www.chcs.org

Understanding and LeveragingContinuity of Care

Cal MediConnect Providers Summit

January 21, 2015

Moderator: Jane Ogle, Consultant, Harbage Consulting

Managed Care Quality and Monitoring Division (MCQMD)

California Department of Health Care Services

January 2015

An Overview of Continuity of Care

in Cal MediConnect

Today’s Presentation will Cover

• Different types of Continuity of Care:

▫ Same provider

▫ Same, or completion of, services

▫ Same medications

186

Duals Plan Letter (DPL) 14-004 –

Continued Access and Assessment

• The Medicare-Medicaid Plan (MMP) will ensure continued access to medically-necessary items, services, and medical and long-term

services and supports providers.

• As part of the process to ensure continuity and coordination of care, MMPs must perform a Health Risk Assessment within 90, or 45,

days of a beneficiary's enrollment. (See DPL 13-002 for details.)

187

DPL 14-004 – Out-of-Network

(OON) Provider Continuity

• An MMP is required to offer continuity of care to members who have an existing relationship with an OON provider.

▫ The member, their Authorized Representative, or provider makes a request to the MMP.

▫ The member must have seen the primary care provider at least once, or the specialist at least twice, in the prior 12 months.

▫ The MMP verifies existing relationship with Medicare or Medi-Cal data, or other provider documentation.

▫ The MMP works with the provider to sign a Letter of Agreement for service for the single member.

▫ The provider continues to serves the member and is paid by the MMP.

188

OON Provider Continuity

Requirements

• MMP required timeline for requests:

▫ Begin work on request within 5 working days.

▫ Complete the request process within 30/15/3 calendar days,depending on the urgency of the member’s need.

• The MPP must also make information available:

▫ Inform member of continuity of care protections and the process to initiate.

▫ Train call center and other staff who regularly contact beneficiaries.

▫ Notify members: (1) of an approved request; and (2) about the transition process 30 days before the end of the COC period.

189

OON Provider Continuity Criteria

• The provider must:

▫ Agree to FFS rate.

▫ Not have quality issues that would disqualify them from the MMP’s provider network.

▫ Agree to abide by the MMP’s Utilization Management policies.

• The duration is up to:

▫ Six months for a Medicare provider and 12 months for Medi-Cal.

• OON Provider Continuity is not available for:

▫ DME, ancillary services, transportation, MMP carve-outs or services not covered by Medicare or Medi-Cal.

190

OON Provider Continuity –

Telephone and Retroactive Req.

• The member may make a request over the telephone, if that is the member’s preference. The MMP must have the ability to take all

necessary member information for the request over the telephone.

• Members and providers may make retroactive requests for OON provider continuity reimbursement within certain requirements:

▫ Services occurred after the member’s enrollment into the MMP.

▫ Member/provider relationship prior to MMP enrollment.

▫ Services occurred after September 29, 2014 (date of the DPL).

▫ Limited to a duration of 30 days of retroactive services from start date of services.

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Nursing Facility Continuity

• The previously stated OON provider continuity requirements apply for nursing facility providers.

In addition:

• A member who is a resident of a nursing facility prior to enrollment in Cal MediConnect will not be required to change nursing facilities

for the duration of the Cal MediConnect Demonstration Program.

• This provision is automatic, meaning the member does not have to make a request to the MMP to invoke this provision.

192

OON Provider Continuity and MMP

Enrollment Changes

• If the member changes MMPs, the continuity of care period may start over one time.

• If the member returns to FFS and later reenrolls in Cal MediConnect, the continuity of care period does not start over.

• If the member changes MMPs, the continuity of care policy does not extend to OON providers that the member accessed through their

previous MMP.

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Continuity in the MMP’s Network

When a member: (1) transitions into an MMP; and (2) has an existing

relationship with a provider that is in the MMP’s network:

• The MMP shall allow the member to continue treatment with a Primary Care Provider (PCP).

• If the MMP contracts with delegated entities, the MMP shall assign the member to a delegated entity that has the member’s preferred

PCP in its network.

• The MMP shall allow the member to continue treatment with a doctors for a 12-month period regardless of whether the doctor is in

the network of the prime plan’s delegated entity to which the

member is assigned.

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Health and Safety Code 1373.96

• State law also allows for OON provider continuity (part of Knox Keene Act):

▫ Not limited to members transitioning from fee-for-service Medi-Cal.

▫ Limited to those receiving treatment for a complex condition or pregnancy.

▫ Applies when the member’s doctor leaves the plan.

▫ Does not apply when a member changes plans by choice (otherwise applicable for plan changes).

195

Medication Continuity

• Medicare Part D transition rules and rights will continue as provided for in current law and regulation for the entire integrated formulary

associated with the Cal MediConnect Plan.

