지속적인 진료 및 관리형 의료 – 자주 묻는 질문
Members who mandatorily transition from Medi-Cal Fee for Service (FFS) to enroll in a Medi Cal Managed Care Plan (MCP) on or after January 1, 2023 have the right to request Continuity of Care (CoC) with providers. Members may request up to 12 months of CoC with a provider if a verifiable pre-existing relationship exists with that provider. Additionally, if a Member has one of the conditions listed in Health and Safety Code (HSC) section 1373.96, the MCP must provide CoC for the completion of a course of treatment for that specific condition by a terminated provider or by a nonparticipating provider at the Member’s request. Members also have the right to CoC for Covered Services and active prior treatment authorizations for Covered Services.
CoC Policy for the 2024 MCP Transition provides guidance to previous and receiving MCPs, both Prime MCPs and their subcontractors, about their obligations to ensure CoC for Members required to change MCPs on January 1, 2024.
2024년 MCP 전환 시에는 보호 방식이 달라집니다. 2024년 MCP 전환에 대한 자세한 내용과 달라지는 방식에 대한 자세한 내용은 치료의 연속성 | 관리형 의료 보험 전환 | DHCS를 참조하세요.
Below you will find the most frequently asked questions for new Medi-Cal Managed Care Members. In the frequently asked questions, a Medi-Cal managed care health plan will be referred to as the “Plan.”
1. If a Member’s provider does not contract with any of the Medi-Cal managed care health plan(s) (Plans) that are available in the Member’s county, how may the Member continue to see this provider?
Answer 1a: If the Member was seeing a FFS provider before being required to enroll into a Plan, the Member may be able to continue to see the FFS provider for up to 12 months while remaining enrolled in the Plan. This 12-month period is the “CoC period.” To continue care with an FFS provider, the Member must:
- 새 요금제에 문의하세요.
- Tell the Plan that they want to continue to receive health care from the FFS provider, and
- 플랜에 FFS 제공업체의 이름을 알려주세요.
The Member may continue to see the FFS provider when the Plan determines that the Member has seen that provider in the past 12 months, the provider has no quality-of-care issues that would make them ineligible for participation in the Plan’s network, and the provider and Plan agree on a payment amount. Within 30 days from the date the Plan received the Member’s request, or sooner if the Member’s medical condition requires more immediate attention, the Plan must tell the Member if they may continue treatment with the FFS provider or if they will be assigned to a provider in the Plan’s provider network. If the FFS provider is willing to continue to see the Member, but the Plan says no, or if the Plan fails to respond to the member’s request in a timely manner, then the Member may file a grievance with the Plan.
Answer 1b: The State now requires Medi-Cal managed care health plans (Plans) to provide some health care services (such as long-term care) that were until recently only available through Medi Cal FFS providers. Members who were receiving such a health care service may request to continue to receive the service from their FFS providers according to the same requirements listed in Answer 1a.
For further information about CoC policies for the populations described in Answers 1a and 1b, please see All Plan Letter 23-022: Continuity of care for Medi-Cal Beneficiaries who newly enroll in Medi-Cal Managed Care from Medi-Cal Fee-for-Service, on or after January 1, 2023.
Answer 1c: Members may also be able to keep seeing their provider if their provider stops participating with the Plan’s provider network. In addition to the requirements set forth in this FAQ for CoC, which are solely based on DHCS policy, additional requirements pertaining to CoC are set forth in the Knox Keene Act, Health and Safety Code H&S section 1373.96 and require most health plans in California—including Medi-Cal plans—to, at the request of a Member, provide for the completion of covered services by a terminated or nonparticipating health plan provider. H&S section 1373.96 requires that these health plans complete services for the following health conditions: acute, serious chronic, pregnancy, terminal illness, the care of a newborn child between birth and age 36 months, and surgeries or other procedures that were previously authorized as a part of a documented course of treatment. Most Plans must allow for the completion of these services for certain timeframes which are specific to each condition and defined under H&S section 1373.96. Under H&S section 1373.96, Members do not need to have transitioned from FFS to Medi-Cal Managed Care to qualify for the completion of services if they have a qualifying health condition. Members should call their Plan for more information about completing services as required by the Knox Keene Act.
