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.”
If a Member’s provider does not contract with any of the Medi-Cal managed care health plan(s) (Plans) that are available in the Member’s county, how may the Member continue to see this provider?
Answer 1a: If the Member was seeing a Medi-Cal Fee-for-Service (FFS) provider before being required to enroll into a Plan, the Member may be able to continue to see the FFS provider for up to 12 months while remaining enrolled in the Plan. This 12-month period is the “Continuity of Care period.” To continue care with a FFS provider, the Member must:
- Contact the new Plan.
- Tell the Plan that they want to continue to receive health care from the FFS provider.
- Tell the Plan the name of the FFS provider.
The member may continue to see the FFS provider when the Plan determines that the Member has seen that provider in the past 12 months, the provider has no quality-of-care issues that would make them 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 Member’s request, or sooner if the Member’s medical condition requires more immediate attention, the Plan must tell the Member if they may continue treatment with the FFS provider or if they will be assigned to a provider in the Plan’s provider network. If the FFS provider is willing to continue to see the Member, but the Plan says no, or if the Plan fails to respond to the Member’s request in a timely manner, then the Member may file a grievance with the Plan.
Answer 1b: The State now requires Medi-Cal managed care health plans (Plans) to provide some health care services (such as long term care) that were until recently only available through Medi Cal FFS) providers. Members who were receiving such a health care service may request to continue to receive the service from their FFS 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 22-032: Continuity of care for Medi-Cal Beneficiaries who newly enroll in Medi-Cal Managed Care from Medi-Cal Fee-for-Service, and for Medi-Cal members who transition into a new Medi-Cal Managed Care Health Plan 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 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 Code HSC 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. HSC 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 HSC Section 1373.96. Under HSC 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.
Which types of providers may a Member continue to see outside the Medi Cal managed care health plan’s (Plan’s) network of providers?
A Member may ask the Plan to allow them to continue to see a Medi Cal Fee-for-Service (FFS) provider who is not in the Plan’s provider network. A member may continue to see their FFS provider for 12
months:
- If the member 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.
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; or durable medical
equipment providers. 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.
Can any Medi-Cal Member in a Medi-Cal managed care health 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 Continuity of Care applies to a Member who previously (in the past 12 months) was seeing a Medi Cal Fee-for-Service (FFS) provider and is now required to enroll into a Plan. Continuity of Care 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 continuity
of care with psychiatrists and/or mental health providers who are permitted
through the California Medicaid State Plan to provide outpatient non-specialty
mental health services. Continuity of Care also applies to members who
mandatorily transition from Covered California to a Plan and members who
transition from UnitedHealthcare Community Plan in San Diego County or AIDS
Healthcare Foundation in Los Angeles due to contract terminations effective
December 31, 2022 to a new Plan. Continuity of Care does not apply to a Member who has been in a Plan for twelve months or more or to a Member who has just become eligible for Medi Cal and must enroll into a Plan. These members must generally see providers who are part of the Plan’s provider network.
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 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 Code (HSC) § 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 HSC Section 133.96 requires these health plans to 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 health condition and defined under HSC § 1373.96. Under HSC 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.
If the Member changes from one Medi-Cal managed care health plan (Plan) to another or loses eligibility and
then later regains eligibility, does the Member get another 12 month period to see their out-of-network Medi Cal Fee-for-Service (FFS) provider?
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 Continuity
of Care.
When will the Medi-Cal managed care health plan (Plan) notify the Member whether or not they can continue to see their current Medi Cal Fee-for-Service provider?
The Plan is required to process each request and provide notice to each Member no later than 30 calendar days from the date the Plan receives the request, or sooner if the Member’s medical condition requires more immediate attention.
Can the Member’s Medi Cal Fee-for-Service (FFS) provider who has been approved by the Medi-Cal managed care health plan (Plan) refer the Member to another out-of-network provider?
No. An out-of-network FFS provider may not refer the Member to another out-of-network provider without prior authorization from the Plan. An out-of-network provider, approved by the Plan, under the 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 Member needs, then the Plan must provide the Member with a referral to a medically necessary specialist outside the Plan’s provider network.
What if the Member’s Medi Cal Fee-for-Service (FFS) provider will not or cannot work with the Medi-Cal managed care health plan (Plan)?
If the FFS provider will not or cannot work with the Plan, then the Plan will transition the Member to a provider who is part of the Plan’s provider network.
What happens if a member has an active treatment authorization?
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.
