Continuity of Care and Managed Care - Frequently Asked Questions

Below you will find the most frequently asked questions for current and potential Medi-Cal Managed Care beneficiaries.

If a Beneficiary’s provider does not contract with any of the Medi-Cal managed care plan(s) (Plans) that are available in the Beneficiary’s county, how may the Beneficiary continue to see this provider?
Which types of providers may a Beneficiary continue to see outside the Medi Cal managed care plan’s (Plan’s) network of providers?
Can any Medi-Cal Beneficiary in a Medi-Cal managed care plan (Plan) continue to see an existing provider who is not part of the plan’s network?
If the Beneficiary changes from one Medi-Cal managed care plan (Plan) to another, does the Beneficiary get another 12 month period to see his or her out-of-network Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider?
When will the Medi-Cal managed care plan (Plan) notify the Beneficiary whether or not he or she can continue to see their current Medi Cal Fee-for-Service or Low Income Health Program provider?
Can the Beneficiary’s Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider who has been approved by the Medi-Cal managed care plan (Plan) refer the Beneficiary to another out-of-network provider?
What if the Beneficiary’s Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider will not or cannot work with the Medi-Cal managed care plan (Plan)?
Does the “extended Continuity of Care period” (up to 12 months from the Beneficiary’s date of enrollment) have any impact on the existing process for Medical Exemption Requests (MERs)?
Is a Medi-Cal managed care plan (Plan) required to grant a Beneficiary’s request for continuing care with their existing Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider?
What does “quality-of-care issue” mean?
How much time does a Beneficiary have to file a grievance if the Medi-Cal managed care plan (Plan) denies the request for the extended Continuity of Care period (up to 12 months from the date of enrollment) with the existing Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider?
What if a Beneficiary who was required to enroll into a Medi-Cal managed care plan (Plan) has a serious, acute, or ongoing medical or health condition that requires urgent treatment or monitoring before the Plan determines whether the Beneficiary may continue treatment with a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider or during the grievance process?
What if the Beneficiary wishes to continue receiving health care services from a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider who is not part of the Medi-Cal managed care plan (Plan) provider network for more than the allowed 12 months?
Will a mandatorily enrolled Beneficiary be allowed to keep a scheduled appointment with a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider after being enrolled into a Medi-Cal managed care plan (Plan)?
After being enrolled into a Medi-Cal managed care plan (Plan), how can a Beneficiary with new or ongoing prescriptions from a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider get those prescriptions filled?
Are Answers 1-15 applicable for Medi-Cal beneficiaries who are receiving services through the Coordinated Care Initiative (CCI) and Cal MediConnect programs? Or are there different policies that apply for these programs?

Continuity of Care Frequently Asked Questions and Answers

1. If a Beneficiary’s provider does not contract with any of the Medi-Cal managed care plan(s) (Plans) that are available in the Beneficiary’s county, how may the Beneficiary continue to see this provider?

Answer 1a: If the Beneficiary was seeing a Medi-Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider before being required to enroll into a Plan, the Beneficiary may be able to continue to see the FFS or LIHP provider for up to 12 months while remaining enrolled in the Plan, as long as the provider agrees to work with the Plan, accepts payment from the Plan, and has no quality-of-care issues. This 12-month period is the “extended Continuity of Care period.” To continue care with a FFS or LIHP provider, the Beneficiary must:

Contact the new Plan.
Tell the Plan that he or she wants to continue to receive health care from the FFS or LIHP provider.
Tell the Plan the name of the FFS or LIHP provider, and ask the Plan to contact the provider on his or her behalf.

The FFS or LIHP provider may continue to see the Beneficiary when the Plan determines that the Beneficiary has seen that provider in the past 12 months, the provider has no quality-of-care issues that would make him or her 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 Beneficiary’s request, or sooner if the Beneficiary’s medical condition requires more immediate attention, the Plan must tell the Beneficiary if he or she may continue treatment with the FFS or LIHP provider or if he or she will be assigned to a provider in the Plan’s provider network. If the FFS or LIHP provider is willing to continue to see the Beneficiary, but the Plan says no, or if the Plan fails to respond to the Beneficiary’s request in a timely manner, then the Beneficiary may file a grievance with the Plan.

Answer 1b: The State now requires Medi-Cal managed care plans (Plans) to provide some health care services (such as outpatient mental health) that were until recently only available through Medi Cal FFS) or LIHP providers. Beneficiaries who were receiving such a health care service may request to continue to receive the service from their FFS or LIHP providers according to the same requirements listed in Answer 1a.
For further information about Continuity of Care policies for the populations described in Answers 1a and 1b, please see All Plan Letter 13-023, Continuity of Care for Medi-Cal Beneficiaries Who Transition from Fee-for-Service Medi-Cal into Medi-Cal Managed Care (PDF).

