Continuity of Care and Managed Care – Frequently Asked Questions
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.
2024 年 MCP 过渡的 CoC 政策为先前的和接收的 MCP（包括主要 MCP 及其分包商）提供了指导，介绍了他们确保 1 月1日、 2024需要更改 MCP 的成员符合 CoC 的义务。
2024 年 MCP 过渡中的保护措施有所不同。 请访问“护理连续性”|“管理式护理计划过渡”|“DHCS”，了解有关 2024 年 MCP 过渡及其变化的更多详细信息。
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. 如果会员的提供商未与会员所在县的任何 Medi-Cal 管理式医疗保健计划（简称“计划”）签约，会员如何继续看望该提供商？
答案 1a：如果会员在被要求加入计划之前正在看 FFS 提供商，则该会员可能能够在继续加入该计划的同时继续看 FFS 提供商长达 12 个月。 这 12 个月的期限为“CoC 期限”。 要继续接受 FFS 提供商的护理，会员必须：
- 联系新计划。
- 告诉计划他们希望继续从 FFS 提供商处获得医疗保健，并且
- 告知计划 FFS 提供商的名称。
当计划确定会员在过去 12 个月内已经看过该提供者，并且该提供者不存在导致其不符合参与计划网络资格的护理质量问题，并且提供者和计划就支付金额达成一致时，会员可以继续看 FFS 提供者。 自计划收到会员请求之日起 30 天内，或者如果会员的医疗状况需要更紧急的关注，则更早，计划必须告知会员他们是否可以继续接受 FFS 提供商的治疗，或者他们是否会被分配给计划提供商网络中的提供商。 如果 FFS 提供商愿意继续为会员看病，但计划拒绝，或者计划未能及时回应会员的请求，则会员可以向计划提出申诉。
答案 1b：州政府现在要求 Medi-Cal 管理式医疗保健计划（简称“计划”）提供一些医疗保健服务（如长期护理），而这些服务直到最近才通过 Medi Cal FFS 提供商提供。正在接受此类医疗保健服务的会员可以按照答案 1a 中列出的相同要求，要求继续从其 FFS 提供商处接受服务。
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. 会员可以继续在 Medi Cal 管理式医疗保健计划（计划）提供商网络之外看哪些类型的提供商？
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:
- 如果会员目前与 FFS 提供商有合作关系，
- 如果该计划与该提供者不存在护理质量问题，
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 该提供商是加州州计划批准的提供商。
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. 加入 Medi-Cal 管理式医疗保健计划（简称“计划”）的任何 Medi-Cal 会员是否可以继续看不属于该计划网络的现有医疗服务提供者？
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 不适用于已加入计划 12 个月或更长时间的会员，或刚刚获得 Medi Cal 资格且必须加入计划的会员。 这些会员通常必须咨询属于该计划提供商网络的提供商。
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. 如果会员从一个 Medi-Cal 管理式医疗保健计划（计划）更改为另一个，或者丧失资格，随后又重新获得资格，会员是否还能获得另外 12 个月的时间去网络外的 Medi Cal 按服务收费 (FFS) 提供者处就诊？
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. Medi-Cal 管理式医疗保健计划（计划）何时会通知会员是否可以继续看其当前的 Medi Cal 按服务收费提供者？
计划必须处理每项请求，并在收到请求之日起不迟于 30 个日历日内通知每位会员，如果会员的医疗状况需要更紧急的关注，则须更早通知。
6. 经 Medi-Cal 管理式医疗保健计划（简称“计划”）批准的会员 Medi Cal 按服务收费 (FFS) 提供商是否可以将会员转介给其他网络外提供商？
不可以。未经计划事先授权，网络外的 FFS 提供商不得将会员转介给其他网络外提供商。 在 CoC 期限内，经计划批准的网络外提供商必须与计划及其签约的提供商网络合作。 如果计划网络中没有会员需要的专家类型，则计划必须为会员提供计划提供商网络之外的有医疗必要性的专家的转诊。
7. 如果会员的 Medi Cal 按服务收费 (FFS) 提供商不愿或不能与 Medi-Cal 管理式医疗保健计划（简称“计划”）合作，该怎么办？
如果 FFS 提供商不愿意或不能与该计划合作，则该计划会将会员转移到属于该计划提供商网络的提供商。
8. 如果会员拥有有效的治疗授权会怎样？
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. 会员可以保留其耐用医疗设备 (DME) 和医疗用品吗？
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. “持续护理期”（自会员入会之日起最长 12 个月）对现有的医疗豁免申请 (MER) 流程有何影响？
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:
- 如果会员目前与 FFS 提供商有合作关系，
- 如果该计划与该提供者不存在护理质量问题，
- 如果提供商接受计划的合同费率或按月付费费率，并且
- 该提供商是加州州立计划批准的提供商
计划的 CoC 期限要求并不会消除合格会员随时提交 MER 或取消注册请求的权利。 现有的 MER 流程（22，加州法规，第 53887 节）和涵盖服务要求的完成情况（H&S 第 1373.96 节） 对于所有需要加入计划的会员来说，该政策仍然有效。