• These transition rules and rights noted above include:

▫ The Contractor must provide an appropriate transition process for Enrollees who are prescribed Part D drugs that are not on its

formulary (including drugs that are on the Contractor’s formulary

but require prior authorization or step therapy under the

Contractor’s utilization management rules). This transition

process must be consistent with the requirements at 42 C.F.R. §

423.120(b)(3).

196

Medication Transition Process

Transition process of 42 C.F.R. § 423.120(b)(3)

• Ensure access to a temporary supply of drugs within the first 90 days of coverage under a new plan.

• Ensure the provision of a temporary fill when an enrollee requests a fill of a non-formulary drug (including drugs that are on a plan's

formulary but require prior authorization or step therapy under a

plan's utilization management rules).

• Ensure written notice is provided to each affected enrollee after adjudication of the temporary fill (according to specified

requirements and timeframes).

• Ensure that reasonable efforts are made to notify prescribers of affected enrollees who receive a transition notice.

See actual 42 C.F.R. section for more detail on the requirements.

197

Welfare and Institutions Code

14185 and Medication• Requires specific timelines for plan processing of authorization

requests for drugs.

• When the plan denies the pharmacist’s payment request because prior authorization is lacking, the pharmacist is allowed, in an

emergency, to dispense a 72-hour supply (and the plan must pay).

This allows time to complete prior authorization.

• Plans must allow the continued use of single-source drugs that are part of a prescribed therapy (by a contracting or non-contracting

provider) in effect for the beneficiary immediately prior to the date of

enrollment, whether or not the drug is covered by the plan, until the

prescribed therapy is no longer prescribed by the contracting

physician.

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Contact Information

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If you think of questions later, email:

DHCSMediConnect_MLTSS@dhcs.ca.gov

mailto:DHCSMediConnect_MLTSS@dhcs.ca.gov

Provider Completion of CareCoordination and Hand-Offs

Bill BarcellonaSr. VP Government AffairsCAPG Sacramento1215 K Street, Suite 1915Sacramento, CA 95814(916) 443-4152

DHCS Policies and Rules

• Continuity of Care (COC) – for dually-eligible

beneficiaries differs from the Knox Keene Standard –

there are new rules for Duals!

• Cal MediConnect COC requirements are set forth in

these three documents:

– Welfare & Institutions Code Sect. 14182.17

– CMS-DHCS Memorandum of Understanding (MOU)

– Duals Plan Letter 13-005 (Revised) Dec. 13, 2014

• Detailed FAQs and beneficiary materials also help

201

Pre-Existing State Requirements

• Cal MediConnect standards apply in addition to existing,

underlying continuity of care rights:

– Welfare & Institutions Code 14185(b) – protects access to any

single-source drug that is part of a prescribed therapy in effect

immediately prior to enrollment, whether or not it is covered by

the Cal MediConnect Plan formulary until the therapy is no

longer prescribed by the contracting physician

– Health & Safety Code 1373.96 – Knox Keene Act protections

apply for managed care enrollees in an active course of

treatment for acute or serious chronic conditions, scheduled

procedures, terminal illness, and pregnancy. Differing time

frames apply under these rights

202

Safe Transition is the Goal

• COC concerns Physician-Patient relationships that exist because of an active course of treatment or scheduled procedure for:– An acute episode requiring treatment

– A chronic condition requiring ongoing treatment

• “Continuity of care protections work a little differently for various types of providers under the CCI. Beneficiaries have the right to continue to receive needed services, but eventually, they must get all covered services from providers who work with the plan.”– Source: http://www.calduals.org/providers/#carecoordination.

203

http://www.calduals.org/providers/

Provider’s Role in Care Transition 204

Transitioning Provider:• Consider a plan network

relationship

• Communicate with the Cal MediConnect Plan or network doctor

• Detail remaining course of treatment to be completed

• Request, review and execute the COC agreement

Delegated ReceivingProvider:• Know the Plan process

• Complete the 90-day patient assessment

• Request periodic updates from the COC provider

• Plan for a full transition of care and keep the patient advised

Physicians should cooperate for the good of the patient and in compliance with their ethical standard of care, recognizing the transition of coverage:

Terms of Cal MediConnect Continuity of Care

• Either a beneficiary or his/her treating out-of-network

physician/provider may request continuity of care

• A Cal MediConnect Plan must allow a beneficiary to maintain

an existing provider relationship and service authorizations at

the time of enrollment for:

– Up to six months for Medicare services under W&I Code

14132.275(k)(2)(A)

– Up to 12 months for Medi-Cal services under W&I Code

14182.17(d)(5)(G)

– Medicare Part D transition rules continue as provided for the entire

integrated formulary associated with the Cal MediConnect Plan

• COC providers can agree to shorter time periods

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Eligible Provider Relationships

• If your beneficiary enrolls in a Cal MediConnect or Medi-Cal managed care health plan and you are not part of the network, your beneficiary has a right to see you for up to six months for Medicare services and 12 months for Medi-Cal services – if you and the plan reach agreeable terms. You must:– Have seen the beneficiary at least once in the 12 months before

his or her enrollment in the plan for primary care, and twice for specialists

– Be willing to work with the plan;

– Accept payment from the plan;* and

– Not be excluded from the plan’s network for quality or other concerns.