2. 회원은 Medi-Cal Managed Care 의료 보험(플랜)의 제공자 네트워크 외부에서 어떤 유형의 제공자를 계속 볼 수 있나요?
A Member may ask the Plan to allow them to continue to see a FFS provider who is not in the Plan’s provider network. A Member may continue to see their FFS provider for 12 months:
- 회원이 현재 FFS 제공업체와 관계를 맺고 있는 경우,
- 플랜에 해당 의료 서비스 제공자에게 의료 서비스 품질 문제가 없는 경우,
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 제공업체는 캘리포니아 주 플랜 승인 제공업체입니다.
If these requirements are met, the Plan must allow the Member to continue to see providers who are physicians; surgeons; specialists; physical therapists; occupational therapists; respiratory therapists; behavioral health treatment providers; speech therapists; durable medical equipment providers; Long-Term Care (LTC) providers which include Skilled Nursing Facilities (SNF), Intermediate Care Facilities for the Developmentally Disabled (ICF/DD), ICF/DD-Habilitative (ICF/DD-H), ICF/DD-Nursing (ICF/DD-N), and Subacute Care (adult and pediatric). The Plan is not required to allow the Member to continue to receive services from providers of radiology; laboratory; dialysis centers; transportation, other ancillary services, carved-out Medi-Cal services (Medi-Cal services that are not provided by the Plan); or services not covered by Medi-Cal.
3. Can any Medi-Cal Member in a Medi-Cal managed care health plan (Plan) continue to see an existing provider who is not part of the plan’s network?
The option to continue seeing an out-of-network provider through the CoC applies to a Member who previously (in the past 12 months) was seeing a Medi-Cal FFS provider and is now required to enroll into a Plan. CoC also applies to specific Medi-Cal Member populations. Members who were receiving specialty mental health services and becomes eligible to receive non-specialty mental health services may receive CoC with psychiatrists and/or mental health providers who are permitted through the California Medicaid State Plan to provide outpatient non-specialty mental health services. CoC also applies to Members who mandatorily transition from Covered California to a Plan, and Members who mandatorily transition from Medi-Cal FFS to enroll in a MCP on or after January 1, 2023. For more information on the 2024 Medi Cal Managed Care Plan Transition Policy please visit Continuity of Care | Managed Care Plan Transition | DHCS.
CoC does not apply to a Member who has been in a Plan for 12 months or more or to a Member who has just become eligible for Medi Cal and must enroll into a Plan. These Members must generally see providers who are part of the Plan’s provider network.
However, Members may also be able to keep seeing their provider if their provider stops participating with the Plan’s provider network. In addition to the requirements set forth in this FAQ for CoC, which are solely based on DHCS policy, additional requirements pertaining to CoC are set forth in the Knox Keene Act, H&S section 1373.96 and require most health plans in California—including Medi-Cal plans—to, at the request of a Member, provide for the completion of covered services by a terminated or nonparticipating health plan provider. The H&S section 133.96 requires these health plans to complete services for the following health conditions: acute, serious chronic, pregnancy and postpartum, terminal illness, the care of a newborn child between birth and age 36 months, and surgeries or other procedures that were previously authorized as a part of a documented course of treatment. Most Plans must allow for the completion of these services for certain timeframes which are specific to each health condition and defined under H&S section 1373.96. Under H&S section 1373.96, Members do not need to have transitioned from FFS to Medi-Cal Managed Care to qualify for the completion of services if they have a qualifying health condition. Members should call their Plan for more information about completing services as required by the Knox Keene Act.
4. If the Member changes from one Medi-Cal managed care health plan (Plan) to another or loses eligibility and then later regains eligibility, does the Member get another 12 month period to see their out-of-network Medi Cal Fee-for-Service (FFS) provider?
The Member only gets 12 months from the date of his or her initial enrollment into a Plan. However, if a Member changes plans within the first 12 months of initial enrollment or loses Medi-Cal Managed Care eligibility and then later regains eligibility, the Member has the right to a new 12 months. If the Member changes plans or loses and then later regains Medi-Cal Managed Care eligibility a second time or more, the 12-month period does not start over and the Member does not have a right to a new 12 months of CoC.