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. Medi-Cal 管理式医疗保健计划（计划）是否需要批准会员继续向其现有的 Medi Cal 按服务收费（FFS）提供商提供医疗服务的请求？
每项计划均须批准强制登记会员的所有 CoC 请求，只要满足以下条件：
- 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,
- 如果该计划与该提供者不存在护理质量问题，
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 该提供商是加州州立计划批准的提供商
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.“护理质量问题”是什么意思？
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. 如果 Medi-Cal 管理式医疗保健计划（简称“计划”）拒绝现有 Medi Cal 按服务收费 (FFS) 提供商的持续护理期（自登记之日起最长 12 个月）请求，会员有多少时间提出申诉？
强制登记的会员可以随时向计划提出申诉。 计划必须根据会员的健康状况要求尽快解决每项申诉并向会员提供书面通知，且不得晚于 MCP 收到申诉通知之日起 30 个日历日，或者在加急申诉的情况下不得超过 72 小时。
14. 如果被要求加入 Medi-Cal 管理式医疗保健计划（简称“计划”）的会员出现严重、急性或持续性的医疗或健康状况，需要在计划确定该会员是否可以继续接受 Medi Cal 按服务收费 (FFS) 提供商的治疗之前或在申诉过程中进行紧急治疗或监测，该怎么办？
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. 如果会员希望继续从不属于 Medi-Cal 管理式医疗保健计划（计划）提供商网络的 Medi Cal 按服务收费（FFS）提供商处接受医疗保健服务超过允许的 12 个月，该怎么办？
每个计划均可选择在 12 个月的 CoC 期限之后与会员的网络外提供商合作，但这并不是强制性的。
16. 强制登记的会员在加入 Medi-Cal 管理式医疗保健计划（简称“计划”）后，是否可以与 Medi Cal 按服务收费 (FFS) 提供商进行预约？
计划必须允许新登记的会员在“CoC 期间”（自登记之日起最多 12 个月）与 FFS 提供商保持预约：
- 如果该预约是与会员在过去 12 个月内见过的 FFS 提供商进行的，并且计划已通过 FFS 使用数据进行了验证，或者计划已通过其他方式验证了现有的关系，
- 如果该计划与该提供者不存在护理质量问题，
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 该提供商是加州州计划批准的提供商。
如果会员从未与提供商预约，但由于严重的医疗状况，从医学上来说会员必须遵守预约，则计划必须允许会员遵守预约，这是 H&S 第 1373.96 节“完成承保服务”的要求。 如果预约与严重医疗状况无关（如 H&S 第 1373.96 节所定义）， 但具有医疗必要性，则计划必须安排会员继续预约或与计划提供者预约。
17. 上述答案是否适用于在专业护理机构 (SNF) 接受长期护理服务的 Medi-Cal 会员？ 或者针对这些会员适用不同的政策吗？
从 年1月2023至 年30月2023 ，居住在 SNF 并从 FFS 过渡到计划的会员将拥有 12 个月的 SNF 安置 CoC。 这些成员无需申请 CoC 即可继续居住在该 SNF。 仅当满足以下所有条件时，会员才可以按照 CoC 留在同一个 SNF：
- 该设施已获得加州公共卫生部的认证和许可；
- 该机构已注册为 Medi-Cal 的提供商；
- SNF 和计划同意符合州法定要求的支付率；并且
- 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.
新加入计划且于30年 6 月2023后居住在 SNF 的会员不会自动收到 CoC，而必须联系其计划来申请 CoC。
18. 上述答案是否适用于在智障中级护理机构 (ICF/DD)、智障中级护理机构-康复机构 (ICF/DD-H) 或智障中级护理机构-护理机构 (ICF/DD-N)（简称 ICF/DD）接受长期护理服务的 Medi-Cal 会员？ 或者针对这些会员适用不同的政策吗？
自1年2024月起，居住在 ICF/DD 养老院并从 FFS 转为计划的会员将获得 12 个月的 ICF/DD 养老院安置 CoC。 这些会员无需申请 CoC 即可继续居住在该 ICF/DD 住宅中。 仅当满足以下所有条件时，会员才可根据 CoC 住在同一 ICF/DD 住宅中：
- 该养老院已获得加州公共卫生部的认证和许可；
- 该养老院是加州州立计划批准的养老院提供商；
- 该计划能够确定会员与该房屋是否存在预先存在的关系；
- ICF/DD 家庭和计划同意符合州法定要求的支付率；并且
- 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.
年 6 月30 、 2023日后新加入计划并居住在 ICF/DD 的会员不会自动收到 CoC，而必须联系其计划来申请 CoC。
19. 上述答案是否适用于在亚急性护理（成人和儿科）机构接受长期护理服务的 Medi-Cal 会员？ 或者针对这些会员适用不同的政策吗？
自1年2024月起，居住在亚急性护理机构并从 FFS 过渡到计划的会员将拥有 12 个月的亚急性护理安置 CoC。 这些会员无需申请 CoC 即可继续居住在该亚急性护理机构中。 仅当满足以下所有条件时，会员才可以入住 CoC 下的同一亚急性护理机构：
- 该设施已获得加州公共卫生部的认证和许可；
- 该设施与 DHCS 亚急性护理单位签订了合同；
- 该设施是加州州立计划批准的提供商；
- 该计划能够确定会员与该机构存在预先存在的关系；
- 该机构和计划同意符合州法定要求的支付率；并且
- 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.
新加入计划并在30年 6 月2023之后居住在亚急性护理中心的会员不会自动收到 CoC，而必须联系其计划来请求 CoC。