Continuity of Care [CAA/TCFR]

Section 113 (division BB) requires continuation of care for patients in the middle of serious and complex* care in the case when their provider's contract expires or is terminated including continuation of care by out-of-state providers. This also applies to members whose employer sponsored health plan changes or is terminated. In these scenarios, members will have the option to continue receiving care for 90 days or until the treatment concludes, whichever is sooner. The health plan is required to notify impacted, and eligible, individuals, the option to continue receiving care.

Market impacts include Grandfathered and Non-Grandfathered Individual Family Plan (IFP), Small Business Markets (SBM), Core, and Premier. Funding types impacted are Fully-Insured, Flex-Funded, and Administrative Services Only (ASO)/Self-Funded.

*Complex care in the context of this provision refers to:

Members with acute illness that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm.
Members with chronic illness or condition that is (i) life-threatening, degenerative, potentially disabling, or congenital; and (ii) requires specialized medical care over a prolonged period of time.
A member receiving a course of institutional or inpatient care from a provider.
Nonelective surgery from the provider, including receipt of post-operative care with respect to surgery
Pregnancy and when the member is undergoing a course of treatment for the pregnancy.
Terminal illness and the member is receiving treatment for such illness from a provider.

Resources

Impact Chart - California vs. Federal Requirements