CHA News Article

DHCS Releases Guidance on Continuity of Care for Cal MediConnect Beneficiaries

The California Department of Health Care Services (DHCS) has released the attached Duals Plan Letter (DPL) 16-002, which supersedes DPL 15-003, to clarify and provide guidance about continuity of care provided by Medicare-Medicaid plans (MMPs) participating in Cal MediConnect, California’s Duals Demonstration Project. The DPL clarifies:

  • Requirements for delegated entities
  • Procedures for requesting continuity of care
  • Timeline for completing continuity of care requests
  • Requirements after the request process is completed
  • MMP extended continuity of care options
  • Beneficiary and provider outreach and education
  • Provider referral outside of the MMP network
  • Skilled-nursing facilities’ (SNFs) additional continuity of care provisions under California law
  • Balance billing prohibitions

CHA submitted comments to DHCS on the draft DPL and is pleased to see that the final DPL clarifies that if a discharged SNF resident requires a return to a SNF level of care due to medical necessity, the beneficiary has the right to return to the same SNF where he or she previously resided under the leave of absence and bedhold policies outlined in DPL 14-002, and the continuity of care policies contained in this DPL.

The specific requirements on the leave of absence, bedhold, or continuity of care policies will apply depending on which policy is applicable in any given circumstance. In addition, a beneficiary who is a SNF resident at the time of enrollment will not be required to change SNFs during the duration of Cal MediConnect if the facility is licensed by the California Department of Public Health, meets acceptable quality standards, and the facility and MMP agree to Medicare rates if the service is a Medicare service — or Medi-Cal rates if the service is a Medi-Cal service — in accordance with the three-way contract between the state, DHCS and the MMPs. This provision is automatic, meaning the beneficiary does not have to make a request to the MMP to invoke this right. The MMP must determine the duration of residency through historical utilization data or documentation from the beneficiary or provider — the same process specified previously for verifying a preexisting provider relationship.