Care Continuity

Enrollment in an integrated care model will limit the member to particular providers, and likely will also change the availability of services, treatments, and medications, both the kinds of services available and the method of getting them.  Such changes can cause significant disruptions in an individual’s life, with negative consequences to health and well-being.  This is particularly true for LTSS which, by definition, are provided on a regular basis over an extended period of time.  At their best, LTSS providers offer companionship along with assistance, and the loss of a long-time provider leaves a significant hole in the life of the person needing assistance.

In order to limit potential disruption, managed care models must implement policies that provide for continuous access to services and providers, as well as safety measures that will come into place when disruptions occur due to various reasons.  The protections set forth below are important to assure that a transition to a MCO does not compromise an individual’s health or well-being.

  • An MCO must automatically extend out-of-network payment to a new enrollee’s existing providers for up to one year or until a transition satisfactory to the individual has been affected (e.g. the provider joins the network or a provider with equivalent specialized expertise and experience, minority language capacity, physical and programmatic accessibility, and/or a willingness to engage in home visits, etc. is identified), to ensure that transition to the MCO does not jeopardize the new enrollee’s health or capacity for independent living in the community.  The MCO must pay the provider at a rate at least equal to what the provider received previously.
  • For situations in which providers are unwilling to accept payment from the plan, the state must establish a mechanism for paying providers during the transition period, and MCO’s must establish procedures for effectively fulfilling out-of-network providers’ medically necessary prescription, specialist, DME, or other treatment referrals.
  • Care continuity protections must apply to all provider categories, including but not limited to personal attendant care, home health services, and durable medical equipment.
  • If a provider has been providing services to an individual currently being enrolled into an MCO, and the provider is not already part of the MCO’s provider network but meets the MCO’s qualification standards, the MCO must be required to offer network admission to the provider.
  • States and MCOs must be required to establish processes to encourage providers to enroll in MCO networks.
  • If the MCO begins to establish training or certification requirements for HCBS providers, the employment, compensation and benefit packages of existing LTSS providers chosen and trained by individual beneficiaries cannot be made conditional upon meeting these new requirements.
  • A community-based provider’s lack of a billing capacity should not be an impediment to enrolling in the plan’s network.  MCOs must work with smaller LTSS providers to help them develop the infrastructure they need to participate in the plan network.
  • Because enrollment in an MCO should never require a person to move, an MCO must be required to make payment available to any appropriately certified nursing facility or assisted living facility in which an enrollee is living at the time of enrollment, for services provided to that enrollee.  The MCO must provide payment at the network rate if that rate is higher than the standard Medicaid rate.
  • MCOs must give due-process notice to both the enrollee and the provider when refusing to make payment to an out-of-network provider who has provided services to the enrollee, or when refusing to authorize such provider to provide services to the enrollee.
  • States and MCOs must proactively identify particularly vulnerable beneficiaries before enrollment, such as those requiring constant oxygen administration or dialysis treatment, and monitor their status with particular care to ensure that appropriate services are provided throughout a transition to managed care and thereafter.
  • For at least 120 days from enrollment of a new member, an MCO must honor all existing authorizations for services or supplies, and must not terminate such an authorized service or supply without due-process notice to the enrollee, and an individualized plan to transition the beneficiary to other services or supports as needed is in place.  In the event an appeal is filed to maintain existing services, aid paid pending must be provided until the appeal is decided, even if the previous authorization period for the services has ended.
  • Any existing grounds for state exemptions from mandatory managed care enrollment, and the procedures for pursuing such exemptions, must continue to be honored and made available, and beneficiaries must be notified about how to obtain an exemption.
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