Transition of Care from Pediatric to Adult Health Care Frequently Asked Questions (FAQ)
These FAQs will help you and your family understand your health care choices for transitioning from the California Children’s Services (CCS) program to adult health care on your 21st birthday. The legal adult age is 18 years old, but members transition out of the CCS program when they turn 21.
Transition Planning
1. What does “health care transition” mean?
A health care transition is a planned and organized transfer from a pediatric and family-centered health care model to an adult and patient-centered model based on your needs. It means learning to manage your own health and health care or designating another adult who can do this for you. You may need to choose a new primary care physician, specialists, and other clinicians for this transition.
2. What is the difference between pediatric and adult health care?
For pediatric health care, your parent(s) (or a qualified caregiver) are making decisions on your behalf and managing your health care, such as appointments, medications, and insurance/payments. At age 18, or the legally emancipated age, you are responsible for making your own health care decisions. If a conservatorship is in place, the conservator will make health care decisions on your behalf. In the adult health care system, you are responsible for communicating with your health care providers, unless you authorize your parent(s) to do so by signing a release form with your medical provider.
3. When do I start planning to transition from pediatric to adult health care?
The CCS program recommends starting the informal transition planning at age 14, considering your developmental maturity, education, social situation, and family readiness.
4. How do I transition into an adult care program, and how long does it take to transfer?
The CCS program recommends the following activities and transition timelines from the CCS program to an adult care program. The listed timelines may be modified as needed depending on your and your family’s needs:
[Note: If your CCS is managed through a Whole Child Model (WCM) managed care plan (MCP), the steps might be different.]
Edad
| Tasks
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14-18
| Work with your CCS program, MCP, and CCS primary care provider (PCP) on transition planning and completing the adolescent health care skills checklist. Work with your specialists and CCS Special Care Center for recommendations and referrals to adult care providers.
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16
| Request an adolescent transition conference with the CCS program or your MCP.
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17-18
| The CCS program will send you an adult services declaration form and a notice of privacy practices. Complete these documents and send them back to let the CCS program know if you want the program to only communicate with you or to continue communicating with your designated family member after you turn 18. If you are unable to make independent decisions, someone must be legally appointed/designated to assist you. |
18-20
| A local CCS program staff member or the person designated from the MCP will contact you to discuss and update your transition health care plan.
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20
| A CCS program staff member or a person designated from the MCP may contact you to make sure you are ready to transition out of the CCS program when you turn 21. The CCS program or the MCP will send you a client exit survey. Please complete and return this survey.
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5. My parents are making health care decisions for me in the CCS program. How do I know if I can make these decisions after I transition to adult health care?
The CCS program will send you an adult services declaration form and a notice of privacy practices before your 18th birthday. Complete these documents and send them back to let the CCS program know if you want the program to only communicate with you or to continue communicating with your designated person after you turn 18. If you are unable to make independent decisions, someone must be legally appointed/designated to assist you.
If you think you will be unable to make your own health care decisions after transitioning to adult health care, you can authorize someone else to do this for you by signing a medical power of attorney (POA). A medical POA is a legal document to name a person to be your POA agent who can make medical decisions for you in case you are unable to make them yourself. Your agent should be someone you trust with your life, such as parents, adult siblings, longtime best friend, etc.
Transitioning to New Providers
1. When will my current PCP/pediatrician stop seeing me?
Some pediatric physicians will see you until your 21st birthday. If your PCP is not a pediatrician, you may be able to continue seeing them after your 21st birthday. Please confirm this with your physician prior to your 18th birthday.
2. I go to a pediatric provider. Why do I have to change to a new PCP?
Pediatricians are trained to care for infants, children, and teens. As you get older, you must choose an adult PCP who is trained to treat adult medical conditions. You may choose an adult PCP after your 18th birthday. While you may transition to an adult provider at age 18, you may remain in the CCS program until your 21st birthday.
3. I see a pediatric PCP and a pediatric subspecialist. Do I need to change both my primary and specialty care physicians at the same time?
You must change your PCP first. Your pediatric PCP can refer you to an adult PCP. Your adult PCP will make the referral for you to see a specialist depending on your condition/disease. Your adult PCP will help you find the specialists best suited for your needs and type of care. By working with your adult PCP, you can create a new care team of subspecialists. Your pediatric subspecialists may also play a role in finding adult specialists best suited for your needs and type of care. In some cases, your pediatric PCP or pediatric subspecialist may connect you with an adult specialist.
