NY Manual
SHP Manual

New York Provider Manual
12.5 Out-of-Network Services | 12.7 Concurrent Review

12.6 Continuity of Care

Healthfirst has established mechanisms to ensure that continuity of care be maintained for members under a variety of circumstances. Each of these situations is discussed in detail below. All questions regarding continuity of care issues should be addressed to Medical Management at 1-888-394-4327. For information on specialists as PCPs and on specialty care centers, please refer to Section 8.

Standing Referrals

Healthfirst allows standing referrals for specialty care in cases in which the member’s diagnosis or condition requires ongoing care from a specialist, specialty center, or specialty institution. In these situations, the PCP or requesting provider must coordinate a standing referral with the member, the specialist, and Healthfirst. To arrange this referral, the requesting provider must call Medical Management to discuss the treatment plan and the need for the extended referral. When appropriate, Medical Management, in consultation with the requesting provider/PCP and the specialist, will issue an authorization designating the approved number of visits, the services to be rendered, and the time period covered by the standing referral. 

For Healthfirst Leaf Plan members, the PCP must submit the referral request for specialist care to Emdeon via the Healthfirst Provider Portal. 

Transition from Nonparticipating to Participating Providers

Healthfirst has policies to address transition periods when a new member is currently undergoing a course of treatment with a nonparticipating provider as well as when a member’s provider leaves the Healthfirst network. These policies are required both in Healthfirst’s provider agreements as well as in Section 4403 of the New York State Public Health Law.

These transition policies apply only in situations when the member is being seen regularly for management of a complex, life-threatening, or degenerative and disabling disease, or is in the second or third trimester of pregnancy and under the care of an OB/GYN.

In all cases, continuation of care with a nonparticipating provider depends upon the provider’s acceptance of Healthfirst’s reimbursement rates as payment in full. The provider must also agree to do the following:

·     Adhere to Healthfirst’s quality assurance requirements
·     Abide by all Healthfirst policies and procedures
·     Provide Healthfirst with medical information related to the member’s care
·     Obtain referrals from the PCP for Healthfirst Leaf Plan members  
·     Obtain prior authorization  from Medical Management  for applicable services
·     Agree not to “balance-bill” the member for services provided (for Healthfirst Medicaid, CHP, FHP, Medicare (all plans) members only).  Healthfirst Leaf Plan -members may be liable for the cost- sharing amounts and may be responsible for the cost of non-covered care).

Continuity of Care Guidelines

LOB New Enrollee Provider Leaves Network
Medicaid to include HARP If a new Enrollee has an existing relationship with a health care
provider who is not a member of the Contractor’s provider network, the Contractor shall permit the Enrollee to continue an ongoing course of treatment by the Non-Participating Provider during a transitional period of up to sixty (60) days from the Effective Date of Enrollment if the Enrollee has a life-threatening disease or condition or a degenerative and disabling disease or condition.

If the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, the transitional period shall continue for the remainder of the pregnancy, including delivery and the provision of post-partum care directly related to the delivery up to sixty (60) days after the delivery.

Ninety (90) days or until the Patient Centered Service Plan (PCSP) is in place, whichever is later, for Long Term Social Services at the same level, scope, and amount as you were receiving

Ninety (90) days for the current care plan or until an alternate care plan is authorized, whichever is later, for new enrollees receiving Adult Day Health Care (ADHC) or AIDS ADHC services .  Can keep their service with existing provider for up to one year unless the enrollee elects to change.
The transitional period shall continue up to ninety (90) days from the date the provider’s contractual obligation to provide services to the Contractor’s Enrollees terminates; or, if the Enrollee has entered the second trimester of pregnancy, for a transitional period that includes the provision of post-partum care directly related to the delivery through sixty (60) days post partum.

Ninety (90) days or until the Patient Centered Service Plan (PCSP) is in place, whichever is later, for Long Term Social Services at the same level, scope, and amount as you were receiving

Ninety (90) days for the current care plan or until an alternate care plan is authorized, whichever is later, for new enrollees receiving Adult Day Health Care (ADHC) or AIDS ADHC services .  Can keep their service with existing provider for up to one year unless the enrollee elects to change.
Medicare For medically necessary treatment associated with a chronic or serious condition, or other Medicare covered services, will provide a limited number of visits with enrollee's current provider or caregiver at the same level scope and amount that they were receiving. Will work with enrollee and their Primary Care Physician (PCP) to find a provider in network that can meet the enrollee's medical needs.

