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 過渡期的《CoC 政策》提供指引，向先前和接收的 MCP（包括主要 MCP 和其分承包商）提供指引，有關他們對於必須在 2024 1 月 1 日更改 MCP 的成員確保所需要更改 MCP 的責任。
2024 年 MCP 過渡中的保護是不同的。 如需有關 2024 MCP 過渡及其變化的更多詳細信息，請訪問照護持續性 | 管理照護計劃轉換 | DHCS。
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. 如果會員的提供者未與會員所在縣提供的任何Medi-Cal Managed Care健康計劃（計劃）簽訂合同，會員如何繼續看該提供者？
答 1a：如果會員在被要求加入計劃之前見 FFS 提供商，會員可能會繼續與 FFS 提供商聯繫，但仍然註冊計劃的同時，該會員可以繼續與 FFS 提供商聯繫最長 12 個月。 這 12 個月期間是「CoC 期」。 為了繼續與 FFS 提供者進行照顧，會員必須：
- 聯絡新計劃。
- 告訴計劃他們希望繼續從 FFS 提供者處獲得醫療保健，並且
- 告知計劃 FFS 提供者的名稱。
當計劃確定會員在過去 12 個月內見過該提供者，該服務提供者沒有任何保健品質問題導致他們無法參與計劃網絡的資格，並且供應商和計劃同意付款金額時，會員可能會繼續與 FFS 提供者聯繫。 計劃在計劃收到會員要求之日起 30 天內，或者如會員的醫療狀況需要更立即關注，計劃必須告知會員是否可繼續與 FFS 提供者接受治療，或是否將會員指派給計劃提供者網絡中的提供者。 如果 FFS 供應商願意繼續與會員見面，但計劃表示否，或如計劃未能及時回應會員的要求，則會員可向計劃提出申訴。
答案 1b：紐約州現在要求Medi-Cal Managed Care保健計劃（計劃）提供一些醫療保健服務（例如長期護理），而這些服務直到最近才只能透過加州醫療補助健康保健計劃FFS提供者提供。正在接受此類醫療保健服務的會員可以根據答案 1a 中列出的相同要求，請求繼續從其 FFS 提供者接受服務。
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. 會員可以繼續在Medi-Cal Managed Care健康計劃（計劃）的提供者網絡之外尋求哪些類型的提供者？
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:
- 如果會員目前與 FFS 提供者有關係，
- 如果計劃與該提供者沒有護理質量問題，
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 該提供者是加州計劃批准的提供者。
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. Medi-Cal Managed Care健康保健計劃（計劃）中的任何加州醫療補助健康保健計劃會員是否可以繼續看不屬於該計劃網絡的現有提供者？
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.
持續性照顧（Continuity of Care）不適用於已加入計劃 12 個月或以上的會員，或剛獲得加州醫療補助健康保健計劃資格且必須加入計劃的會員。 這些會員通常必須與屬於該計劃的提供者網路一部分的提供者聯繫。
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.如果會員從一個 Medi-Cal 管理醫療保健計劃（計劃）更改為另一個或失去資格，然後再獲得資格，會員是否可以再次獲得 12 個月的時間來查看其網絡外的 Medi Cal 服務費（FFS）提供者？
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 Managed Care健康計畫（計畫）何時通知會員是否可以繼續看其目前的Medi-Cal Fee-for-Service提供者？
本計劃必須在計劃收到申請日起 30 個日曆日內處理每個申請並向每位會員提供通知，或者如果會員的醫療狀況需要更快地處理。
6.Medi-Cal Fee-for-Service FFS經Medi-Cal Managed Care 健康計劃（計劃）批准的會員的 ( ) 提供者是否可以將會員轉介給其他網路外提供者？
FFS 。 本計畫核准的網路外提供者，在持續性照顧（Continuity of Care）期間，必須與本計畫及其簽約的提供者網路合作。 如果該計劃的網路中沒有會員需要的專家類型，則該計劃必須向會員推薦該計劃的提供者網路之外的具有醫療必要性的專家。
7. 如果會員的Medi-Cal Fee-for-Service ( FFS ) 提供者不會或無法與Medi-Cal Managed Care健康計劃（計劃）合作怎麼辦？
如果FFS提供者不願意或無法與該計劃合作，則該計劃會將會員轉移到屬於該計劃的提供者網路一部分的提供者。
八.如果會員擁有積極治療授權，會怎麼辦？
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.
九.會員可以保留其耐用醫療器材 (DME) 和醫療用品嗎？
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.
十.「保健持續期」（自會員註冊日起計 12 個月）是否對現有的醫療豁免申請程序有任何影響？
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:
- 如果會員目前與 FFS 提供者有關係，
- 如果計劃與該提供者沒有護理質量問題，
- 如果提供者接受計劃的合約費率或 FFS 費率，並且
- 該提供者是加州計劃批准的提供者
計劃的持續性照顧（Continuity of Care）期限要求並未消除合格會員隨時提交MER或退出請求的權利。 現有 MER 流程（《加州法規》第 22 條，第 53887 條）和完成承保服務要求（H&S 第 1373.96 條） 必須註冊計劃的所有會員保持有效。
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)
十一. 是否需要Medi-Cal Managed Care健康計劃（計劃）來批准會員向其現有Medi-Cal Fee-for-Service ( FFS ) 提供者提供持續護理的請求？
每個計劃都必須滿足強制註冊會員對持續性照顧（連續性護理）的所有請求，只要：
- 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,
- 如果計劃與該提供者沒有護理質量問題，
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 該提供者是加州計劃批准的提供者
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.
