Under some circumstances, CCHP will provide continuity of care for new members who are receiving medical services from a non-participating provider, such as a doctor or hospital, when CCHP determines that
continuing treatment with a non-
participating provider is medically
appropriate. If you are a new member, you may request permission to continue receiving medical services from a non- participating provider if you were receiving this care before enrolling in CCHP and if you have one of the following conditions:
CONTRA COSTA HEALTH PLAN
Medi-Cal Evidence of Coverage & Disclosure Form
Rev. 08.21.14 EOC-18 Medi-Cal 2014-2015_EOC
x An acute condition. Completion of covered services shall be provided for the duration of the acute condition.
x A serious chronic condition. 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 CCHP in consultation with you and the non-participating provider, and consistent with good professional practice. Completion of covered services shall not exceed twelve (12) months from the time you enroll with CCHP.
x A pregnancy, including postpartum care. Completion of covered services shall be provided for the duration of the pregnancy.
x A terminal illness. Completion of covered services shall be provided for the duration of the terminal illness. Completion of covered services may exceed twelve (12) months from the time you enroll with CCHP.
x Performance of a surgery or other procedure that your previous plan authorized as part of a documented course of treatment and that has been recommended and documented by the non-participating provider to occur within 180 days of the time you enroll with CCHP.
Please contact us at 1-877-661-6230 (press 4) to request continuing care or to obtain a
copy of our Continuity of Care policy. Eligibility to receive continuity of care is normally based on your medical condition. Eligibility is not based strictly upon the name of your condition.
We will request that the non-participating provider agree to the same contractual terms and conditions that are imposed upon participating providers providing similar
services, including payment terms. If the non-participating provider does not accept the terms and conditions, CCHP is not required to continue that provider’s services. CCHP is not required to provide continuity of care as described in this section to a newly covered member who was covered under an individual member agreement and undergoing a treatment on the effective date of her Medi-Cal coverage. Continuity of care does not provide coverage for benefits not otherwise covered under this agreement If a request is granted or denied, the Plan will inform the member in writing as to the decision within five (5) business days or up to thirty (30) days if additional information is requested and necessary to make a determination. If we determine that you do not meet the criteria for continuity of care and you disagree with our determination, see CCHP’s Grievance and Appeals Process in Section 8.
If you have further questions about continuity of care, you are encouraged to contact the Department of Managed Health Care (DMHC) which protects HMO consumers. The DMHC can be contacted by telephone at its toll-free telephone number, 1-888-HMO-2219; or at the TDD number for the hearing impaired, 1-877-688-9891;
or online at www.hmohelp.ca.gov.
Continuity of Care - Terminated Provider
When CCHP and a provider end their contract, you may be able to get continuity of care. See below on how to ask CCHP for continuity of care. If CCHP ends a contract with a provider group or hospital, we will tell you in writing sixty (60) days before it happens. We will also tell you which provider group or hospital you will be re- assigned to. If CCHP ends an agreement with a provider group or hospital without notice to avoid a danger to our members,
CONTRA COSTA HEALTH PLAN
Medi-Cal Evidence of Coverage & Disclosure Form CCHP will tell all members assigned to that
provider group or hospital within thirty (30) days of that date.
If you are being treated for a specific condition when we end a contract with a participating provider (for reasons other than medical disciplinary cause, criminal activity, or the provider’s voluntary termination), you may be able to continue getting covered care from the provider for your condition. These specific conditions are:
x An acute condition (See Section 2 for definition) for the duration of the acute condition;
x A serious chronic condition (See Section 2 for definition), for a duration enough to complete a course of treatment and arrange for a safe transfer, not to exceed twelve (12) months from the contract’s end date;
x A pregnancy, for the duration of the pregnancy and the immediate post- partum period;
x A terminal illness (See Section 2 for definition), for the duration of the terminal illness;
x Care for a newborn child whose age is between birth and thirty six (36) months, for a period not to exceed twelve (12) months from the contract’s end date; x Performance of surgery or other
procedure that has been okayed by the plan as part of a documented course of treatment and has been recommended and documented by the provider to occur within one hundred eighty (180) days of the contract’s end date.