Answer 1c: Beneficiaries may also be able to keep seeing their provider when they change Plans or if their provider stops participating with the Plan’s provider network. The options listed below do not require that a Beneficiary has transitioned from LIHP or FFS in the past 12 months.
In addition to the requirements set forth in this FAQ for Extended Continuity of Care, which are solely based on DHCS policy, additional requirements pertaining to Continuity of Care are set forth in the Knox Keene Act, Health and Safety (H&S) Code § 1373.96 and require most health plans in California—including Medi-Cal plans—to, at the request of a Beneficiary, provide for the completion of covered services by a terminated or nonparticipating health plan provider. The H&S Code requires that these health plans complete services for the following 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 MCPs must allow for the completion of these services for certain timeframes which are specific to each condition and defined under H&S Code § 1373.96. Beneficiaries should call their Plan for more information about completing services as required by the Knox Keene Act.

2. Which types of providers may a Beneficiary continue to see outside the Medi Cal managed care plan’s (Plan’s) network of providers?

A Beneficiary may ask the Plan to allow him or her to continue to see a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider who is not in the Plan’s provider network. For purposes of Continuity of Care for enrollees new to managed care, the Department of Health Care Services (DHCS) is using the definition of an individual provider found in Health and Safety Code Section 1373.96. However, Plans are not required to work with providers who meet this definition if the providers offer carved-out Medi-Cal services (Medi-Cal services that are not provided by the Plan), or services not covered by Medi-Cal. The Plan must allow the Beneficiary to continue to see providers who are physicians, surgeons, or specialists. The Plan is not required to allow the Beneficiary to continue to receive services from providers of durable medical equipment, transportation, other ancillary services, or carved-out services.

3. Can any Medi-Cal Beneficiary in a Medi-Cal managed care 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 extended Continuity of Care period only applies to a Beneficiary who previously (in the past 12 months) was seeing a Medi Cal Fee-for-Service or Low Income Health Program provider and is now required to enroll into a Plan. This extended Continuity of Care period does not apply to a Beneficiary who has been in a Plan for twelve months or more or to a Beneficiary who has just become eligible for Medi Cal and must enroll into a Plan. These beneficiaries must generally see providers who are part of the Plan’s provider network.

However, Beneficiaries may also be able to keep seeing their provider when they change Plans or if their provider stops participating with the Plan’s provider network. The options listed below do not require that a Beneficiary has transitioned from LIHP or FFS in the past 12 months. In addition to the requirements set forth in this FAQ for Extended Continuity of Care, which are solely based on DHCS policy, additional requirements pertaining to Continuity of Care are set forth in the Knox Keene Act, Health and Safety (H&S) Code § 1373.96 and require most health plans in California—including Medi-Cal plans—to, at the request of a Beneficiary, provide for the completion of covered services by a terminated or nonparticipating health plan provider. The H&S Code requires these health plans to complete services for the following 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 MCPs must allow for the completion of these services for certain timeframes which are specific to each condition and defined under H&S Code § 1373.96. Beneficiaries should call their Plan for more information about completing services as required by the Knox Keene Act.

4. If the Beneficiary changes from one Medi-Cal managed care plan (Plan) to another, does the Beneficiary get another 12 month period to see his or her out-of-network Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider?

No. The Beneficiary only gets 12 months from the date of his or her initial enrollment into a Plan. If a Beneficiary changes plans within the first 12 months of initial enrollment, however, the Beneficiary’s right to continue seeing out-of-network providers will continue until the 12 month period expires.

5. When will the Medi-Cal managed care plan (Plan) notify the Beneficiary whether or not he or she can continue to see their current Medi Cal Fee-for-Service or Low Income Health Program provider?

The Plan is required to process each request and provide notice to each Beneficiary no later than 30 calendar days from the date the Plan receives the request, or sooner if the Beneficiary’s medical condition requires more immediate attention.

6. Can the Beneficiary’s Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider who has been approved by the Medi-Cal managed care plan (Plan) refer the Beneficiary to another out-of-network provider?

No. An out-of-network FFS or LIHP provider may not refer the Beneficiary to another out-of-network provider without prior authorization from the Plan. An out-of-network provider, approved by the Plan, under the extended Continuity of Care 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 Beneficiary needs, then the Plan must provide the Beneficiary with a referral to a medically necessary specialist outside the Plan’s provider network.

7. What if the Beneficiary’s Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider will not or cannot work with the Medi-Cal managed care plan (Plan)?

