CA Care Mgmt 04-COC_TOC Policy and Form 01.2020 FINAL

To ensure continuity of care (COC) and transition of care (TOC) for members in certain situations:
- When their provider or hospital is terminated from Anthem's network, and they were receiving treatment for specific conditions.
- When newly covered enrollees were receiving services prior to having coverage with Anthem Blue Cross and their provider is not in-network.
- When continuity of care is at risk due to circumstances beyond the member's control.
This policy excludes cases where members voluntarily switched from a previous provider or health plan.
This policy applies to individual plan members only when their primary provider is terminated from the network or if their health plan is withdrawn.

COC/TOC allows members in treatment to continue with non-participating providers until treatment is complete or safely transitioned to a participating provider.
Members remain responsible for co-payments, deductibles, and cost-sharing, similar to seeing a participating provider.
The length of the transition is case-dependent, influenced by the severity of the condition and the necessary time for safe provider transfer.
Non-participating providers must agree to the same terms as participating providers.
Policies exclude services completed by providers terminated for disciplinary reasons or criminal activity.
HMO members should usually contact their medical group for COC needs, except for specific services like behavioral health.

Situations where continuity of care applies:
Termination of a hospital, PMG/IPA, or PPO provider's contract with Anthem Blue Cross.
Newly covered enrollees switched to Anthem Blue Cross involuntarily.
Newly covered enrollees in cases where prior plan was withdrawn.

Acute Condition: Sudden onset requiring prompt attention. Coverage until complete treatment.
Serious Chronic Condition: Ongoing treatment necessary to prevent worsening. Coverage until safe provider transfer, not exceeding 12 months.
Pregnancy: Coverage for duration of pregnancy and immediate postpartum.
Maternal Mental Health Condition: Covers up to 1 year postpartum if diagnosed.
Terminal Illness: Coverage for duration of condition, potentially exceeding 12 months.
Care for Newborn (up to 36 months): Coverage for up to 12 months post-termination or effective date.
Scheduled Surgery: Authorized surgery within 180 days covered.

Exemptions for continuity of care:
- Members who voluntarily changed providers or plans.
- Members whose providers were terminated for disciplinary reasons or who don't wish to accept similar payment rates.
- Members contacting the EAP for assistance do not qualify under this policy.

Acute Condition: Sudden medical issue requiring quick attention.
COC: Process for in-network rate continuation with a terminating provider.
TOC: New enrollee continuation with a non-participating provider under specified conditions.
Participating Provider: A doctor with an active contract with Anthem Blue Cross.
Non-Participating Provider: A doctor without a current contract.

Members are notified of their rights during open enrollment and upon request via Member Services.
Requests can be made through the Member Services number provided on the insurance card.
The appropriate unit gathers information to determine eligibility and establish a case in the Medical Management system.
Determinations are made within 2 business days of receiving necessary information, and members are notified by phone and in writing.
If provider refuses in-network rates, members are informed of this refusal. HMO/EPO plan members may not receive reimbursement for out-of-network providers; PPO/POS plan members are reimbursed at out-of-network rates.

Process reviews are conducted for compliance and efficiency, reported to the West Region Medical Management Quality Review Committee (WRMMQRC).