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
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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.)
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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.
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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.
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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.
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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.
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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).
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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).
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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.
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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:
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
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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
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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.
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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.
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*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
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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.
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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.
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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
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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.
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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/.
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Thank You!
Bill Barcellona
Sr. VP Government Affairs
CAPG Sacramento
1215 K Street, Suite 1915
Sacramento, CA 95814
(916) 443-4152
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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
Neighborhood Legal Services of Los
Angeles 223
(800) 896-3202
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
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Questions and Discussion