206

*The higher of the Medicare or plan rate for services

Excluded Provider Relationships

• Continuity of care protections do not apply to:– Suppliers of medical equipment

– Medical supplies

– Transportation services and providers

– Home health providers

– Physical therapy providers

• Plans may choose not to provide COC where– An existing provider relationship cannot be proven

– The out-of-network provider refuses to accept the fee schedule

– Documented quality of care concerns

• And remember that no COC rights exist for services not covered by Medi-Cal or Medicare

207

COC for Medi-Cal Benefits

• Nursing Facilities: Beneficiaries have the right to stay

in their current nursing home under Cal MediConnect,

unless it is excluded from the plan’s network for quality

or other concerns.

• Long Term Supports & Services (LTSS): Beneficiaries

won’t have to change In-Home Supportive Services

(IHSS), Community-Based Adult Services (CBAS) or

Multipurpose Senior Services Program (MSSP)

providers.

208

Mechanisms to Identify COC needs

Plans and their network providers are required to identify and facilitate COC needs:

• Health Risk Assessments (HRAs): Plans will conduct HRAs to identify higher risk beneficiaries who could benefit from care coordination.

• Interdisciplinary Care Teams: Teams composed of the beneficiary, the plan care coordinators and key providers will help manage and coordinate care for the higher risk beneficiaries.

• Individualized Care Plans: Care plans will facilitate timely access to care and services needed by beneficiaries.

• Plan Care Coordinators: Coordinators will help facilitate communication among a beneficiary’s providers, including physicians, long-term supports and services providers and behavioral health providers. They will also help connect beneficiaries to social services to help them live as independently as possible.

• 90-day Patient Assessment Visit: Once the beneficiary is enrolled into the Cal MediConnect plan, the in-network physician must conduct an assessment visit within 90 days.

209

Handling the Request

• Once made, the Plan has three deadlines under which to

process the COC request:

– 30 calendar days from date of receipt of the request

– 15 calendar days if the beneficiary’s medical condition is more

urgent, or there is an upcoming appointment or “other pressing

care need”

– 3 calendar days if there is risk of harm to the beneficiary

• Common requests

• Beneficiaries have grievance and appeals rights

210

Retroactive Continuity of Care

• Plans will retroactively approve and reimburse physicians for continuity of care for services that were already provided if requirements are met.

• All physician continuity of care requirements continue to apply, including a validated preexisting relationship between the beneficiary and physician.

• The beneficiary, authorized representative or physician providing continuity of care must request the continuity of care within 30 calendar days of the first service provided after the beneficiary joins the Cal MediConnect plan.

• The physician can continue to treat the beneficiary for those 30 days and will be reimbursed if all continuity of care requirements are met.

• Once the plan and physician have agreed to terms, the physician must agree to follow the Cal MediConnect plan’s utilization management requirements.

211

Information Sources

Beneficiary Fact Sheet: http://www.calduals.org/wp-

content/uploads/2014/02/ContinuityofCare_14-02-

131.pdf.

Provider Fact Sheet: http://www.calduals.org/wp-

content/uploads/2014/11/PhysToolkit-

ContOfCare_11.10.14.pdf.

COC Reference Page: http://www.calduals.org/continuity-

of-care-under-cal-mediconnect/.

212

http://www.calduals.org/wp-content/uploads/2014/02/ContinuityofCare_14-02-131.pdfhttp://www.calduals.org/wp-content/uploads/2014/11/PhysToolkit-ContOfCare_11.10.14.pdfhttp://www.calduals.org/continuity-of-care-under-cal-mediconnect/

Thank You!

Bill Barcellona

Sr. VP Government Affairs

CAPG Sacramento

1215 K Street, Suite 1915

Sacramento, CA 95814

(916) 443-4152

wbarcellona@capg.org.

