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.

Servicios de atención médica conductual para miembros de atención grupal

  • Mantiene un proceso para las transferencias en bloque de afiliados de un grupo de proveedores terminados a un nuevo grupo de proveedores u hospital.
  • Mantiene un proceso para facilitar la Continuidad del Cuidado (COC) para un nuevo afiliado que ha estado recibiendo servicios de un proveedor de salud mental no participante para una condición de salud mental aguda, grave o crónica cuando un empleador cambia de plan de salud. Esto incluye un período de transición razonable para continuar el curso del tratamiento con el PNB antes de transferirlo a un proveedor participante e incluye la prestación de servicios de salud mental de manera oportuna, apropiada y médicamente necesaria del PNA. El proceso establece que el período de tiempo del período de transición tiene en cuenta caso por caso, la gravedad de la condición del afiliado y la cantidad de tiempo razonablemente necesario para realizar una transferencia segura. El proceso garantiza que se den consideraciones razonables al efecto clínico potencial de un cambio de proveedor en el tratamiento de la afección por parte del miembro. El proceso describe el proceso para revisar la solicitud de un miembro para continuar el curso del tratamiento con el proveedor de salud mental del PNB.
  • Los proveedores de salud mental no participantes no están obligados a ser contratados con la Alianza o su delegado, pero requerirán un contrato escrito como condición del derecho a tratar a un miembro de la Alianza, definiendo los mismos términos y condiciones contractuales que son impuestos a los proveedores participantes, incluida la ubicación dentro del área de servicio, metodologías de reembolso y tasas de pago. Esto incluirá una evaluación de la calidad del proveedor de salud mental del PNA.
  • Facilita la finalización de los servicios cubiertos de conformidad con la Sección 1373.96 del Código de H&S de California.
  • Proporciona una Evidencia de Cobertura (EOC) para la comunicación de los miembros que describe la política e informa a los miembros de sus derechos para la finalización de los servicios cubiertos.
  • Mantiene los procesos para garantizar que se tengan en cuenta razonablemente los posibles efectos clínicos en el tratamiento de un miembro causados por un cambio en el proveedor.

En caso de que un proveedor sea despedido, todos los miembros asignados son notificados por escrito de la terminación y su derecho a continuar la atención 60 días antes de la fecha de vigencia de la terminación, y se les informa de los procedimientos para seleccionar a otro proveedor.