If the FFS or LIHP provider will not or cannot work with the Plan, then the Plan will transition the Beneficiary to a provider who is part of the Plan’s provider network.

8. Does the “extended Continuity of Care period” (up to 12 months from the Beneficiary’s date of enrollment) have any impact on the existing process for Medical Exemption Requests (MERs)?

DHCS will provide Medi-Cal managed care plans with a list (the Exemption Transition Data Report) of beneficiaries whose MERs were denied. Plans are required to consider a request for exemption from Plan enrollment that is clinically denied as a request for Continuity of Care to complete a course of treatment with an existing Medi-Cal Fee-for-Service (FFS) provider.
Otherwise, the extended Continuity of Care requirements only mandate Plans to provide access to certain out-of-network providers for beneficiaries who are required to transition from FFS) or the Low Income Health Program (LIHP) into a Plan. To ensure a smooth transition into a Plan, a Beneficiary may continue to see their FFS or LIHP provider for 12 months:

If the Beneficiary has a current relationship with the FFS provider,
If the Plan does not have quality-of-care issues with that provider, and
If the provider will accept the Plan’s contracted rates or FFS rates, whichever is higher.

The extended Continuity of Care period requirements for Plans do not eliminate the rights of qualifying beneficiaries to file a MER or a disenrollment request at any time. The existing MER process (Title 22, California Code of Regulations, Section 53887) and the completion of covered services requirements (Health and Safety Code, Section 1373.96) remain in place for all beneficiaries who are required to enroll into Plans. The MER process does not apply to LIHP members who transition directly into a Plan.

Further information on MERs is provided in All Plan Letter (APL) 13 013, Continuity of Care for New Enrollees Transitioned to Managed Care after Requesting a Medical Exemption (PDF).

9. Is a Medi-Cal managed care plan (Plan) required to grant a Beneficiary’s request for continuing care with their existing Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider?

Each Plan is required to grant all requests from a mandatorily enrolled Beneficiary for extended Continuity of Care as long as:

The Plan has confirmed, based on service data that it receives regularly from DHCS, that the Beneficiary’s FFS or LIHP provider provided services to the Beneficiary any time within the last 12 months; OR, the Plan has verified the existing relationship through other means;
The provider agrees to accept the Plan’s contracted rates or Medi-Cal (FFS) rates, whichever is higher; and
The provider has no quality-of-care issues that, otherwise, would make them ineligible to provide services to any Plan Beneficiaries.

Additionally, Plans must comply with requirements of the California Health and Safety Code, Section 1373.96, which outlines specific circumstances in which Plans must provide all Plan beneficiaries with access to out-of-network providers.

10. What does “quality-of-care issue” mean?

Under these circumstances, a quality-of-care issue means a Medi-Cal managed care 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 other Plan beneficiaries.

11. How much time does a Beneficiary have to file a grievance if the Medi-Cal managed care plan (Plan) denies the request for the extended Continuity of Care period (up to 12 months from the date of enrollment) with the existing Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider?

A mandatorily enrolled Beneficiary may file a grievance with the Plan at any time. The Plan must resolve each grievance and provide written notice to the Beneficiary as quickly as the Beneficiary’s health condition requires, and no later than 30 calendar days from the date the MCP receives notice of the grievance, or 3 days in the case of an expedited grievance.

12. What if a Beneficiary who was required to enroll into a Medi-Cal managed care plan (Plan) has a serious, acute, or ongoing medical or health condition that requires urgent treatment or monitoring before the Plan determines whether the Beneficiary may continue treatment with a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider or during the grievance process?

If the Beneficiary 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 Beneficiary obtains all medically necessary Medi-Cal covered services. For information about prescription medication, see Question 15 below. A Plan primary care provider will assist the Beneficiary in obtaining all urgent medically necessary services and medications.

13. What if the Beneficiary wishes to continue receiving health care services from a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider who is not part of the Medi-Cal managed care plan (Plan) provider network for more than the allowed 12 months?

Each Plan may choose to work with the Beneficiary’s out-of-network provider past the 12-month extended Continuity of Care period, but they are not required to do so.

14. Will a mandatorily enrolled Beneficiary be allowed to keep a scheduled appointment with a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider after being enrolled into a Medi-Cal managed care plan (Plan)?

Plans are required to allow newly enrolled beneficiaries to keep scheduled appointments with FFS or LIHP providers during the “extended Continuity of Care period” (up to 12 months from the date of enrollment):

If the appointment is with a FFS or LIHP provider the Beneficiary has seen in the past 12 months, as verified by the Plan through FFS utilization data or other means;
If the provider is willing to accept payment from the Plan; and
If there are no quality-of-care issues with that provider.