213

mailto:wbarcellona@capg.org

Cal MediConnect

Continuity of Care

The Consumer Experience

Cal MediConnnect Ombudsman for LA County

214

Neighborhood Legal Services of Los

Angeles

The Role of the Ombudsman

Neighborhood Legal Services of Los

Angeles (NLSLA), the Cal MediConnect

Ombudsman for Los Angeles County, works

to ensure that beneficiaries can access all

needed medical care. This includes

consumer education and direct consumer

assistance with continuity of care requests

for Medicare and Medi-Cal covered

services.

Neighborhood Legal Services of Los Angeles 215

Special Considerations Regarding Continuity

of Care for Dually Eligible Beneficiaries

Dually eligible beneficiaries are among our most vulnerable community members and face many challenges to accessing care:◦ Elderly and frail individuals◦ Complex medical conditions◦ Cognitive impairment ◦ Mental health issues◦ Language barriers◦ Low literacy

Many dually eligible beneficiaries are unable to request continuity of care on their own behalf without significant assistance

Neighborhood Legal Services of Los Angeles 216

Continuity of Care Challenges

Non-Contracted Providers

◦ Require CoC authorizations

◦ Time limits

◦ Connecting member with network services

Contracted Providers

◦ Specialists may require CoC authorizations

◦ Connecting member with network services

Neighborhood Legal Services of Los Angeles 217

Continuity of Care Challenges

Passive enrollment surprise

Retroactive authorizations

Durable Medical Equipment (DME) and supplies

Physical, speech and occupational therapy

Transportation

Neighborhood Legal Services of Los Angeles 218

Case Example – Stella

Passively enrolled in a Cal MediConnect plan

82 years old: diabetes, cancer

Same oncologist for past six years

PCP is contracted with Stella’s Cal

MediConnect plan

Needs testing strips, incontinence supplies,

and transportation to appointments

Wants to continue seeing oncologist

Neighborhood Legal Services of Los Angeles 219

Case Example – Gilbert

Passively enrolled in a Cal MediConnect

plan effective 12/1/14

DOB 12/17/43; 71 years old

Appointment in PCP office 12/1/14

PCP is not contracted with Gilbert’s Cal

MediConnect plan

Needs: chemotherapy, transportation to

appointments

Neighborhood Legal Services of Los Angeles 220

Case Example – Gilbert

Passively enrolled in a Cal MediConnect plan effective 12/1/14

DOB 12/17/43; 71 years old

Appointment in PCP office 12/1/14

PCP is not contracted with Gilbert’s Cal MediConnect plan

Treated by PCP

PCP does not run insurance during visit

PCP seeks payment

Neighborhood Legal Services of Los Angeles 221

What Can Providers Do to Help

Their Patients? Contract with Cal MediConnect plans

Comply with CoC authorization process

Forward prescriptions and treatment authorization requests (TARs) to plans, as requested

Educate patient on Cal MediConnect network and accessing plan resources

Engage with the state and health plans to provide feedback and recommendations to improve the continuity of care process

Neighborhood Legal Services of Los Angeles 222

David Kane, Staff Attorney

davidkane@nlsla.org

Neighborhood Legal Services of Los

Angeles 223

(800) 896-3202

mailto:davidkane@nlsla.org

Provider Summit

Cal MediConnect

Los Angeles

January 21, 2015

Susan Therese Bell, RN, MBA

Director of CCI

Care1st Health Plan

Care1st was created in 1994 by three medical groups & a disproportionate share hospital dedicated to providing health care services to vulnerable populations through State and Federal government programs

One of the only Traditional and Safety Net provider-owned Health Maintenance Organizations (HMOs) in California

Awarded contracts for Medicare and Medi-Cal

Care1st offers 7,000+ provider networks & serves approximately 480,000 members in California and Arizona, and recently expanded into Texas

NCQA Commendable Accreditation. Ranked as a top Medicaid health plan in California by Consumer Reports.

Early Intervention

Member

Member Service

HRA

&

ICP

Care Manager

Member Outreach

Provider

Caring for Complex Members

Working with our delegated provider groups

Transitioning the member’s care

Providers per DPL 14-004

Vendors, Agencies, DME and LTSS providers

Completing HRA and ICP, if needed

Referrals to Programs and Resources

Behavioral Health

Case Management

HCBS Services

Delegated COC

Care Navigator speaks with beneficiary about their COC needs

Care Navigator provides education to the beneficiary regarding COC

Provider relationship is validated

COC request is forwarded to the Provider Group

Provider group provides authorization and notifies beneficiary

Care Coordination Member Story

New member transitioning out of Hospice Care

Required seamless coordination of services previously provided by Hospice agency

Provider appointments and new orders

Multiple vendors Durable Medical Equipment

Oxygen

Home Health Nurses

Incontinence Supplies

Dually eligible beneficiary coverage

230

Questions and Discussion