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  • Care Management > Continuity of Care with Out-of-Network Providers

    Continuity/Transition of Care - New Members

    Upon enrollment, the member shall select a PCP from whom the member may request continuation of care. When appropriate, EmblemHealth will permit new members to continue seeing their current out-of-network practitioner for up to 60 days or as otherwise required to accommodate the needs of medically fragile children and foster children covered by Medicaid.

    If on the effective date of enrollment a member has a life-threatening disease or condition or a degenerative and disabling disease or condition, the member may continue to see their current out-of-network practitioner for up to 60 days. In the case of pregnancy, if the member has entered into her second trimester, she may continue to see the nonparticipating practitioner through delivery and postpartum care for up to 60 days for care related to the delivery for Medicaid members. All transitions of care and continuity of services must be reviewed and approved by EmblemHealth or the member's assigned managing entity (see back of member ID card) prior to the services continuing. For the request to be considered, the member must have at least one of the following health conditions:

    1. A condition in the midst of ongoing course of treatment with an out-of-network provider
    2. Second and third trimester of pregnancy (up to 60 days postpartum directly related to the delivery for Medicaid members)

    If transitions of care and/or continuity of care is approved, it will be for a period of up to 60 days from the effective date of enrollment when the eligibility criteria are met. A single case agreement for continued services with an out-of-network health care provider must be agreed upon by EmblemHealth and the provider. The provider must do all of the following:

    • Accept our reimbursement rates as payment in full
    • Adhere to our Quality Improvement program
    • Provide medical information related to the enrollee's care
    • Otherwise adhere to our policies and procedures including those regarding referrals and obtaining prior approvals and a treatment plan approved by our applicable Prior Authorization department. (See the How to Obtain Prior Approval section in this chapter.)

      EmblemHealth will not deny coverage of an ongoing course of care unless an appropriate provider of alternate level of care is approved for such care.

      This transitional method does not require EmblemHealth to provide coverage for benefits not otherwise covered or diminish or impair pre-existing condition limitations contained in the member agreement.

      Continuity of Care - Medicaid Children

      For continuity of care purposes, EmblemHealth allows children to continue with their care providers, including medical, behavioral health, and Home and Community-Based Service (HCBS) providers, for a continuous episode of care. This requirement will be in place for the first 24 months of the transition. It applies only to episodes of care that were ongoing during the transition period from fee for service to managed care.

      To preserve continuity of care, children enrollees will not be required to change Health Homes or their Health Home Care Management Agency at the time of the transition. EmblemHealth will pay on a single case basis for children enrolled in a Health Home when the Health Home is not contracted with EmblemHealth. For children transitioning from Medicaid Fee-For-Service, EmblemHealth will continue to authorize covered Home and Community Based Service (HCBS) and Long Term Services and Supports (LTSS) in accordance with the most recent Plan of Care for at least 180 days following the date of transition of children’s specialty services newly carved into managed care. Service frequency, scope, level, quantity, and existing providers at the time of the transition will remain unchanged (unless such changes are requested by the enrollee or the provider refuses to work with the plan) for no less than 180 days, during which time, a new Plan of Care is to be developed.

      During the initial 180 days of the transition, EmblemHealth will authorize any children’s specialty services newly carved into managed care that are added to the Plan of Care under a person-centered process without conducting utilization review. For 24 months from the date of transition of the children’s specialty services carve-in, for fee-for-Service children in receipt of HCBS at the time of enrollment, EmblemHealth will continue to authorize covered HCBS and LTSS in accordance with the most recent Plan of Care for at least 180 days following the effective date of enrollment. Service frequency, scope, level, quantity, and existing providers at the time of enrollment will remain unchanged (unless such changes are requested by the enrollee or the provider refuses to work with the plan) for no less than 180 days, during which time a new Plan of Care is to be developed.