4. My physician is a family medicine physician who I plan to stay with as an adult. Why do I have to plan a transition to another provider?
If you have a family medicine physician or family nurse practitioner, and you wish to keep seeing them, you may continue to see them even after your transition to adult health care. If you see pediatric specialists, such as a nephrologist, dermatologist, pulmonologist (they sign many durable medical equipment (DME) prescriptions), or psychiatrist, you must transition to a specialist who cares for adults.
If you receive physical therapy and/or occupational therapy services at the CCS program Medical Therapy Unit (MTU), you must change to an adult provider for those services. By working with your family medicine physician or family nurse practitioner and the Medical Therapy Program (MTP) team, you can receive prescriptions and recommendations for services and create a new team of adult care specialists just for you.
As you approach adulthood and are required to make independent health care decisions, please consider the following:
- See the physician by yourself, use supported decision making, or legally designate a decision maker on your behalf.
- Call health care providers to make your own appointments and arrange for transportation to and from appointments.
- Make your own co-payments for health care services.
- Provide your insurance cards to health care providers.
- Sign medical forms either independently or with supported decision making.
- Decide who you want to authorize to view your medical records.
- Call for refills and pick up prescriptions.
5. I understand the CCS program allows broad access to providers. After I leave the CCS program, how is my access to providers determined? What happens if I need to change providers?
Your access may be limited by your Medi-Cal MCP selection. Contact your MCP or your PCP for options. Access to a specific provider may require a change in your selected MCP and medical group. This should be considered well before your 21st birthday.
6. Can I keep my subspecialist after I transition?
Yes, in some cases you may be able to keep your subspecialist depending on their field of specialization and facility type. Please discuss the ability to keep your subspecialist with your case manager.
Medications and Durable Medical Equipment (DME)
1. I take multiple medications. How can I get them after I transition to adult health care?
Your adult PCP or adult specialist will determine what medications you will need and write you a prescription. If you have Medi-Cal and will continue to have Medi-Cal after you transition, there will be no change in how you get your medications. If you have other health coverage, that plan will cover your medications. You are encouraged to maintain health insurance to keep access to care and your out-of-pocket costs low. You must attend appointments with your PCP and pediatric specialists and have those prescriptions written before transitioning out of the CCS program.
2. I use DME and/or supplies. How do I get my DME/Orthotics/Prosthetics (O&P) and/or other supplies after transitioning to adult health care?
If you have DME, you are encouraged to plan for any equipment needs at least six months before your 21st birthday so your equipment will be in place when you transition out of the CCS program. Your PCP and MTP therapists can help you.
If you have Medi-Cal, it will cover your DME/O&P when your PCP, nurse practitioner, clinical nurse specialist, or physician assistant writes a prescription, the item is medically necessary, and it is covered by Medi-Cal. They can either send the prescription directly to a DME provider or give the prescription to you and let you choose your own DME provider. The DME provider will submit the order and prescription to the health plan for approval or denial. Some DME/O&P items may not be covered by Medi-Cal. Your DME vendor may be able to determine which items are available to you.
Your adult PCP, nurse practitioner, clinical nurse specialist, or physician assistant must annually review your need for certain DME/O&P items. A new prescription for all DME O&P items is required annually for all DME/O&P items and replacement parts.
Similarly, your adult care PCP must annually review your need for all supplies and will write you a new prescription when your prescription expires. The prescription must be dated within 12 months of the date of service and may require you to make an office visit.
Authorization for DME/O&P and other supplies will be submitted to the health plan for review and approval even if you are in a WCM county. You should get all your DME/O&P and other supplies updated by your PCP or specialty provider(s) before transitioning to adult care. A change in vendor may be required, or you may need to obtain an out-of-network approval based on your MCP.
Insurance and Coverage
1. I am currently enrolled in Medi-Cal and CCS. What will be my insurance after I transition to adult health care?
If you have full scope Medi-Cal in the CCS program and your financial condition doesn’t change, you will continue to have full scope Medi-Cal after transitioning to an adult care program. You will need to do the following every year:
- Work with your Medi-Cal County Eligibility Office to renew your Medi-Cal coverage each year.
