If you:

1. Have Fee-for-Service (FFS) Medi-Cal and must enroll in a Medi-Cal managed care plan, OR
2. Have a Medi-Cal managed care plan and must enroll in a different Medi-Cal managed care plan,

You may be able to continue to see your existing Medi-Cal health care providers even when your existing providers are not enrolled in your new managed care plan. This is called “continuity of care.” You have the right to continue getting the same care, meaning either the same provider or the same services, even though your Medi-Cal coverage has changed.

1. What if I am in Fee-for-Service Medi-Cal and must enroll in a Medi-Cal managed care plan?

You have Continuity of Care rights, as outlined in All Plan Letter 22-032. You may request Continuity of Care for up to 12 months if you have a pre-existing relationship with your provider. This means that you have seen the provider at least once for a non-emergency visit in the year before enrolling in the managed care plan.

For example, if you were enrolled in your managed care plan on January 1, 2024, and you had seen your Primary Care Provider for a routine visit on January 2, 2023 (or anytime later in 2023), your relationship with your Primary Care Provider would be considered “pre-existing.”

The protections in All Plan Letter 22-032 are in addition to state law protections under the Knox Keene Act.

2. What if I am already enrolled in a Medi-Cal managed care plan and must change to a new managed care plan on January 1, 2024?

You have similar Continuity of Care rights, as outlined in Department of Health Care Services’ (DHCS) 2024 Managed Care Plan Continuity of Care Policy.

NOTE: If you do not have to change your plan, but you decide to change it by choice after January 1, 2024, the new Continuity of Care policy does not apply to you.

3. How long does Continuity of Care last?

Your provider and managed care plan will decide how long you can get Continuity of Care, but it generally cannot be longer than 12 months.

There are 3 situations in which Continuity of Care may last longer than 12 months:

1. If you are receiving hospice care, your Continuity of Care must cover your terminal illness.
2. If you are pregnant or have recently given birth, your Continuity of Care must cover 12 months after the completion of your pregnancy or 12 months after a post-partum mental health diagnosis.
3. If you are receiving hospital inpatient care, Continuity of Care must cover the duration of the acute condition.

4. How do I access Continuity of Care?

You, your authorized representative, or your provider must request Continuity of Care from your new Medi-Cal managed care plan. You can do this by calling your new plan or having your authorized representative or doctor call your plan. Your plan’s phone number is in your enrollment packet and on your health plan card.

When you call, give your managed care plan the contact information for the provider who you wish to continue seeing so that the plan can contact the provider. It is important to let your health care provider and the provider’s front office know you have asked to continue seeing the provider under Continuity of Care protections.

Enhanced Continuity of Care for Special Populations

DHCS is requiring health plans to provide more Continuity of Care protections to Medi-Cal beneficiaries in certain Special Populations. If you are part of a Special Population, your new managed care plan should start the Continuity of Care process for you by reaching out to your providers from 2023 and establishing Continuity of Care agreements with your providers without you making the request to ensure that there are no disruptions in your care. We still recommend contacting your new managed care plan, as described above, to be sure your request is received. To determine if you are in a Special Population, see Question 22.

5. What do I need to get my request approved?

To approve your Continuity of Care request, your managed care plan will require that:

1. You have a pre-existing relationship with the provider, meaning that you have seen the provider at least once for a non-emergency visit in the year before enrolling in the managed care plan (see Question 1). Your managed care plan may be able to identify your pre-existing relationship through Department of Health Care Services (DHCS) data, but you can also provide your own documentation of the previous non-emergency visit,
2. The provider is willing to accept your managed care plan’s contract rates,
3. The provider meets your managed care plan’s professional standards and does not have any quality-of-care issues, and
4. The provider is a California State Medicaid Plan approved provider.

We recommend making Continuity of Care requests before receiving services from your provider.

If you are making the request AFTER you receive services from the provider, your request for continuity of care must be made within 30 calendar days after the date of service.

6. When will I hear back on my request?

The timeline for your managed care plan to approve or deny your Continuity of Care request depends on the potential risks to your health. Depending on the risk, DHCS will consider your request urgent, immediate, or non-urgent.

All requests from Special Populations required to transition to new managed care plans will be considered urgent.

If your need to see your Continuity of Care provider is urgent or you have a pending appointment, let your new plan know this.

