Enrolling in Community Care Health gives you access to a large network of qualified doctors and other providers. But if you’re already being treated by a provider outside the Community Care Health network at the time of enrollment, then you may qualify for continuity of care. You may also qualify for continuity of care if you are an existing enrollee receiving care from a provider who leaves the Community Care Health network. This means you can finish the treatment or have a few more visits before fully transitioning to a provider within the Community Care Health network. This is called “Completion of Covered Services.”
There are six conditions that may qualify for continuity of care:
- An Acute Condition - A medical condition, including mental health, that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of Covered Services will be provided for the duration of the acute condition.
- A Serious Chronic Condition - A medical condition due to disease, illness, or other medical or mental health problem or medical or mental health disorder that is serious in nature, and that persists without full cure or worsens over an extended period of time, or requires ongoing treatment to maintain remission or prevent deterioration. Completion of Covered Services will be provided for the period of time necessary to complete the active course of treatment and to arrange for a clinically safe transfer to a participating provider (a provider in the Community Care Health network), as determined by Community Care Health’s Chief Medical Officer or his or her designee in consultation with the member, and either (i) the terminated provider or (ii) the non-participating provider and, as applicable, the receiving participating provider, consistent with good professional practice. Completion of Covered Services for this condition will not exceed 12 months from the provider’s termination date or 12 months from the effective date of coverage for a newly enrolled member.
- A Pregnancy - diagnosed and documented by (i) the terminated provider prior to termination of the provider agreement, or (ii) by the non-participating provider prior to the newly enrolled member’s effective date of coverage with Community Care Health. Completion of Covered Services will be provided for the duration of the pregnancy and the immediate postpartum period. In addition, for maternal mental health conditions diagnosed and documented by a terminating/non-participating provider, completion of covered services for the maternal health condition shall not exceed 12 months from the diagnosis or from the end of pregnancy, whichever occurs later.
- A Terminal Illness – An incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of Covered Services will be provided for the duration of the terminal illness, which may exceed 12 months from the provider contract termination date or 12 months from the effective date of coverage for a new enrollee.
- Surgery or Other Procedure – Performance of a surgery or other procedure that has been authorized by Community Care Health or the member’s assigned Participating Provider as part of a documented course of treatment and has been recommended and documented by the: (i) terminating provider to occur within 180 calendar days of the agreement’s termination date, or (ii) Non-Participating Provider to occur within 180 calendar days of the newly enrolled member’s effective date of coverage with Community Care Health.
- Care for Child who is a Newborn to 36 Months of Age – Care for a child who is a newborn to 36 months of age, not to exceed 12 months from the member’s effective date of coverage with Community Care Health for newly enrolled members, or twelve months from the agreement termination date for members receiving services from terminated providers.
Request Continuity of Care Benefits
You can read our continuity of care policy by clicking here. You can also call us at 1-855-343-2247 if you have any questions. If you have one of the conditions that may qualify for Continuity of Care, please complete the Continuity of Care Request Form. Send the completed form to us by U.S. mail, fax or email:
U.S. Mail: Community Care Health
Attention: Continuity of Care Department
P.O. Box 45026
Fresno, CA 93718
Phone: 1-855-343-2247
Fax: 1-559-599-0022
Email: COC@communitycarehealth.org