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.

Behavioral Health Care Services for Group Care Members

  • Maintains a process for block transfers of enrollees from a terminated provider group to a new provider group or hospital.
  • Maintains a process to facilitate the Continuity of Care (COC) for a new enrollee who has been receiving services from a non-participating mental health provider for an acute, serious, or chronic mental health condition when an employer changes health plans. This includes a reasonable transition period to continue the course of treatment with the NPP prior to transferring to a participating provider and includes the provision of mental health services on a timely, appropriate, medically necessary basis from the NPP. The process provides that the length of time of the transition period take into account on a cases-by-case basis, the severity of the enrollee’s condition and the amount of time reasonably necessary to make a safe transfer. The process ensures that reasonable considerations are given to the potential clinical effect of a change of provider on the member’s treatment of the condition. The process describes the process to review a member’s request to continue the course of treatment with the NPP mental health provider.
  • Non-participating mental health providers are not required to be contracted with the Alliance or its delegate but will require a written contract as a condition of the right to treat an Alliance member, defining the same contractual terms and conditions that are imposed upon the participating providers, including location within the service area, reimbursement methodologies and rates of payment. This will include a quality review assessment of the NPP mental health provider.
  • Facilitates the completion of covered services pursuant to California H&S Code Section 1373.96.
  • Provides an Evidence of Coverage (EOC) for member communication describing the policy and informing members of their rights to the completion of covered services.
  • Maintains processes to ensure that reasonable consideration is given to the potential clinical effects on a member’s treatment caused by a change in provider.

In the event a provider is terminated, all assigned members are notified in writing of the termination and their right to continue care 60 days prior to the termination effective date, and are informed of the procedures for selecting another provider.