Urgent

If there is an “identified risk of harm” to your health, your managed care plan must complete the request as soon as possible, but no longer than 3 calendar days. “Risk of harm” means an imminent and serious threat to your health.

Immediate

If your medical condition requires more immediate attention, such as a doctor’s appointment or other pressing service, your managed care plan must complete your request within 15 calendar days.

Non-Urgent

If your medical condition is not urgent or immediate, your managed care plan must process your request within 30 calendar days.

7. How will I hear back?

Your managed care plan must notify you of the date it received your request and give you their decision using your preferred form of communication (call, text message, or email). Your managed care plan must also send you a written decision by mail within 7 calendar days after processing the request. For urgent requests, the managed care plan must notify you within the shortest timeframe that’s appropriate for your condition, but no longer than 3 calendar days.

8. What happens if my request is approved?

If your request is approved, your managed care plan and your provider will enter into a Continuity of Care for Providers agreement. You can continue receiving services from that provider for the timeframe allowed in your statement of decision (up to 12 months). Your notice should also include information on the process that will occur to transition your care at the end of the timeframe and information about your right to choose a different, in-network provider (if you choose).

Under the Continuity of Care agreement, your managed care plan will pay your provider for your medical services.

9. What happens if my request is denied?

Your managed care plan may deny your request if the 4 requirements in Question 6 are not met. Your notice must explain the reason for the denial and give you information on how to file a grievance or appeal of the decision. See All Plan Letter 21-011 for more information about the grievance and appeal process. Also see DRC’s publication on Managed Care Grievances and Appeals.

If your plan and your provider have not been able to agree on an agreement or a rate, or your plan has documented quality of care issues with your provider, your plan must offer you an alternative in-network provider. If you do not choose one, your plan must refer you to one.

10. What happens after my Continuity of Care period (no longer than 12 months) comes to an end?

After your Continuity of Care period comes to an end, you must switch to a new provider who is in-network with your managed care plan. Your managed care plan must contact you and your provider about the process for transitioning to an in-network provider 30 calendar days before the end date.

11. What if I change managed care plans after my first enrollment?

If you change plans by choice after your first enrollment, or if you lose and then regain eligibility for a plan during the 12-month Continuity of Care period, your 12-month Continuity of Care period for a pre-existing provider can start over one time. For example, if you enroll in a managed care plan on January 1, 2023. Then, you change to a new managed care plan, by choice, on April 1, 2023. The 12-month Continuity of Care period can start over one time on April 1, 2023 and you may see your pre-existing provider until April 1, 2024.

If you switch again, there will not be a new 12-month Continuity of Care period.

Transitions from FFS Medi-Cal to a Managed Care Plan

12. Which providers can I continue seeing?

If you are changing from FFS Medi-Cal to a Medi-Cal managed care plan, Continuity of Care protections may allow you to see:

• Primary Care Providers
• Specialists, and
• Select ancillary Providers, including speech, physical, occupational, respiratory therapists, and behavioral health treatment (BHT) providers.

You CANNOT get Continuity of Care protections to see other ancillary Providers, such as:

• Radiology
• Laboratory
• Dialysis centers
• Non-Emergency Medical Transportation (NEMT)
• Non-Medical Transportation (NMT)
• Other ancillary services, and
• Providers not enrolled in Medi-Cal.

13. What if I already have an appointment scheduled with a specialist through my Fee-for-Service Medi-Cal? Can I still attend the appointment after I am enrolled in a managed care plan?

If the appointment is with an out-of-network specialist you have seen in the last year for a non-emergency visit and Continuity of Care is established (following the process in Question 5 and requirements in Question 6), you can keep the scheduled appointment, as long as it will happen during your Continuity of Care period.

If the appointment is with an out-of-network specialist you have NOT seen in the last year for a non-emergency visit and Continuity of Care is NOT established, your managed care plan has 2 options: 1) Your managed care plan may let you keep your existing appointment, or 2) Your managed care plan will schedule an appointment with an in-network provider of the same specialty on or before the scheduled date of the existing appointment. If your managed care plan is unable to schedule the new appointment in time, it must make a “good faith effort” to allow you to keep your original appointment. For additional information, see APL 23-022 and the 2024 Medi-Cal Managed Care Plan Transition Policy Guide.

14. Can I continue receiving services that have already been authorized when I transition from FFS Medi-Cal to Managed Care?

