Continuity of Care


Keep same doctors even if you change Insurance Plans or Networks…

Continuity of care

Continuity of care with a Non-Participating Provider may be available if your provider leaves the Blue Shield network, or if you are a newly-covered Member whose previous health plan was withdrawn from the market.

You can request to continue treatment with your Non-Participating Provider in the situations described above if you are currently receiving the following care:

 Ongoing treatment for an acute or serious chronic condition;
 Pregnancy care, including care immediately after giving birth;
 Treatment for a terminal illness;
 Other services authorized by a now-terminated provider as part of a documented course of treatment; or
 Care for a child up to 36 months old.

To request continuity of care,  fill out the Continuity of Care Application. Blue Shield will confirm your eligibility and review your request for Medical Necessity.

The Non-Participating Provider Finder must agree to accept Blue Shield’s Allowed Charges as payment in full for your ongoing care. If the  provider agrees and your request is authorized, you may continue to see the Non-Participating Provider at the Participating Provider Cost Share for:

 Up to 12 months; or
 If you have a terminal illness, for the duration of the terminal illness.  Excerpt from Blue Shield Trio Silver HMO EOC 

See the Your payment information section for more information about the Allowed Charges.

Continuity of Care
SB 133

For people who buy their own insurance and have to switch plans because their insurer is pulling up stakes, the Hernandez bill would require the new plan to cover treatment by the same physicians, even if they are not in the new insurer’s network.

The provision would apply for enrollees under treatment for a chronic, acute or terminal illness, and in cases of pregnancy. The coverage would be contingent on the doctor accepting the payment offered by the new health plan, and the insurer would have to continue covering the services of that provider for up to one year. The coverage could extend beyond a year if the patient were terminally ill.

Similar protections already exist for people with job-based insurance policies that are under the purview of state regulators.  CA Healthline

Commonwealth Fund explanation of ACA/Obamacare and it’s effect on State Law

Blue Shield Flyer on Continuity of care

SB 133, Health care coverage: continuity of care.

LEGISLATIVE COUNSEL’S DIGEST

Existing law requires a health care service plan and a health insurer that provides services at alternative rates of payment, at the request of an enrollee or insured, to provide the completion of services by a terminated provider if the enrollee or insured is undergoing a course of treatment for one of any specified conditions, including a serious chronic condition… Existing law also requires a health care service plan to provide for the completion of covered services by a nonparticipating provider to a newly covered enrollee who, at the time his or her coverage became effective, was receiving services from that provider for one of any specified conditions. Existing law prohibits completion of covered services for a serious chronic condition from exceeding 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee or insured. Existing law requires a health care service plan to provide a disclosure form regarding the benefits, services, and terms of a plan contract and requires the disclosure form to include a description of how an enrollee can request continuity of care under the provisions described above.

This bill would provide that an enrollee or insured who has a condition that will require a transplant is not limited by the 12-month period described above and would require the completion of covered services to be provided for the duration of the condition and until the time he or she undergoes the transplant surgery and receives the necessary followup care that is consistent with good professional practice.

***

Continuity of Care?
AB 369

California Bill AB 369 requires a health plan, at the request of a newly covered enrollee under an individual contract, or a health insurer at the request of a new covered insured under an individual insurance policy, to arrange for the completion of covered services by a non-participating provider for one of the conditions specified in existing law, if the new covered enrollee or insure meets both of the following:

  1. Had coverage that was terminated between December 1, 203 and March 31, 2014, inclusive because the plan or insurer ceased to provide or arrange health benefits or the plan or insurer withdrew from the market; and,
  2. At the time coverage became effective, the newly covered enrollee or insured was receiving services from that provider for one of the specified condition.  healthnet pulse.com

Blue Cross information and form to request continuity of care

special-enrollment-triggering-events/md-network/

Blue Shield 

Health Net Individual Form to request continuity of care

Transfer Rights

10133.56.  (a) A health insurer that enters into a contract with a professional or institutional provider to provide services at alternative rates of payment pursuant to Section 10133 shall, at the request of an insured, arrange for the completion of covered services by a terminated provider, if the insured is undergoing a course of treatment for any of the following conditions:

(1) An acute condition. An acute condition is 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.
(2) A serious chronic condition. A serious chronic condition is 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 treatment and to arrange for a safe transfer to another provider, as determined by the health insurer in consultation with the insured and the terminated provider and consistent with good professional practice. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date.
(3) A pregnancy. A pregnancy is the three trimesters of pregnancy and the immediate postpartum period. Completion of covered services shall be provided for the duration of the pregnancy.
(4) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of covered services shall be provided for the duration of a terminal illness, which may exceed 12 months from the contract termination date.
(5) The care of a newborn child between birth and age 36 months. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date.
(6) Performance of a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract’s termination date.

Laws may change FASTER than we can keep up.  Be sure to visit the State of CA website on Insurance Law, before using anything in a citation.

AB 369 HN Bulletin Continuity of Care  health net pulse.com

Medicare Advantage Plans in 2015 will allow you to opt out if the MD Network is significantly changed.

medicare-advantage-plans/#comment-11065  carriers have been notifying clients if during the year a provider chooses to cancel their HMO contract since those folks have to pick a new PCP

Specimen Policy #EOC with Definitions

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy with Definitions

Steve Explains how to read EOC

FYI  Health Net  Forms

Transition of Care

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4 comments on “Continuity of Care same doctor chronic illness if you change plans

  1. I might be losing Medi-Cal as I’ll be making too much money.

    I have chronic pain, and am prescribed an opioid to control it.

    Because it’s a controlled substance, I can get only a 30 day supply of pain meds at a time.

    However, if I were to transition out of Medi-Cal and go with a new health care provider, it could take 90+ days to see a new specialist who could prescribe pain meds

    So there would be a 60+ day gap of no pain meds, not good.

    Would “continuity of care” apply to me?

  2. My son was diagnosed with Hodkins Lymphoma in June 2018 and he will turn 26 in April 2020. He is on my UHC health care plan through my employer. He is in remission currently but will need maintenance treatment that goes beyond his birthday next year.

    1) Can he get a waiver from UHC to continue the treatment just to complete this maintenance treatment, several months after his birthday, say to the middle or end of 2020?

    • Please read this page carefully, 3 times and then when you think you understand it, read it again. Justice Felix Frankfurter.

      Continuity of care and I’ve only read this page ONE time, seems to only apply to a new company taking over care, nothing to force a current company to continue coverage.

      Check out COBRA, Disabled Children and of course an individual plan under ACA/Obamacare would be guaranteed issue, no pre x and when you lose coverage, you have a special enrollment. Get quotes here.

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