十二.「護理質量問題」是什麼意思？
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.
十三.如果 Medi-Cal 管理醫療保健計劃（計劃）拒絕向現有的醫療保健費（FFS）提供者申請持續護理期（最多 12 個月起計），會員需要多長時間提出申訴？
必須註冊的會員可隨時向計劃提出申訴。 本計劃必須盡快解決每宗申訴並提供會員的健康狀況要求的書面通知，並且在 MCP 收到申訴通知之日起 30 個日曆日內，如果發生加快投訴，則不超過 72 小時。
14. 如果被要求加入Medi-Cal Managed Care健康計劃（計劃）的會員患有嚴重、急性或持續的醫療或健康狀況，需要緊急治療或監測，然後計劃才會決定該會員是否可以加入，該Medi-Cal Fee-for-Service辦FFS
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.
十五.如果會員希望繼續從未屬於 Medi-Cal 管理醫療保健計劃（計劃）提供者網絡的 Medi Cal 服務收費（FFS）提供者的醫療保健服務（FFS）服務提供者的醫療保健服務，該怎麼辦？
每個計劃都可以選擇在超過 12 個月持續性照顧（Continuity of Care）期限後與會員的網路外提供者合作，但他們不需要這樣做。
16. 強制登記會員在加入Medi-Cal Fee-for-Service FFSMedi-Cal Managed Care健康計劃（計劃）後是否可以與 ( ) 提供者預約？
需要計劃，才能允許新註冊會員在「CoC 期間」（註冊日起計 12 個月）與 FFS 提供者保持預定的約會：
- 如果預約是與會員在過去 12 個月內看到的 FFS 提供者，該服務已經透過 FFS 使用資料驗證，或者，該計劃已經透過其他方式驗證現有關係，
- 如果計劃與該提供者沒有護理質量問題，
- If the provider will accept the Plan’s contracted rates or FFS rates, and
- 該提供者是加州計劃批准的提供者。
如果會員從未見過的服務提供者，但由於嚴重的醫療狀況，他們必須在醫療上保持預約，則該計劃必須允許會員按照 H & S 第 1373.96 條「完成保障服務」的要求保留。 如預約與嚴重的醫療狀況不相關（如 H & S 第 1373.96 條所定義）， 但是在醫療上有必要的，計劃必須安排會員保留預約或與計劃提供者安排約會。
17. 上述答案是否適用於在熟練護理機構 (SNF) 接受長期照護服務的加州醫療補助健康照護計畫會員？ 或者是否適用於這些會員的政策？
由 1, 2023 年 1 月至 6 月 30, 2023, 生效，居住在 SNF 並從 FFS 轉換為計劃的會員將獲得 12 個月的聯邦基金會安置。 這些成員不必要求委員會繼續居留在該國家聯邦基金會。 只有在以下所有條件適用的情況下，會員只允許在同一 SNF 下的《CoC》下逗留：
- 該設施已獲得加州公共衛生部的認證和許可；
- 該機構已註冊為加州醫療補助健康保健計劃的提供者；
- SNF 和計劃同意符合州法定要求的付款率；以及
- 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.
新註冊計劃並於 6 月 30, 2023 之後居住在 SNF 的會員不會收到自動 CoC，而必須聯絡其計劃以申請 CoC。
18. 上述答案是否適用於在發育障礙中級護理機構 (ICF/DD)、ICF/DD-Habilitative (ICF/DD-H) 接受長期護理服務的加州醫療補助健康保健計劃會員，還是ICF/DD-護理（ICF/DD-N）（簡稱ICF/DD）之家？ 或者是否適用於這些會員的政策？
自 2024 年 1 月 1 日起，居住在 ICF/DD 家中並從 FFS 轉換為計劃的會員將獲得 12 個月的 CoC 以進行 ICF/DD 家居放置。 這些成員不必要求 CoC 繼續居住在該 ICF/DD 家中。 只有在以下所有條件適用的情況下，會員只能在 CoC 下住在同一個 ICF/DD 家中：
- 該住宅已獲得加州公共衛生部的認證和許可；
- 該房屋是加州計劃批准的提供者；
- 該計劃能夠確定會員是否與家庭已存在的關係；
- ICF/DD 住宅和計劃同意符合州法定要求的付款率；以及
- 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.
新註冊計劃並於 6 月 30 2023 之後居住於 ICF/DD 的會員不會收到自動 CoC，而必須與其計劃聯繫以要求 CoC。
19. 上述答案是否適用於在亞急性照護（成人和兒科）機構接受長期照護服務的加州醫療補助健康照護計畫會員？ 或者是否適用於這些會員的政策？
由 2024 年 1 月 1 日起，居住在亞急性護理設施並從 FFS 轉換為計劃的會員將獲得 12 個月的次急性護理安置辦理服務。 這些會員不必要求執行長者繼續居住在該次急性護理設施。 只有在以下所有條件適用的情況下，會員只允許在 CoC 下住在同一次急性護理設施：
- 該設施已獲得加州公共衛生部的認證和許可；
- 該設施與 DHCS 亞急性護理中心簽訂了合約；
- 該設施是加州計劃批准的提供者；
- 該計劃能夠確定會員是否與該設施已存在的關係；
- 該設施和計劃同意符合州法定要求的付款率；以及
- 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.
新註冊計劃的會員，並於 6 月 30 2023 之後居住於亞急性護理服務的會員不會收到自動 CoC，而必須聯絡其計劃以申請 CoC。