatment to maintain remission or prevent deterioration. Completion of covered services shall be provided for a period of time necessary to complete a course of active treatment and to arrange for a safe transfer to another provider, as determined by the Alliance in consultation with the member and the terminated provider or non-contracting provider, consistent with good professional practice. Completion of covered services under this paragraph shall not exceed 12 months from the end of the contract or 12 months from the start of coverage for a newly covered Member.

Surgeries or Procedures – Performance of a surgery or other procedure will be covered for current members if it has already been authorized by the Alliance, if the surgery or procedure was part of a documented course of treatment and had been recommended and documented by the provider to occur within 180 days of the termination of the provider. For new members, a surgery or procedure will be covered if authorized by a previous plan, as part of a documented course of treatment and had been recommended and documented by the provider to occur within 180 days of the start of coverage for a newly enrolled member.

Terminal illness – An incurable or irreversible condition that has a high probability of causing death within one (1) year or less. Completion of covered services is provided for the duration of the terminal illness, even if it goes past the 12 months from the end of the contract of 12 months from when the coverage started for a new enrollee.

Please Note: The terminated or NPP must agree to terms and conditions and rates consistent with those used by the Alliance or provider group in the same or similar geographic area. This policy is not applicable for current members if the provider was terminated for medical disciplinary cause, fraud or other criminal activity.

If the provider refuses rates or terms, the Alliance will make every effort to transition member to an appropriately qualified in-network provider.

If a qualified in-network provider is not available, the Alliance will continue to negotiate rates or locate another qualified provider to care for member.

團體護理成員的行為健康護理服務

  • 維護將註冊者從終止的提供程式組轉移到新供應商組或醫院的阻止傳輸過程。
  • 在僱主更改健康計畫時,為新註冊者(COC)提供持續護理 (COC) 流程,該註冊者因急性、嚴重或慢性心理健康情況而從非參與精神衛生提供者處獲得服務。 這包括在轉到參與提供者之前繼續接受國家精神衛生中心的合理過渡期,包括從國家精神衛生中心及時、適當、醫療上提供心理健康服務。 該程序規定,過渡期的時間長短應逐案考慮,登記人病情的嚴重程度以及安全轉移的合理必要時間。 該過程確保合理考慮提供者變更對會員治療疾病的潛在臨床影響。 該過程描述了審查成員請求繼續與 NPP 心理健康提供者一起治療的過程。
  • 非參與精神健康提供者無需與聯盟或其代表簽訂合同,但需要書面合同作為公平對待聯盟成員的權利的條件,並定義與聯盟成員相同的合同條款和條件。對參與的提供者施加,包括服務區內的地點、報銷方法和支付率。 這將包括對NPP心理健康提供者進行品質審查評估。
  • 促進根據加州H&S代碼第1373.96條完成涵蓋的服務。
  • 為成員通信提供涵蓋證據 (EOC),描述政策並告知成員完成涵蓋服務的權利。
  • 保持流程,確保合理考慮因提供者變更對會員治療的潛在臨床影響。

如果提供者被終止,則所有分配的成員都將收到終止通知,以及他們在終止生效日期前 60 天繼續護理的權利,並被告知選擇其他供應商的程式。