5. When will the Medi-Cal managed care health plan (Plan) notify the Member whether or not they can continue to see their current Medi Cal Fee-for-Service provider?
The Plan is required to process each request and provide notice to each Member no later than 30 calendar days from the date the Plan receives the request, or sooner if the Member’s medical condition requires more immediate attention.
6. Can the Member’s Medi Cal Fee-for-Service (FFS) provider who has been approved by the Medi-Cal managed care health plan (Plan) refer the Member to another out-of-network provider?
No. An out-of-network FFS provider may not refer the Member to another out-of-network provider without prior authorization from the Plan. An out-of-network provider, approved by the Plan, under the CoC period, must work with the Plan and its contracted network of providers. If the Plan does not have the type of specialist in its network that the Member needs, then the Plan must provide the Member with a referral to a medically necessary specialist outside the Plan’s provider network.
7. What if the Member’s Medi Cal Fee-for-Service (FFS) provider will not or cannot work with the Medi-Cal managed care health plan (Plan)?
If the FFS provider will not or cannot work with the Plan, then the Plan will transition the Member to a provider who is part of the Plan’s provider network.
8. 회원에게 활성 치료 승인이 있는 경우 어떻게 되나요?
If a Member has an active prior treatment authorization for a service, it remains in effect following a Member’s enrollment into a Plan for 90 days. The Plan will arrange for services under the active prior treatment authorization with a provider that is in the Plan’s network, or if there is no provider in the Plan’s network to provide the service, with an out-of-network provider if the Plan and out-of-network provider come to an agreement. After 90 days, the active treatment authorization remains in effect for the duration of the treatment authorization or until the Plan provides a new authorization if medically necessary, whichever is shorter.
9. 회원은 내구 의료 장비(DME) 및 의료용품을 보관할 수 있나요?
Yes. Members can keep their existing DME rentals and medical supplies from their existing provider for at least 90 days following their enrollment into a Plan. If the existing provider is not in the Plan’s network of providers, after 90 days, the Plan may switch the Member to a provider that is in the Plan’s network and arrange for new DME and medical supplies to be delivered to the Member if medically necessary. Call your Plan for help with these services.
10. "치료 연속성 기간"(회원 가입일로부터 최대 12개월)이 기존 의료비 면제 요청(MER) 절차에 영향을 미치나요?
DHCS will provide Medi-Cal managed care health plans with a list (the Exemption Transition Data Report) of Members whose MERs were denied. Plans are required to consider a request for exemption from Plan enrollment that is clinically denied as a request for CoC to complete a course of treatment with an existing FFS provider.
Otherwise, the CoC requirements mandate Plans to provide access to certain out-of-network providers for Members who are required to transition from FFS into a Plan. To ensure a smooth transition into a Plan, a Member may continue to see their FFS provider for 12 months:
- 회원이 현재 FFS 제공업체와 관계를 맺고 있는 경우,
- 플랜에 해당 의료 서비스 제공자에게 의료 서비스 품질 문제가 없는 경우,
- 제공자가 플랜의 계약 요금 또는 FFS 요금을 수락하는 경우 , 그리고
- 제공업체는 캘리포니아 주 플랜 승인 제공업체입니다.
The CoC period requirements for Plans do not eliminate the rights of qualifying Members to file a MER or a disenrollment request at any time. The existing MER process (22, California Code of Regulations, section 53887) and the completion of covered services requirements (H&S section 1373.96) remain in place for all Members who are required to enroll into Plans.
Further information on MERs is provided in All Plan Letter (APL) 17-007, Continuity of Care for New Enrollees Transitioned to Managed Care After Requesting a Medical Exemption and Implementation of Monthly Medical Exemption Review Denial Reporting (PDF)
11. Is a Medi-Cal managed care health plan (Plan) required to grant a Member’s request for continuing care with their existing Medi Cal Fee-for-Service (FFS) provider?