      To facilitate a smooth transition of HCBS and LTSS authorizations, for children in receipt of HCBS, EmblemHealth will begin accepting Plans of Care on May 1, 2018, for 1) our enrolled population or 2) a child for whom the Health Home Care Manager or Independent Entity has obtained consent to share the Plan of Care with EmblemHealth and the family has demonstrated the Plan selection process has been completed. EmblemHealth will continue to accept Plans of Care for children in receipt of HCBS in advance of the effective date of enrollment when EmblemHealth is notified by another Plan, a Health Home Care Manager or the Independent Entity that there is consent to share the Plans of Care with EmblemHealth and the family has demonstrated the Plan selection process has been completed.

      All ambulatory levels of care identified within the children's expanded benefits will be included in prior approval and concurrent review processes and include review and approval of the Plan of Care for the Medically Fragile population in accordance with the requirements set forth by the “Office of Health Insurance Programs Principles for Medically Fragile Children". And prior authorization will be required for the HCBS Plan of Care to determine medical necessity and to ensure it is a person-centered Plan of Care that meets individual needs. EmblemHealth will facilitate the transfer of the Plan of Care between the Health Home and/or Care Management Agency, EmblemHealth Utilization Management, and the appropriate delegate.The Care Management Agency requests authorization from EmblemHealth Utilization Management, meets with the member directly, and completes the brief and full required assessment with the member.After the assessment, the Care Management Agency develops a Plan of Care with the member that recommends HCBS and has a goal around each HCBS recommended. This Plan of Care is sent from the Care Management Agency to their lead Health Home (depending on the guidelines prescribed by the lead Health Home) and an EmblemHealth Care Management liaison via the secure fax number.

      The EmblemHealth Care Management liaison and/or Care Manager reviews the Plan of Care, determines medical and behavior health needs, and forwards the Plan of Care to the appropriate EmblemHealth Utilization Management staff and/or delegate.If there are any questions or issues with the Plan of Care, the EmblemHealth Care Management liaison and/or Care Manager acts as the liaison between the Care Management Agency, lead Health Home, EmblemHealth Utilization Management, and the appropriate delegate to coordinate care and services. EmblemHealth Utilization Management works to approve the Plan of Care, and sends a level of service determination letter to the Care Management Agency or lead Health Home with recommended HCBS providers.The HCBS provider completes their own assessment and submits a prior authorization request directly to EmblemHealth Utilization Management and or delegate directly. Utilization Management will collaborate by outreaching to Care Management to review Plan of Care deviations and discuss any required appropriate adjustments to either service delivery or the Plan of Care.

      HCBS are required to manage EmblemHealth members in compliance with CMS HCBS Final Rule and any applicable State guidance, and that the Plan Of Care (POC) is developed in a person-centered manner, compliant with federal regulations and state guidance, and meets individual needs. HCBS is required,to ensure appropriate POCs are in place, maintained, or discontinued based on person-centered planning. In addition, HCBS are to monitor ongoing services and utilize the authorization form every time they submit a request for services by following the CMS HCBS Final Rule and workflow when developing a POC and request authorization from EmblemHealth. EmblemHealth will review the HCBS process to ensure that it is managed in compliance with CMS HCBS Final Rule and any applicable State guidance, and that the POC is developed in a person-centered manner, compliant with federal regulations and state guidance, and meets individual needs. Depending on the POC review and findings, EmblemHealth will conduct outreach to review such deviations, and require appropriate adjustments to either service delivery or the POC. EmblemHealth will review and issue determinations within authorization request time frames as described in the Medicaid Managed Care Model Contract, and may request additional information related to the requested service authorization from the HCBS provider. HCBS process and POC are to be in accordance with CMS HCBS Final Rule at all times. EmblemHealth will monitor to determine if any service utilization patterns that deviate from any approved POC are identified by reviewing POC and continued authorization.

      Continuity of Care Children in Foster Care

      Continuty of care for foster children will follow the same processes as for the Medicaid children described above with the addition of the following, which are specific to foster children:

      To facilitate a smooth transition of HCBS and LTSS authorizations, for children in receipt of HCBS, EmblemHealth will begin accepting Plans of Care on November 1, 2018, for a child in the care of a LDSS/licensed Voluntary Foster Care Agencies, where Plan election has been confirmed by the LDSS/Voluntary Foster Care Agencies.