If the appointment is with a provider the Beneficiary 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 Beneficiary to keep the appointment as required for “completion of covered services” by Health and Safety Code, Section 1373.96. If the appointment is not related to a serious medical condition (as defined in Section 1373.96), but is medically necessary, the Plan must arrange for the Beneficiary to either keep the appointment or schedule an appointment with a Plan provider.

15. After being enrolled into a Medi-Cal managed care plan (Plan), how can a Beneficiary with new or ongoing prescriptions from a Medi Cal Fee-for-Service (FFS) or Low Income Health Program (LIHP) provider get those prescriptions filled?

This answer has several parts:

A pharmacist in the Plan’s provider network will fill a new or ongoing prescription from the Beneficiary’s FFS or LIHP provider if the drug is on the Plan’s list of approved drugs (formulary).
However, Plans must allow beneficiaries to continue use of any single-source drug (a drug produced by only one manufacturer) that is part of a prescribed therapy in effect for the Beneficiary immediately prior to the date of enrollment, even if the drug is not on the Plan’s formulary, until the Beneficiary can be seen by a Plan doctor to establish a care plan, as required by Welfare & Institutions (W&I) Code, Section 14185(b).
For a new or ongoing prescription from the Beneficiary’s FFS or LIHP provider for a multi-source drug that is not on the Plan’s formulary, the Plan will notify the pharmacist that a prior authorization is required, and the Plan will request a medical justification from the FFS or LIHP provider and make a decision within 24-hours [per W&I Code 14185(a)(1)] based upon that medical justification.
If the Plan pharmacist determines that the Beneficiary has an emergency need to refill an ongoing prescription that is not on the formulary, the pharmacist will provide an emergency supply (three days’ worth) of the drug while Plan pharmacist and the Plan complete the prior authorization process, as required by California W&I Code Section 14185(a)(2).

16. Are Answers 1-15 applicable for Medi-Cal beneficiaries who are receiving services through the Coordinated Care Initiative (CCI) and Cal MediConnect programs? Or are there different policies that apply for these programs?

Most of the information in Answers 1-15 also applies to the CCI and Cal MediConnect programs, but there are some policies that are different for CCI and Cal MediConnect. The policies that are different are explained in this answer.

In the Cal MediConnect program, which will operate in several counties, a Medi-Cal Beneficiary who is also receiving Medicare benefits can receive both sets of benefits through one managed care plan (Plan). In these same counties, the CCI program allows all Medi-Cal Plan members to receive Long Term and Services and Supports (LTSS) through the Plan. LTSS include In Home Supportive Services (IHSS), nursing facility (NF) services, and other services.

A Cal MediConnect Plan is required to offer Continuity of Care to members who have an existing relationship with a provider that is not in the Plan’s network for up to six months for a Medicare provider and up to 12 months for a Medi-Cal provider. The Plan can verify the existing relationship through Medicare or Medi-Cal data, or other provider documentation. To qualify as an “existing relationship” the Beneficiary must have seen a primary care provider at least once, or a specialist at least twice, in the prior 12 months. The Plan will process each request and provide notice to each Beneficiary no later than 30 calendar days from the date the Plan receives the request, or within 15 calendar days if the Beneficiary’s medical condition requires more immediate attention. The Plan is also required to 1) inform beneficiaries of Continuity of Care protections and the process to initiate and 2) train call center and other staff who regularly contact beneficiaries. If the Beneficiary changes Plans, the Continuity of Care period may start over one time. If the Beneficiary returns to Fee-for-Service and later reenrolls in Cal MediConnect, the Continuity of Care period does not start over. If the Beneficiary changes Plans, the Continuity of Care policy does not extend to in-network providers that the Beneficiary accessed through their previous Plan.

Also, for Beneficiaries in a Cal MediConnect Plan, Medicare Part D transition rules and rights will continue as provided in current law and regulation for the entire integrated formulary associated with the Plan.

In CCI counties, two Continuity of Care protections apply for Beneficiaries who were receiving NF services before the NF benefit was transferred to the responsibility of the Plan. A Beneficiary who was a long term resident of a NF prior to enrollment in a Plan will not be required to change NFs during the duration of the CCI program if the NF is properly licensed, meets quality standards, and agrees to Medi-Cal rates. In addition, Plans must recognize any prior treatment authorization made by DHCS for NF services for not less than six months after the Beneficiary enrolls in a Plan.

For further information, please see DHCS Dual Plan Letter 13-005, Continuity of Care (PDF).

Last modified date: 3/21/2019 9:05 PM