- Ensure your local Medi-Cal office has all of your current contact information and notify them of any financial changes.
Questions or concerns about coverage and benefits should be directed to your MCP.
2. I am currently enrolled in the CCS state-only program (non-Medi-Cal). What will be my insurance after I transition to adult health care?
Your CCS state-only program coverage will end on your 21st birthday. You will not be automatically enrolled in Medi-Cal when your CCS state-only program benefits are discontinued, you should consider applying prior to your transition. If you have other health coverage, your services will continue under your other health insurance after transitioning to adult health care. You may get health insurance in various ways, such as continuing insurance coverage under your parents until age 26, qualifying for a federal or state government plan, obtaining health insurance through an employer, or purchasing health insurance from the Marketplace (Covered California) or other sources.
Programs, Supports and Resources
1. Will my parent/family income determine if I qualify for Medi-Cal after I turn 18?
No, once you turn 18, your parent/family income is no longer counted toward your Medi-Cal financial eligibility determination. Medi-Cal will determine your eligibility for services based on your income alone.
2. What adult care programs and services are available? Which adult care program could I transition to?
You must be enrolled in Medi-Cal to be eligible to transition from the CCS program to any of the following adult care programs and services for which you qualify based on your condition/disease and your transition readiness assessment:
- Mga waiver
- Community-Based Services for the Developmentally Disabled (HCBS-DD) Waiver
The Home and Community-Based Services for the Developmentally Disabled (HCBS-DD) Waiver is administered by the California Department of Developmental Services, which will authorize your home and community-based services if you are a developmentally disabled person who is a Regional Center consumer. - Home and Community-Based Alternatives (HCBA) Waiver
The HCBA Waiver provides care management services if you are at risk for nursing home or institutional placement. Care management and waiver services are provided in your community-based residence. This residence can be privately owned, secured through a tenant lease arrangement, or the residence of your family member. - Assisted Living Waiver (ALW)
You may transition to ALW if you are eligible for Medi-Cal without a Medi-Cal share of cost, require a nursing facility level of care, and wish to live in a residential care setting or in publicly funded senior and/or disabled housing. - HIV/AIDS Waiver or Medi-Cal Waiver Program (MCWP)
The Medi-Cal Waiver Program (MCWP), formerly known as the AIDS Waiver, provides comprehensive case management and direct care services as an alternative to nursing facility care or hospitalization if you are living with HIV/AIDS.
- Pinamamahalaang Pangangalaga
- Enhanced Care Management (ECM)
ECM may be available to you if you are enrolled in a Medi-Cal MCP and qualify for an ECM Population of Focus (POF). ECM may address your clinical and non-clinical needs through intensive coordination of health and health-related services.
DHCS, Medi-Cal MCPs, and providers across the state are launching ECM in phases, by POF, from 2022 to 2024. Each POF requires a unique model, referral pipeline, and provider network to meet the needs of eligible members, but the key features of ECM across POFs include community-based providers, person-centered care, and high-touch in-person support. Children and youth POFs include: - Children and youth experiencing homelessness.
- Children and youth with serious mental health and/or substance use disorder needs.
- Children and youth enrolled in CCS or CCS WCM with additional needs beyond the CCS condition.
- Mga Suporta sa Komunidad
If you are enrolled in a Medi-Cal MCP, you may qualify for several Community Supports to meet your social needs, including medically supportive meals, housing deposits, or other housing supports. You will have a single Lead Care Coordinator who will arrange care and services among the physical, behavioral, dental, developmental, and social services delivery systems, making it easier for you to get the right care at the right time in the right setting.
Medi-Cal eligibility is not required to transition from the CCS program to the Genetically Handicapped Persons Program (GHPP).
- Genetically Handicapped Persons Programa (GHPP)
GHPP is a health care program for adults with specific genetic diseases. GHPP may help members with their health care costs. GHPP works with physicians, nurses, pharmacists, and other members of the health care team in providing needed health services.
3. What resources are available to support me and my family during a transition from pediatric to adult health care?
There are many resources that provide information about the transition from a children’s program to an adult care program. Resources include:
- Your pediatric PCP or specialist.
- The CCS program case manager or MCP case manager in the county in which you live.
- Your pediatric care hospital.
Additional resources:
