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DHCS announces new continuity of care rules for duals demonstration project



September 17, 2014
Area(s) of Interest: Access to Care Advocacy Payor Issues and Reimbursement Public Payors 

The California Department of Health Care Services (DHCS) recently announced new continuity of care rules for the Cal MediConnect duals demonstration project. The project – an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities – transitions a large portion of the state's dual eligible beneficiaries to managed care plans.


Although the program already had continuity of care provisions, the new rules make it easier for a patient to continue receiving needed care from out-of-network physicians without interruption.


The new continuity of care rules allow beneficiaries who meet certain criteria to keep their current providers for up to six months for Medicare services and up to 12 months for Medi-Cal services. Patients must demonstrate they’ve seen the out-of-network physician at least once in the previous 12 months for primary care and twice in the previous 12 months for specialists.


Providers can request continuity of care


The new rules will now allow providers to request continuity of care for their patients under the duals demonstration project. Previously, only the patient could initiate such a request. This new rule will help beneficiaries who have difficulty navigating the health care system so they can maintain their provider for up to 12 months.


Continuity of care can be requested via telephone


Under the new rules, continuity of care requests can be made via telephone and plans will be prohibited from requiring beneficiaries to submit a request through a paper form.


Plans must process request within 3 days


Under the new rules continuity of care requests must be processed within three days if there is a risk of harm to the beneficiary. Urgent requests will be processed within 15 days and all other requests are to be processed within 30 days.


Retroactive continuity of care


Under these new rules, providers or the beneficiary can now request continuity of care after delivering the service – ensuring payment for treatment. To qualify, the request must be received within 20 business days of the first service following the beneficiaries’ enrollment in Cal MediConnect. Once a beneficiary is approved for continuity of care, providers must work with the health plans to ensure compliance with the plan’s utilization and management policies.


These changes in continuity of care do not apply to providers of DME, transportation or ancillary services.


DHCS is expected to release a Dual Plan Letter within the next few weeks with direction on the new continuity of care rules for the Cal MediConnect population with an effective date.


CMA is pleased with the efforts DHCS has made to strengthen the physician-patient relationship and will continue to work with the department in ensuring adequate access to care.

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