Each Plan is required to grant all requests from a mandatorily enrolled Member for CoC as long as:
- The Plan has confirmed, based on service data that it receives regularly from DHCS, that the Member’s FFS provider provided services to the Member any time within the last 12 months from the Member’s date of enrollment into a Plan; OR, the Plan has verified the existing relationship through other means,
- 플랜에 해당 의료 서비스 제공자에게 의료 서비스 품질 문제가 없는 경우,
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 제공업체는 캘리포니아 주 플랜 승인 제공업체입니다.
Additionally, Plans must comply with requirements of the H&S section 1373.96, which outlines specific circumstances in which Plans must provide Members with access to out-of-network providers at the Member’s request and if the Member has one of the health conditions listed in H&S section 1373.96.
12. "의료 서비스 품질 문제"란 무엇인가요?
Under these circumstances, a quality-of-care issue means a Medi-Cal managed care health plans (Plan) can document its concerns with the provider’s quality of care to the extent that the provider would not be eligible to provide services to any of the Plan’s Members.
13. How much time does a Member have to file a grievance if the Medi-Cal managed care health plan (Plan) denies the request for the Continuity of Care period (up to 12 months from the date of enrollment) with the existing Medi Cal Fee-for-Service (FFS) provider?
A mandatorily enrolled Member may file a grievance with the Plan at any time. The Plan must resolve each grievance and provide written notice to the Member as quickly as the Member’s health condition requires, and no later than 30 calendar days from the date the MCP receives notice of the grievance, or no longer than 72 hours in the case of an expedited grievance.
14. What if a Member who was required to enroll into a Medi-Cal managed care health plan (Plan) has a serious, acute, or ongoing medical or health condition that requires urgent treatment or monitoring before the Plan determines whether the Member may continue treatment with a Medi Cal Fee-for-Service (FFS) provider or during the grievance process?
If the Member has urgent medical needs, they must call their Plan primary care provider and their Plan. Under State and federal law, the Plan is required to ensure that the Member obtains all medically necessary Medi-Cal covered services. A Plan primary care provider will assist the Member in obtaining all urgent medically necessary services and medications. Additional requirements pertaining to CoC are set forth in the Knox Keene Act, H&S section 1373.96 and require most health plans in California—including Medi-Cal plans—to, at the request of a Member, provide for the completion of covered services by a terminated or nonparticipating health plan provider.
15. What if the Member wishes to continue receiving health care services from a Medi Cal Fee-for-Service (FFS) provider who is not part of the Medi-Cal managed care health plan (Plan) provider network for more than the allowed 12 months?
Each Plan may choose to work with the Member’s out-of-network provider past the 12-month CoC period, but they are not required to do so.
16. Will a mandatorily enrolled Member be allowed to keep a scheduled appointment with a Medi Cal Fee-for-Service (FFS) provider after being enrolled into a Medi-Cal managed care health plan (Plan)?
Plans are required to allow newly enrolled Members to keep scheduled appointments with FFS providers during the “CoC period” (up to 12 months from the date of enrollment):
- If the appointment is with a FFS provider the Member has seen in the past 12 months, as verified by the Plan through FFS utilization data OR, the Plan has verified the existing relationship through other means,
- 플랜에 해당 의료 서비스 제공자에게 의료 서비스 품질 문제가 없는 경우,
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 제공업체는 캘리포니아 주 플랜 승인 제공업체입니다.
If the appointment is with a provider the Member has never seen, but because of a serious medical condition it is medically necessary that they keep the appointment, then the Plan must allow the Member to keep the appointment as required for “completion of covered services” by H&S section 1373.96. If the appointment is not related to a serious medical condition (as defined in H&S section 1373.96), but is medically necessary, the Plan must arrange for the Member to either keep the appointment or schedule an appointment with a Plan provider.
17. Are answers above applicable for Medi-Cal Members who are receiving Long-Term Care services in a Skilled Nursing Facility (SNF)? Or are there different policies that apply for these Members?