Yes. You have a right to continue receiving the same Medi-Cal covered services after enrolling in a managed care plan from FFS Medi-Cal.

Your managed care plan must honor all active prior treatment authorizations for services for your first 90 days on the plan. You do not have to request this because it should happen automatically, but we recommend making the request. Your managed care plan must arrange for the authorized services to be delivered by an in-network provider. If there is no in-network provider, your plan must find an out-of-network provider to provide the service.

After 90 days, your active treatment authorization will remain in effect through its original duration or until your managed care plan completes a new assessment, whichever is sooner. If the 90-day window ends and your managed care plan has not completed a new assessment, your plan may reassess your treatment authorization at any time.

The assessment is done when you visit an in-network provider who reviews your condition and completes a new treatment plan. The new treatment plan must include an assessment for the services in your existing treatment authorization.

15. Is there Continuity of Care for my Durable Medical Equipment (DME) and medical supplies when I change from FFS Medi-Cal to Medi-Cal Managed Care?

Yes. You are allowed to keep your existing DME rentals and supplies from your existing DME provider approved under FFS Medi-Cal for:

1. 90 days after your enrollment in the managed care plan, AND
2. Until you have been reassessed by the managed care plan, AND
3. Until you have your new DME or supplies and they are ready to be used.

The reassessment is done when you visit an in-network provider (in-person or via telehealth) who reviews your condition and completes a new treatment plan. The new treatment plan must include an assessment of services in your existing DME authorization.

After 90 days, your managed care plan can reassess your authorization for DME at any time and may require you to switch to an in-network provider. If your managed care plan does not complete a new assessment, the existing authorization remains active for its original duration.

16. What if my DME was ordered at the time of my transition to managed care from FFS Medi-Cal, but not yet delivered?

The same policy from Question 15 applies if your DME has been ordered, but not yet delivered at the time of your transition. Your managed care plan must allow for your DME to be delivered and for you to keep it for at least 90 days and until reassessment.

17. Will my transportation services covered by FFS Medi-Cal (Non-Emergency Medical Transportation and Non-Medical Transportation) Continue?

Your managed care plan must allow you to keep the type of transportation you have been authorized but the plan may require you to switch to an in-network provider.

Transitions from one Managed Care Plan to a Different Managed Care Plan

18. Which providers can I continue seeing?

If you are changing from one Managed Care Plan to a new managed care plan, Continuity of Care protections may allow you to see:

• Primary Care Providers
• Specialists, and
• Select ancillary Providers, including speech, physical, occupational, respiratory therapists, and behavioral health treatment (BHT) providers.
• Doulas
• Dialysis Centers
• Enhanced Care Management (ECM) Providers
• Community Supports Providers
• Skilled Nursing Facilities (SNFs)

You CANNOT get Continuity of Care protections to see other ancillary Providers, such as:

• Radiology
• Laboratory
• Non-Emergency Medical Transportation (NEMT)
• Non-Medical Transportation (NMT)
• Providers not enrolled in Medi-Cal.

19. What services can I continue getting if I must change to a new managed care plan?

Continuity of Care for services allows you to continue receiving covered Medi-Cal services for 6 months (from January 1, 2024 to July 1, 2024) without getting a new authorization from the new managed care plan if:

1. You have an active Prior Authorization for the service, OR
2. You have an Active Course of Treatment without Prior Authorization. The “Active Course of Treatment” must be documented in your medical records before January 1, 2024. It means you are actively engaged with a provider and following the prescribed course of treatment as outlined by your provider for a particular medical condition.

20. What happens after the 6-month of Continuity of Care period ends for services authorized under my former managed care plan?

If you still need the service after the 6-month Continuity of Care period ends, your new in-network provider should request an authorization from your new managed care plan.

21. Do I have Continuity of Care rights for my DME and medical supplies if I am transitioning to a new managed care plan on January 1, 2024?

Yes. If you’re transitioning to a new managed care plan on January 1, 2024, you can keep your existing DME rentals and medical supplies for at least 6 months after your transition and until your next reassessment. If your DME or medical supplies were previously approved but will not be provided until after the transition, your plan must allow you to keep your DME rental or supplies for at least 6 months, until you have a new assessment. If your new plan does not complete a new assessment, your existing authorization will remain in effect for the duration of the treatment authorization.