For the rest of the pregnancy if the member has entered the second trimester on the date of enrollment becomes effective. This includes delivery and the provision of postpartum care directly related to the delivery for up to sixty (60) days after the delivery.
If you are undergoing a specified course of treatment with a provider who leaves our network, we will authorize a transitional period of up to 90 days from the date the provider leaves Healthfirst to ensure continuity of your care and prevent any disruptions in your treatment plan. In addition, if you are in your second trimester of pregnancy (more than three (3) months pregnant) when your provider leaves our network, we will authorize a transitional period of up to 60-days postpartum (after the baby is born) to ensure continuity of care.
Complete Care  If the service is regarding a Medicaid only benefit the Medicaid rules apply otherwise Medicare rules apply If the service is regarding a Medicaid only benefit the Medicaid rules apply otherwise Medicare rules apply
EP If the enrollee is in an ongoing course of treatment with a Non-Participating Provider when their coverage under this Certificate becomes effective, they may be able to receive Covered Services for the ongoing treatment from the Non-Participating Provider for up to 60 days from the effective date of their coverage under this Certificate. This course of treatment must be for a life-threatening disease or condition or a degenerative and disabling condition or disease. If the Enrollee has entered the second trimester of pregnancy at the Effective Date of Enrollment, the transitional period shall continue for the remainder of the pregnancy, including delivery and the provision of post-partum care directly related to the delivery up to sixty (60) days after the delivery. If the enrollee is in an ongoing course of treatment when their Provider leaves the network, then the enrollee may be able to continue to receive Covered Services for the ongoing treatment from the former Participating Provider for up to 90 days from the date their Provider’s contractual obligation to provide services to them terminates. 
QHP/HNY If the enrollee is in an ongoing course of treatment with a Non-Participating Provider when their coverage under this Certificate becomes effective, they may be able to receive Covered Services for the ongoing treatment from the Non-Participating Provider for up to 60 days from the effective date of their coverage under this Certificate. This course of treatment must be for a life-threatening disease or condition or a degenerative and disabling condition or disease. The enrollee may also continue care with a Non-Participating Provider if they are in the second or third trimester of a pregnancy when their coverage under this Certificate becomes effective. The enrollee may continue care through delivery and any post-partum services directly related to the delivery. If the enrollee is in an ongoing course of treatment when their Provider leaves the network, they may be able to continue to receive Covered Services for the ongoing treatment from the former Participating Provider for up to 90 days from the date the Provider’s contractual obligation to provide services to the enrollee terminates. If the enrollee is pregnant and in their second or third trimester, they may be able to continue care with a former Participating Provider through delivery and any postpartum care directly related to the delivery.
FIDA The FIDA Plan allows Participants receiving any Covered Item or Service at the time of Effective Date of Enrollment other than Nursing Facility services or Behavioral Health Services to maintain current Providers, including with Providers who are currently out of the FIDA Plan’s Provider Network (i.e., Non-Participating Providers), and service levels, including prescription drugs, until the later of:
For at least ninety (90) calendar days after the Effective Date of Enrollment; or
Until the PCSP is finalized and implemented.

The FIDA Plan allows Participants who reside in a Nursing Facility to maintain current Nursing Facility Providers for the duration of the Demonstration.

The FIDA Plan shall allow Participants who are receiving Behavioral Health Services to maintain current Behavioral Health Service Providers (i.e., Participating and Non-Participating) for the current Episode of Care.  The IDT may review a current Episode of Care to determine whether it needs to be continued with the Behavioral Health Service Provider that was providing services before the Participant’s Enrollment in the FIDA Plan.  This requirement will be in place for not to exceed two (2) years from the date of a Participant’s Effective Date of Enrollment and applies only to Episodes of Care that were ongoing during the transition period from Medicaid Fee-For-Service (FFS) to Enrollment in a FIDA Plan.



Providers are required to continue a course of treatment until arrangements are made to transition the member’s care to another provider. Specifically, providers are required to continue providing services to Healthfirst members for a period of ninety (90) days from the date that they leave our plan.


The FIDA Plan allows Participants who reside in a Nursing Facility to maintain current Nursing Facility Providers for the duration of the Demonstration.

 

Medical Records

When a member selects a new PCP, upon his/her request the former PCP should transfer the member’s records to the new provider in a timely manner, thereby ensuring continuity of care.