Continuity of Care in California: Can You Keep Your Doctor?

Continuity of care

#Introduction

Continuity of care definition means that you may be able to use a  Non-Participating Provider  if your provider leaves your insurance companies network, or if you are a newly-covered Member whose previous health plan was withdrawn from the market. (Please follow the links and requests for care, it may be that any prior plan counts)

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;  FYI see also Hospice
 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 your Insurance Companies Continuity of Care Application. and show  Medical Necessity.

The Non-Participating Provider Finder must agree to accept your Insurance Companies  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. * ^{Sample Group Health Plan} *   ^{Excerpt from Blue Shield Trio Silver HMO EOC} 

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

• Health Net Continuity of Care Assistance Request Forms
  • Policy Details
• LA Care Explanation
• Sample Group Health Plan *
  • Excerpt from Blue Shield Trio Silver HMO EOC 
• dmhc.ca.gov/continuity of care
• See the Advocates Guide to Surprise Medical Bills
• Medi Cal – Continuity of Care  dhcs.ca.gov
  • FAQ’s
• Anthem Info & Link to request for Continuity of Care
  • Request Form

#Continuity of Care
California Senate Bill SB 133 

If you buy your own coverage and your current plan leaves the market your  new plan must 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}

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?
California Assembly Bill 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, 2013 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

• special-enrollment-triggering-events/md-network/
• Blue Shield 1 page summary
• dmhc.ca.gov/continuity of care
• California Code of Regulations  22, § 53286 – Continuity of Care
• AB 1286 Frommer 2004
• AB 369 2014
• Commonwealth Fund explanation of ACA/Obamacare and it’s effect on State Law 4.13.2016
• Blue Shield Flyer on Continuity of care
• SB 133 fact sheet