22. What if I am part of a Special Population?

If you are part of a Special Population, you have more protections for Continuity of Care for services. You are in a “Special Population” if you are:

• Authorized to receive Enhanced Care Management (ECM) services
• Authorized to receive Community Supports
• Enrolled in Complex Care Management
• Enrolled in 1915(c) waiver programs (Includes HCBA waiver and HCBS-DD Waiver)
• Receiving In-Home Supportive Services (IHSS)
• Enrolled in California Children’s Services (CCS)/CCS Whole Child Model
• Receiving foster care, and former foster youth through age 25
• In active treatment for the following chronic communicable diseases: HIV/AIDS, tuberculosis, hepatitis B and C
• Taking immunosuppressive medications, immunomodulators, and biologics
• Receiving treatment for end-stage renal disease (ESRD)
• Living with an intellectual or developmental disability (I/DD) diagnosis
• Living with a dementia diagnosis
• In the transplant evaluation process, on any waitlist to receive a transplant, undergoing a transplant, or received a transplant in the previous 12 months
• Pregnant or postpartum (within 12 months of pregnancy completion or maternal mental health diagnosis)
• Receiving specialty mental health services (adults, youth, and children)
• Receiving treatment with pharmaceuticals whose removal risks serious withdrawal symptoms or mortality
• Receiving hospice care
• Receiving home health
• Residing in Skilled Nursing Facilities (SNF)
• Receiving hospital inpatient care
• Post-discharge from inpatient hospital, SNF, ICF/DD, or sub-acute facility (within 30 days of stay)
• Newly prescribed DME (within 30 days of January 1, 2024)
• Members receiving Community-Based Adult Services

In addition to the 6-month protection window, your new managed care plan must assess whether it is necessary for you to continue these services. The assessment is done when you visit an in-network provider (in-person or via telehealth) who reviews your condition and completes a new treatment plan. The new treatment plan must include an assessment of services in your existing treatment authorization from your previous managed care plan.

Your new managed care plan must also work proactively to identify members with Active Courses of Treatment that will need to be authorized beyond 6 months. Your plan must contact providers of the treatment to establish any necessary Prior Authorizations.

23. What if I am part of a Special Population and I am receiving care management services?

If you are part of a Special Population listed under Question 23 and you receive care management services from your previous health plan (for example, from your Complex Care Management [CCM] Care Manager or your Enhanced Care Management [ECM] Care Manager), you can get Continuity of Care for these services, too.

Your previous managed care plan is required to share information from your Care Manager with your new managed care plan to make this transition easier. This includes your contact information, preferred form of communication, results of your available screening and assessment findings, and your Care Management Plan. Your previous managed care plan must finish transferring this information to your new managed care plan within 15 calendar days of your transition to a new Care Manager.

If you receive CCM services, you should continue receiving them from your new managed care plan.

If you receive ECM services, you should also continue receiving them from your new managed care plan, because all managed care plans are expected to be contracted with all ECM providers by 2024. But, if your ECM provider is not in-network with your new managed care plan, you must follow the process in Questions 5-11.

24. What if I am receiving in-patient hospital care on January 1, 2024?

Your previous managed care plan must inform your new managed care plan that you are receiving in-patient care by December 22, 2023. It must continue to update your new managed care plan every day though January 9, 2024, including holidays and weekends. Your new managed care plan must contact the hospital to coordinate your care.

25. Will my transportation services (Non-Emergency Medical Transportation and Non-Medical Transportation) Continue?

If you have pre-authorization for transportation services, your new plan must take steps to ensure that you are able to keep your current type of transportation for at least 6 months after the transition. The plan may require you to change to an in-network provider. After 6 months, the plan may reassess your need for transportation.

26. What if I am currently on a waitlist to see a specialist with my managed care plan? Will I have to start at the back of the line on a new waitlist after January 1, 2024?

If you are currently on a waitlist for an appointment with a specialist, you should contact your new managed care plan and request an in-network specialist appointment within the same timeframe as your existing appointment. Your new managed care plan should either 1) let you keep your existing appointment, OR 2) schedule an appointment with an in-network provider of the same specialty. The appointment with the in-network provider must be on or before the scheduled date of the existing appointment.

27. Where can I find additional information about Continuity of Care?

Additional information from DHCS is available at https://www.dhcs.ca.gov/services/Pages/ContinuityOfCare.aspx and information from the National Health Law Program is available at https://healthlaw.org/resource/continuity-of-care-in-medi-cal-managed-care-updated-2023/