Effective January 1, 2023 through June 30, 2023, Members residing in a SNF and transitioning from FFS to a Plan will have 12 months of CoC for the SNF placement. These Members do not have to request CoC to continue to reside in that SNF. Members are allowed to stay in the same SNF under CoC only if all of the following applies:
- 이 시설은 캘리포니아 공중보건부의 인증 및 허가를 받았습니다;
- 해당 시설은 Medi-Cal에 의료 서비스 제공자로 등록되어 있습니다;
- SNF와 플랜은 주 법적 요건을 충족하는 지급률에 동의합니다.
- The facility meets the MCP’s applicable professional standards and has no disqualifying quality-of-care issues.
Following their initial 12-month CoC period, Members may request an additional 12 months of CoC, following the process established by APL 23-022.
A Member newly enrolling into a Plan and residing in a SNF after June 30, 2023 do not receive automatic CoC and must instead contact their Plan to request CoC.
18. 위의 답변은 발달 장애인 중간 케어 시설(ICF/DD), ICF/DD-재활(ICF/DD-H) 또는 ICF/DD-간호(ICF/DD-N)(이하 ICF/DD) 가정에서 장기 케어 서비스를 받고 있는 Medi-Cal 가입자에게도 적용됩니까? 아니면 이러한 회원에게 적용되는 다른 정책이 있나요?
1월 1, 2024부터 ICF/DD 가정에 거주하고 FFS에서 플랜으로 전환하는 가입자는 12개월 동안 ICF/DD 가정 배정을 위한 CoC를 받게 됩니다. 이러한 회원은 해당 ICF/DD 가정에 계속 거주하기 위해 CoC를 요청할 필요가 없습니다. 회원은 다음 사항이 모두 해당되는 경우에만 CoC에 따라 동일한 ICF/DD 가정에 머물 수 있습니다:
- 이 숙소는 캘리포니아 공중보건국의 인증 및 허가를 받았습니다;
- 이 홈은 캘리포니아 주 플랜 승인 제공업체입니다;
- 플랜은 회원이 해당 가정과 기존 관계가 있는지 확인할 수 있습니다;
- ICF/DD 가정과 플랜은 주 법적 요건을 충족하는 지급률에 동의합니다.
- The home meets the MCP’s applicable professional standards and has no disqualifying quality-of-care issues.
Following their initial 12-month “CoC period,” Members may request an additional 12 months of CoC, following the process established by APL 23-022.
0}년 2023 월 30일 이후에 플랜에 새로 가입하고 ICF/DD에 거주하는 회원은 자동 CoC를 받지 못하며 대신 해당 플랜에 연락하여 CoC를 요청해야 합니다.
19. 위의 답변은 아급성기 케어(성인 및 소아) 시설에서 장기 요양 서비스를 받고 있는 Medi-Cal 가입자에게도 적용됩니까? 아니면 이러한 회원에게 적용되는 다른 정책이 있나요?
1월 1, 2024부터 아급성 치료 시설에 거주하며 FFS에서 플랜으로 전환하는 가입자는 아급성 치료 배정에 대해 12개월의 CoC를 적용받게 됩니다. 이러한 회원은 해당 아급성기 치료 시설에 계속 거주하기 위해 CoC를 요청할 필요가 없습니다. 회원은 다음 사항이 모두 해당되는 경우에만 CoC에 따라 동일한 아급성기 치료 시설에 머물 수 있습니다:
- 이 시설은 캘리포니아 공중보건부의 인증 및 허가를 받았습니다;
- 이 시설은 DHCS 아급성기 치료실과 계약되어 있습니다;
- 이 시설은 캘리포니아 주 플랜 승인 제공업체입니다;
- 플랜은 회원이 시설과 기존 관계가 있는지 확인할 수 있습니다;
- 시설과 플랜은 주 법적 요건을 충족하는 지불 요율에 동의합니다.
- The facility meets the MCP’s applicable professional standards and has no disqualifying quality-of-care issues.
Following their initial 12-month “Continuity of Care period,” Members may request an additional 12 months of CoC, following the process established by APL 23-022.
0}년 2023 월 30일 이후에 플랜에 새로 가입하고 아급성기 치료에 거주하는 가입자는 자동 CoC를 받지 않으며, 대신 해당 플랜에 연락하여 CoC를 요청해야 합니다.