You may ask CCHP to allow medically necessary treatment by that provider until the services are done, but no longer than twelve (12) months from the end of the contract (unless otherwise stated above). CCHP will pay the provider for benefits, but
writing the same terms and conditions of the terminated provider’s previous agreement. This includes payment that’s similar to currently contracting providers giving similar services and who are practicing in a similar location area as the terminated provider. If the terminated provider does not accept these same terms, conditions and rates, then CCHP does not have to continue providing such services.
Asking for Continuity of Care
x You can write CCHP or come to our offices;
x Your request will be given to Utilization Management (UM);
Whenever possible, your request should be made to the attention of UM at:
Contra Costa Health Plan 595 Center Ave. Suite 100
Martinez, CA 94553 or call 1-877-661-6230 (press 4). If you ask for continuity of care services, UM will document the request and get back to you at the time the request is made. Each verbal or written request should include: x The name and contact information of
your existing provider,
x How long you have seen this existing provider,
x The services being given by the existing provider, and
x Why you think you should continue with this existing provider.
As soon as UM gets reasonably necessary information it will decide whether to grant or deny your request for continuity of care. This decision will be made in a timely manner appropriate for the nature of the member’s clinical condition. If a request is granted or denied, CCHP will tell you in writing within 5 business days or up to 30
CONTRA COSTA HEALTH PLAN
Medi-Cal Evidence of Coverage & Disclosure Form
Rev. 08.21.14 EOC-20 Medi-Cal 2014-2015_EOC
days if we need and ask for more information to make a decision.
If you would like to ask for a copy of our continuity of care policy, please call Authorizations at 1-877-661-6230 (press 4).
Continuity of Care - Exemptions to Continue Medi-Cal Fee-For-Service
If you are an American Indian or a member of an American Indian household or you choose to get health care services through an Indian Health Service facility and you have written acceptance from an Indian Health Service facility for care on a fee-for-service basis, you may request an exemption to continue Medi-Cal fee-for-service for up to twelve (12) months.
If you are getting fee-for-service Medi-Cal treatment from a Medi-Cal provider who’s not under contract with CCHP, you may ask for a medical exemption to continue fee-for- service Medi-Cal. You must have a “complex medical condition” as defined in California Law.
x If the Health Care Options Program gives you a medical exemption, you may continue treatment with a fee-for-service provider until your medical condition stabilizes enough to allow you to safely move to a CCHP provider.
x You will have up to twelve (12) months from the date the medical exemption is first allowed by the Health Care Options Program (subject to extension).
x Your fee-for-service treating doctor and DHCS will decide whether the medical condition has stabilized.
x If you are given an exemption because of pregnancy, you may stay with the fee- for-service Medi-Cal provider through delivery and the end of the month in which ninety (90) days after birth occurs.
California Children’s Services (CCS) For Eligible Medi-Cal Members under the Age of 21
You have the right to services for your children (eligible Medi-Cal members under the age of 21) who qualify for the California Children’s Services (CCS) program. A child may be eligible to get CCS services if he or she has a qualifying condition.
x A qualifying condition is a serious illness or chronic medical condition. x When a child is determined by the
County CCS program to be eligible for CCS services, CCHP will give primary care and services unrelated to the CCS eligible condition and will coordinate services with the CCS program.
x CCHP will provide medically necessary covered services until CCS eligibility has been determined.
For more information about CCS and how to access CCS services from providers outside
of CCHP’s network, call CCHP’s
Authorization Unit at (925) 957-7260 or call CCS at (925) 313-6100. The CCS Coordinator and CCS staff can tell you which providers you may use for services related to your child’s CCS-eligible condition.
How to Use the Medi-Cal Fee-For-Service Program
x When you use the Medi-Cal Fee-For- Service program for Medi-Cal benefits that are not covered by CCHP, you must find a provider who is contracted by the State for these services and who will accept Medi-Cal payment.
x You should then take your Medi-Cal Beneficiary Identification Card (BIC) to the provider who has agreed to give you the service.
x For additional information, please call a Member Services Representative at 1-
CONTRA COSTA HEALTH PLAN
Medi-Cal Evidence of Coverage & Disclosure Form 877-661-6230 (press 2), For hearing
impaired call California Relay at 1-800- 735-2929.