Continuity of Care
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
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. The bill would require a health care service plan to include notice of the process to obtain continuity of care in its disclosure form and in any evidence of coverage issued after January 1, 2018. The bill would also require a plan to provide a written copy of this information to its contracting providers and provider groups, and a copy to its enrollees upon request.
Existing law requires a health care service plan and a health insurer to arrange for the completion of covered services by a nonparticipating provider for one of any specified conditions for a newly covered enrollee or a newly covered insured under an individual health care service plan contract or an individual health insurance policy if, at the time his or her coverage became effective, the newly covered enrollee or newly covered insured was receiving services from that nonparticipating provider for a specified condition and whose prior coverage was withdrawn from the market between December 1, 2013, and March 31, 2014, inclusive, as specified.This bill would delete the requirement that coverage was withdrawn from the market between December 1, 2013, and March 31, 2014, inclusive, thereby extending the requirement described above to any prior coverage that was withdrawn from the market. The bill would also require a health care service plan and a health insurer to arrange for the completion of covered services by a nonparticipating provider for a newly covered enrollee and a newly covered insured under an individual health care service plan contract or an individual health insurance policy if the health care service plan or health insurer withdrew a health benefit plan from an entire, or from a portion of a, geographic region of the state, as described.
Continuity of Care?
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:
- 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,
- 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
receiving care from that provider for any of the following conditions, and the completion of covered services required to be provided apply to services rendered to you on and after your effective date of your current coverage with Health Net:
- An acute condition (including an acute mental health 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;
- A serious chronic condition (including a serious chronic mental health condition) not to exceed twelve months from your effective date of coverage under your current Health Net plan. 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;
- A pregnancy (including the duration of the pregnancy and immediate postpartum care);
- Care of a newborn up to 36 months of age not to exceed twelve months from your effective date of coverage under your Health Net plan;
- A terminal illness (for the duration of the terminal illness). A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less; or
- A surgery or other procedure that has been authorized by your prior health carrier as part of a documented course of treatment. AB 369 HMO Health Net Member Letter
Blue Cross information and form to request continuity of care