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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more
California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

19-029 Continuity of Care Changes for Medi-Cal Members

Date: 01/22/19

New requirements for FFS Medi-Cal members transitioning to Medi-Cal managed care

On December 7, 2018, the Department of Health Care Services (DHCS) issued revised All Plan Letter (APL) 18-008, notifying health plans of updated continuity of care (COC) requirements. California Health & Wellness Plan (CHWP) is complying with the requirements in this APL, as outlined in this update.

CONTINUITY OF CARE CRITERIA

As a reminder, member requests for continuity of care with a provider must meet specified criteria.

  • There are no documented provider quality-of-care issues where it is determined that the provider is ineligible to continue providing services to CHWP members.
  • There is evidence of an ongoing relationship with the nonparticipating provider or terminated provider.
  • The nonparticipating provider is willing to accept the higher of CHWP’s contract rates or Medi-Cal fee-for-service (FFS) rates.
  • The provider is a California State Plan approved provider.
  • The provider supplies CHWP with all relevant treatment information for medical necessity determination, including a current treatment plan, as long as it is allowable under federal and state privacy laws and regulations.

RETROACTIVE REQUESTS

CHWP retroactively approves and reimburses providers for covered services that were already provided when the request meets all the above criteria and the services meet the following requirements:

  • Services occurred after the member’s enrollment into a CHWP plan.
  • Dates of service are within 30 calendar days of the first service for which the provider requests retroactive reimbursement.

Retroactive reimbursement requests must be submitted within 30 calendar days of the first service to which the request applies.

NON-SPECIALTY BEHAVIORAL HEALTH SERVICES

CHWP provides continuity of care with an out-of-network specialty mental health service (SMHS) provider in these instances:

  • The member’s behavioral health condition has stabilized such that the member no longer qualifies to receive SMHS from the county mental health plan (MHP).
  • The member becomes eligible to receive non-specialty behavioral health services from Cenpatico.

In these situations, the continuity of care requirement only applies to psychiatrists and/or behavioral health providers approved to provide outpatient, non-specialty mental health services.

Behavioral Health services are administered through Cenpatico, CHWP’s behavioral health contractor. Cenpatico contact information is located on the member’s CHWP identification (ID) card.

CONTINUITY OF CARE CHANGES FOR MEDI-CAL MEMBERS

At the request of the member, provider or member’s authorized representative, Cenpatico must allow up to 12 months of continuity of care with an out-of-network county MHP provider. After the continuity of care period ends,

  • The member must choose a behavioral health provider in Cenpatico’s network for non-specialty mental health services.
  • If the member later requires additional SMHS from the county MHP to treat a serious behavioral illness and experiences sufficient improvement to be referred back to the Cenpatico network for non-specialty mental health services, the 12-month continuity of care period may start over one time.

The member does not have the right to a new 12-month continuity of care period if the member requires SMHS from the county MHP subsequent to the continuity of care period when the member returns to the Cenpatico network provider or changes health plans.

HEALTH HOMES PROGRAM

CHWP provides continuity of care with an out-of-network provider for Medi-Cal FFS beneficiaries who voluntarily transition to CHWP in order to enroll in the Health Homes Program (HHP). HHP launches July 1, 2019, in Imperial County, and services will be provided to beneficiaries through a network of clinics and community-based organizations. Beneficiaries will not be required to change primary care providers.

ADDITIONAL INFORMATION

Providers are encouraged to access CHWP’s provider portal online at www.cahealthwellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact your Provider Relations representative or call 1-877-658-0305.