+ All Categories
Home > Documents > Understanding and Leveraging Continuity of...

Understanding and Leveraging Continuity of...

Date post: 13-Jul-2020
Author: others
View: 1 times
Download: 0 times
Share this document with a friend
Embed Size (px)
of 47 /47
www.chcs.org Understanding and Leveraging Continuity of Care Cal MediConnect Providers Summit January 21, 2015 Moderator: Jane Ogle, Consultant, Harbage Consulting
  • 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


  • 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.)


  • 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.


  • OON Provider Continuity


    • 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.


  • 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.


  • 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.


  • 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.


  • 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.


  • 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.


  • 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).


  • 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. §



  • 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.


  • 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



  • Contact Information


    If you think of questions later, email:

    [email protected]

    mailto:[email protected]

  • 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


  • 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


  • 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.



  • Provider’s Role in Care Transition 204

    Transitioning Provider:• Consider a plan network


    • 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


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


    – 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


  • 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.


    *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


  • 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)



  • 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.


  • 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


  • 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.


  • Information Sources

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



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



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




  • Thank You!

    Bill Barcellona

    Sr. VP Government Affairs

    CAPG Sacramento

    1215 K Street, Suite 1915

    Sacramento, CA 95814

    (916) 443-4152

    [email protected]


    mailto:[email protected]

  • Cal MediConnect

    Continuity of Care

    The Consumer Experience

    Cal MediConnnect Ombudsman for LA County


    Neighborhood Legal Services of Los


  • 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


    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


    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


    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

    [email protected]

    Neighborhood Legal Services of Los

    Angeles 223

    (800) 896-3202

    mailto:[email protected]

  • 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 Service




    Care Manager

    Member Outreach


  • 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


    Home Health Nurses

    Incontinence Supplies

    Dually eligible beneficiary coverage

  • 230

    Questions and Discussion