      EmblemHealth will continue to accept Plans of Care for children in receipt of HCBS in advance of the effective date of enrollment when EmblemHealth is notified that a child in the care of a LDSS/licensed Voluntary Foster Care Agencies, Plan selection has been confirmed by the LDSS/Voluntary Foster Care Agencies.

      Children in foster care who are moved outside of the original county they have been living in may transition to a new primary care provider and other health care providers without disrupting the care plan that is in place. They may also access providers with expertise in treating children involved in foster care as necessary to ensure continuity of care and the provision of all medically necessary benefit package services.

      Continuity/Transition of Care - Benefits Exhausted or Ended

      We collaborate with the members and their providers and practitioners to assure that members receive the services needed, within the benefit limitations of their contracts. When benefits end for members, the Utilization Management department will assist, if applicable, in the transition of their care.

      Continuity of Care - When Providers Leave the Network

      When a member's health care practitioner leaves EmblemHealth, the member will be given the option of continuing an ongoing course of treatment with his or her current practitioner for a transitional period of up to 90 days. If the member has entered the second trimester of pregnancy, the transitional period includes the provision of postpartum care through 60 days postpartum directly related to the delivery. Members who wish to continue seeing their current health care practitioner for a limited time must contact or have their provider contact the appropriate Anticipated Care department (see the How to Obtain Prior Approval section in this chapter).

      EmblemHealth will permit a member to continue with their current practitioner as long as the reason for leaving is not related to imminent harm to patients, to a determination of fraud or to a final disciplinary action by a state licensing board that impairs the health professional's ability to practice. The practitioner must agree to all of the following:

      1. Continue to accept reimbursement at the rates applicable prior to the start of the transitional period as payment in full
      2. Adhere to EmblemHealth's quality assurance requirements and provide us with necessary medical information related to such care
      3. Otherwise adhere to our policies, which include but are not limited to, procedures regarding referrals, obtaining prior approval for services and obtaining an approved treatment plan

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      Glossary terms found on this page:

      An activity of EmblemHealth or its subcontractor that results in:

      • Denial or limited authorization of a service authorization request, including the type or level of service
      • Reduction, suspension or termination of a previously authorized service
      • Denial, in whole or in part, of payment for a service
      • Failure to provide services in a timely manner
      • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

      Services that have been approved for payment based on a review of EmblemHealth's policies.

      Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

      Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

      When the maximum number of visits for a specific service is reached, further benefits will not be considered.

      The government agency responsible for administering the Medicare and Medicaid programs.

      A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

      An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

      An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

      Any medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months and renders the member unable to engage in any substantial gainful activities.

      The date on which the coverage of an insurance policy goes into effect at 12:01 am.

      A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

      An individual who is enrolled and eligible for coverage under a health plan contract. Also called a member.

      A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

      A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

      An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.

      A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

      An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

      A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.

      A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

      Specific circumstances or services listed in the contract for which benefits will be limited.

      Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

      Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

      A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

      Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

      • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
      • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
      • It is in accordance with accepted standards of good medical practice in the community.
      • It is furnished in a setting commensurate with the member's medical needs and condition.
      • It cannot be omitted under the standards referenced above.
      • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
      • It is not furnished primarily for the convenience of the member, the member's family or the provider.
      • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

      The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

      Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

      An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

      The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

      A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

      The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

      A health care provider, such as a physician, skilled nursing facility, home health agency or laboratory, that does not have an agreement with EmblemHealth plans to provide covered services to members. Also called a Non-Participating Provider.

      A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

      A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

      A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

      A pre-existing condition is any disease, symptom or condition that was present on the first day of coverage and for which medical advice or treatment was recommended or received during the six-month period prior to the enrollment date.

      The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

      A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

      • Doctor of medicine
      • Doctor of osteopathy
      • Dentist
      • Chiropractor
      • Doctor of podiatric medicine
      • Physical therapist
      • Nurse midwife
      • Certified and registered psychologist
      • Certified and qualified social worker
      • Optometrist
      • Nurse anesthetist
      • Speech-language pathologist
      • Audiologist
      • Clinical laboratory
      • Screening center
      • General hospital
      • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

      A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

      The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

      A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

      A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.

      A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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