Can a member keep their Durable Medical Equipment (DME) and Medical Supplies?
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. Can your Plan for help with these services.
Does the “Continuity of Care period” (up to 12 months from the Member’s date of enrollment) have any impact on the existing process for Medical Exemption Requests (MERs)?
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 Continuity of Care to complete a course of treatment with an existing Medi-Cal Fee-for-Service (FFS) provider.
Otherwise, the Continuity of Care 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:
- If the Member 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.
The Continuity of Care period requirements for Plans do not eliminate the rights of qualifying members 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 members who are required to enroll into Plans.
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)
Is a Medi-Cal managed care health plan (Plan) required to grant a Member’s request for continuing care with their existing Medi Cal Fee-for-Service (FFS) provider?
Each Plan is required to grant all requests from a mandatorily enrolled Member for Continuity of Care as long as:
- 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;
- The provider agrees to accept the Plan’s contracted rates or Medi-Cal FFS rates; and
- The provider has no quality-of-care issues that, otherwise, would make them ineligible to provide services to any Plan Members.
Additionally, Plans must comply with requirements of
the California Health and Safety Code (HSC) 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 HSC section 1373.96.
What does “quality-of-care issue” mean?
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 other Plan members.
How much time does a Member have to file a grievance if the Medi-Cal managed care health plan (Plan) denies the request for the Continuity of Care period (up to 12 months from the date of enrollment) with the existing Medi Cal Fee-for-Service (FFS) provider?
A mandatorily enrolled member may file a grievance with the Plan at any time. The Plan must resolve each grievance and provide written notice to the Member as quickly as the Member’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.
What if a Member who was required to enroll into a Medi-Cal managed care health plan (Plan) has a serious, acute, or ongoing medical or health condition that requires urgent treatment or monitoring before the Plan determines whether the Member may continue treatment with a Medi Cal Fee-for-Service (FFS) provider or during the grievance process?
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. For information about prescription medication, see Question 15 below. A Plan primary care provider will assist the Member in obtaining all urgent medically necessary services and medications.
What if the Member wishes to continue receiving health care services from a Medi Cal Fee-for-Service (FFS) provider who is not part of the Medi-Cal managed care health plan (Plan) provider network for more than the allowed 12 months?
Each Plan may choose to work with the Member’s out-of-network provider past the 12-month Continuity of Care period, but they are not required to do so.
Will a mandatorily enrolled Member be allowed to keep a scheduled appointment with a Medi Cal Fee-for-Service (FFS) provider after being enrolled into a Medi-Cal managed care health plan (Plan)?
Plans are required to allow newly enrolled members to keep scheduled appointments with FFS providers during the “Continuity of Care period” (up to 12 months from the date of enrollment):
- If the appointment is with a FFS provider the Member 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 Member 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 Member 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 Member to either keep the appointment or schedule an appointment with a Plan provider.
Are Answers 1-16 above applicable for Medi-Cal members who are receiving long term care services in a skilled nursing facility? Or are there different policies that apply for these members?
Effective January 1, 2023 through June 30, 2023, members residing in a skilled nursing facility (SNF) and transitioning from Medi-Cal FFS to a Plan will have 12 months of continuity of care for the SNF placement. These members do not have to request continuity of care to continue to reside in that SNF. Members are allowed to stay in the same SNF under continuity of care only if all of the following applies:
- The facility is enrolled and licensed by the California Department of Public Health;
- The facility is enrolled as a provider in Medi-Cal;
- The SNF and Plan agree to payment rates that meet state statutory requirements; and
- 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 continuity of care, following the process established by APL 22-032
A member newly enrolling into a Plan and residing in a SNF after June 30, 2023 do not receive automatic continuity of care and must instead contact their Plan to request continuity of care.
Are Answers 1-16 above applicable to Medi-Cal members who transition from UnitedHealthcare Community Plan in San Diego County to a new Plan due to contract terminations effective December 31, 2022?
Yes. Most of the continuity of care information in Answers 1-16 also apply to Medi-Cal members who transition from UnitedHealthcare Community Plan (UHC) in San Diego County to a new Plan. Instead of a member requesting continuity of care with a FFS provider, the member would contact their new Plan to keep seeing their UHC provider. A member may continue seeing their UHC provider for up to 12 months from the date of their enrollment into the new Plan:
- If the member has a current relationship with the UHC provider,
- If the new Plan does not have quality-of-care issues with that provider, and
- If UHC will accept the Plan's contracted rates or FFS rates.
