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How does continuity of care work?
How does continuity of care work?
Aetna Better Health® of Florida will be responsible for COC for new members transitioning onto our Medicaid and Florida Healthy Kids plans. If a new member is already receiving a preauthorized, ongoing course of treatment for a covered service, we’ll cover the costs for that course of treatment, even if delivered by an out-of-network provider. New Long-Term Care members receive a comprehensive assessment and a plan of care, and services are authorized and arranged to address their needs.
We ask providers with transitioning members to cooperate in all respects with providers of other managed care plans to ensure the best health outcomes for our members.
Extensions beyond the 60-day period
Extensions beyond the 60-day period
Some COC services may qualify for an extension beyond the sixty-day period. We’ll continue to pay for care from the member’s current provider beyond 60 days, regardless of whether the provider is in-network, for services, including:
Prenatal and postpartum care
Services throughout pregnancy and through completion of postpartum care (six (6) weeks after birth).
Transplants
Care and follow-up for one (1) year post-transplant.
Oncology (radiation and/or chemotherapy)
Services for the duration of the current round of treatment.
Hepatitis C treatment
The full course of therapy for hepatitis C treatment medications..
The 60-day continuation period
The 60-day continuation period
For new members, we will honor documented authorization of ongoing covered services for sixty (60) days after their effective date of enrollment. We’ll approve this continuation of services until the member’s primary care provider (PCP), or behavioral health provider (depending on the type of care) reviews the member’s treatment plan, which shall be no more than sixty (60) calendar days after the effective date of enrollment.
Provider payment for pre-authorized services
Provider payment for pre-authorized services
Providers, regardless of network, should continue to provide any preauthorized services to new members of our plan. We’ll pay claims for those services for up to 60 days after they enroll. Claims will be paid at 100% of the Medicaid fee schedule unless a separate rate is negotiated.
Learn more about Florida’s COC provisions
Statewide Medicaid managed care: continuity of care provisions
The Agency for Health Care Administration (Agency) contracts with Medicaid health and dental plans to provide services to health plan enrollees in the Statewide Medicaid Managed Care (SMMC) program. The Agency recently entered into new contracts with health and dental plans. As part of those contracts, the Agency achieved program changes that greatly benefit enrollees and providers.
The Agency will transition to the new contracts through a regional phased roll-out. The first regional roll-out occurred on Saturday, December 1, 2018. Roll-out for phase two will occur Tuesday, January 1, 2018.
Health and dental plans are required to ensure continuity of care (COC) during the transition period for Medicaid recipients enrolled in the SMMC program. COC requirements ensure that when enrollees transition from one health plan to another, one service provider to another, or one service delivery system to another (i.e., fee-for-service to managed care), their services continue seamlessly throughout their transition. The Agency has instituted the following COC provisions:
Health care providers should not cancel appointments with current patients.
Health plans must honor any ongoing treatment that was authorized prior to the recipient’s enrollment into the plan for up to 60 days after the roll-out date in each region.
Providers will be paid.
Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Plans must pay for previously authorized services for up to 60 days after the roll-out date in each region and must pay providers at the rate previously received for up to 30 days.
Providers will be paid promptly.
During the continuity of care period, plans are required to follow all timely claims payment contractual requirements. The Agency will monitor complaints to ensure that any issues with delays in payment are resolved.
Prescriptions will be honored.
Plans must allow recipients to continue to receive their prescriptions through their current provider, for up to 60 days after the roll-out date in each region, until their prescriptions can be transferred to a provider in the plan’s network.
More information about COC provisions can be referenced on the COC program highlight document, which is posted on the Agency’s website at www.ahca.myflorida.com/smmc. Once on the page, click Program Changes, then the Outreach and Presentations link.
Aetna Better Health of Florida’s Rural Health Clinic Grant (RHC) funding is to assist providers in covering fees or consultations needed in order to adopt or expand the use of electronic health records (EHR) system, connectivity to the state Health Information Exchange and other community providers. Any funds issued by Aetna Better Health of Florida will be used exclusively to promote enhancements of EHR system.
If you’re a rural health clinic interested in this grant, you can complete our EHR questionnaire and email it to us.