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Broker Guide
Continuity of Care FAQ
This program allows newly enrolled members with qualifying medical conditions to complete their care with their current healthcare provider, or helps them make a smooth transition to their Blue Shield network provider.
Frequently Asked Questions
Frequently Asked Questions
Who is eligible for continuity of care services?
1) New enrollees:
Blue Shield of California HMO plans are required to provide continued care with non-network providers for qualifying conditions to all new group enrollees whose current provider does not belong to Blue Shield's HMO provider network and whose employer does offer not a plan with an option to remain with the current provider (e.g., PPO, POS plans or another HMO plan).

Our Continuity of Care Program does not apply to new enrollees of Individual and Family Plans, PPO plans or POS plans.
 
2) Established members:
For established members, when a contracted provider leaves Blue Shield's provider network, our Continuity of Care Program applies to all members of Blue Shield of California and Blue Shield Life & Health Insurance Company (Blue Shield Life) underwritten group and IFP health plans.
Is Blue Shield of California required to provide continuity of care to newly enrolled or established out-of-state members who have health plans underwritten in California?
Blue Shield cannot, by law, enroll members in HMO or POS plans when they do not live or work in a Blue Shield HMO service area.  The Continuity of Care Program applies to all out-of-state established members of Blue Shield of California and Blue Shield Life & Health Insurance Company underwritten group and IFP plans when their provider ceases to participate in the Blue Shield provider network.
Is continuity of care available for members who are receiving treatment for a serious mental health condition?
Yes. Our mental health services administrator, U.S. Behavioral Health Plan (USBHPC), must also comply with the same provisions of California law. Our member materials tell new enrollees and established members that they can obtain further information about completing treatment with their current mental health provider by contacting USBHPC directly. USBHPC will administer continuity of care services for members receiving mental health services.
What criteria must be met for newly enrolled or established members to continue receiving care from their current provider?
Examples of conditions and situations that may qualify for completion of care with the new enrollee's current provider who does not belong to Blue Shield's HMO provider network or for established members when the provider  is terminating as a contracted Blue Shield provider include, but are not limited to:

 
An acute condition requiring prompt medical attention and that has a limited duration (not to exceed the acute phase of the condition when care can be safely transferred to a Blue Shield contracting provider)

 
A serious chronic condition, for the period of time necessary to complete a course of treatment and to arrange for safe transfer of care to a Blue Shield contracting provider (but not to exceed 12 months from the effective date of coverage or the provider's termination date)

 
Pregnancy, including immediate postpartum period

 
Care for a child who is newborn to 36 months (not to exceed 12 months from effective date of coverage or the provider's termination date)

 
A surgery or other treatment that was previously recommended and documented by the provider to take place within 180 days of the effective date of coverage or the provider's termination date and which is authorized by Blue Shield.

 
Terminal illness, which has a high probability of causing death within one year or less is covered for the duration of the terminal illness
Does our Continuity of Care Program cover all services the member receives?
Services covered under the Continuity of Care Program do not include benefits that are not otherwise covered under the terms and conditions of the member's health plan contract.
If an employer group offers a Blue Shield PPO plan and a Blue Shield HMO plan, are employees who select the HMO plan eligible to continue treatment with their non-network provider? Are employees of groups who only offer an HMO plan eligible for continuity of care?
Only new enrollees of Access+ HMO plans are eligible when their employer does not offer an option that would allow the employee to remain with the current provider (e.g., PPO or POS plan, or another HMO plan with that provider in its network).  When the employer only offers the Access+ HMO plan, new enrollees are eligible for continuity of care services. 
How does Blue Shield of California notify new group members that they may be eligible to continue receiving care from their current provider?
New enrollment kits for HMO only employer groups  contain a letter summarizing our Continuity of Care Program and how to apply for services. This notice also provides new enrollees with Blue Shield's HMO Member Services telephone number and a  Continuity of Care Program application form (PDF, 159KB).
What if Blue Shield producers or employers need extra copies of the Continuity of Care Program Application and Important Notice for New Enrollees?
Producers can download these forms from the Producer Connection's Help Current Clients pages. Employers can download English and Spanish versions of the Continuity of Care Program application forms, Important Notice for New Enrollees, and the Continuity of Care Program policy from the download forms section of Employer Connection.
How does Blue Shield of California notify established members that they may be eligible to continue receiving care from a terminating provider?
Blue Shield of California HMO members will receive notice of the date that their Personal Physician, IPA/medical group or assigned hospital will terminate from Blue Shield of California's provider network. The notification will advise members that they may be eligible for continuity of care and to call the Member Services telephone number on their Blue Shield of California member identification card for more information.
Does Blue Shield have a policy statement for continuity of care?
Yes. The Continuity of Care Policy Statement for Members (PDF, 69KB)   is available from Customer Service or Member Services. Our new enrollee materials and provider termination notifications advise members to contact service representatives for this information.
What are Blue Shield's internal procedures for handling members who request continuity of care?
Customer Service, Member Services, Provider Relations and Medical Management have developed workflows to coordinate and provide a smooth transition of responsibility among departments for these requests. Member Services generally receives new enrollee applications for the Continuity of Care Program.  Customer Service and Member Services receive calls from members requesting further information about the program, triages member requests to continue treatment with non-network providers, and forwards applications and information received over the phone to Medical Management.
 
Medical Management obtains medical records, reviews the patient's medical treatment and works with Provider Relations, as needed, to negotiate terms with the non-contracted or terminating provider. If the provider agrees to the required conditions, Medical Management authorizes the completion of care and notifies the member in writing of any special provisions and/or limitations. 
How will the members who request continuity of care learn about Blue Shield's decision
We will send these members a letter notifying them of our decision.
What are the required continuity of care terms and conditions for non-network providers or terminated providers?
The law permits health plans to require that non-network providers and terminating providers agree to accept the health plan's negotiated rates and other conditions required of contracted providers. Terminating hospital providers will be required to accept an extension of the terms of their terminated contract with Blue Shield for continued treatment of a qualified member.
 
Personal Physicians or specialists of terminating IPA/medical groups will be required to accept Blue Shield's allowance for currently contracted non-capitated providers providing similar services in the same geographic area.

If the provider does not agree, Blue Shield will deny the enrollee's request for completing care with the non-network or terminating provider.  In those instances, Medical Management will assist with the transfer of the enrollee's medical care to a Blue Shield network provider. Medical Management will ensure that reasonable consideration is given to the potential effects that changing provider(s) may have on the enrollee's medical condition.
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