Transition (Continuity) of Care Assistance

What is transition of care?
In California, transition benefits are defined by the Knox-Keene Act and regulated by the California Department of Managed Care. They require that managed care plans provide members with the right, under certain circumstances, to continue receiving medical services from their non-contracted physician or hospital. The objective of providing transition of care is to allow members in the middle of care with a non-network or non-plan provider a period of time to facilitate transition to a network or plan provider. The Knox-Keene Act protects your right to keep your non-contracted doctor for covered services for six specific conditions.

What six specific medical conditions are considered for Transition of Care assistance?
1. Pregnancy and immediate post-partum period

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

3. 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 has been authorized.

4. Terminal illness which has a high probability of causing death within one year or less is covered for the duration of the terminal illness

5. Serious chronic condition for the period of time necessary to complete a course of treatment and to arrange for safe transfer of care (but not to exceed 12 months from the effective date of coverage or the provider’s termination date)

6. 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.

All decisions regarding transition of care will be made by the plan and require acceptance of contractual and payment terms by the non-contracted provider.

Who is eligible for Transition of Care assistance?
Members undergoing treatment for a specific medical condition or pregnancy with a Brown & Toland provider who are affected by UCSF’s change in affiliation from Brown & Toland to Hill Physicians. As an example only:

If you remain with your B&T PCP, but are receiving specialty care at UCSF

If your PCP joins Hill Physicians, but you are seeing B&T specialists

Transition of Care assistance will be effective 1/1/10 and transition of care staff at your medical plan (Health Net or Anthem Blue Cross) will also help identify network providers who can provide necessary care once the transition period ends.

How long does the Transition of Care period last?
Based upon the medical condition and as prescribed by the Knox-Keene act, transitional coverage is provided as outlined above.

How do I request Transition of Care Assistance from Anthem Blue Cross?
Brown & Toland members who are in a current course of treatment with Brown & Toland will need to contact Anthem Blue Cross Customer Service 888-209-7975 and request transition assistance. Once the transition assistance is requested and approved the member will be allowed to complete the treatment with their current provider.

How do I request Transition of Care Assistance from Health Net?
Health Net’s member communication in mid-October to UCSF PCP members with Brown & Toland, will include a Transition of Care form.  If a member feels that they qualify for Transition of Care based on this information, they need to complete and return the form to Health Net.  Once Health Net receives the request, they will reach out to the member directly to determine if they qualify.  Brown & Toland would provide Transition of Care directly to those members who have Brown & Toland PCP’s, but who will lose their UCSF specialist.

If my request for Transition of Care Assistance is denied, what is the process for appeal?
You have the right to appeal under the appeals & grievance process by contacting either Anthem Blue Cross or Health Net directly.

Anthem Blue Cross
Call Anthem Blue Cross at the number listed on your insurance card, or submit a written appeal at the following address: Anthem Blue Cross PLUS, Grievance and Appeal Management, P.O. Box 4310 Woodland Hills, CA 91367

Health Net
Call Health Net Member Services Department at 1-800-539-4072 or submit a Member Grievance Form through the Health Net website at http://www.healthnet.com/uc. You may also file your complaint in writing by sending information to: Health Net, Member Services Appeals and Grievance Department, P.O. Box 10348, Van Nuys, CA 91410-0348

HMO 101

What is an HMO?
A Health Maintenance Organization (HMO) provides complete medical services from a closed network of providers. Generally, coverage is not provided and benefits are not paid if you get care outside of the network without prior approval from your primary care physician (PCP) and your medical group. HMO plans use PCPs to manage your care. The HMO provides comprehensive services for a monthly premium through a group of providers, i.e. Medical Group, in a fixed geographic area.

How are HMO’s organized?
Your HMO(medical plan) and Medical Group have contractual agreements with doctors, labs, hospitals and other providers or facilities. The medical provider submits claims to your insurance through your medical group.
HMO_Organization_Chart.pdf

What is a primary care physician?
A primary care physician (PCP) is a doctor you choose to manage all your health care. Your PCP coordinates your medical care, providing preventive and routine care and referrals to specialists and hospitals when you need them. A PCP can be an internist, a family or general practitioner, or a pediatrician for a child.You choose your PCP/medical group from the network of doctors in your health plan.

What is a Medical Group?
A medical group is an association of medical providers who work closely together and negotiate with insurance companies as one legal entity.Your medical group is the group of doctors and other providers that your primary care doctor is in. The medical group has a contract with the HMO (insurance plan) to provide your care. Your medical group is pre-paid by your medical plan to provide care to you.

Do I need to select a PCP?
You must choose a PCP if you are enrolled in Health Net, Western Health Advantage (WHA) and Anthem Blue Cross PLUS. Participants enrolled in the Kaiser Permanente plan are not required to choose a PCP. The selected PCP must be within 30 miles of your work or home address.

If you do not select a PCP/Medical group, it will be assigned to you. Always check you medical plan ID to ensure you are assigned to your desired PCP/medical group.

Newborns are automatically assigned to the mother’s medical group for the first 30 days. After that time, the baby may be assigned to a different PCP/Medical group.

Can each member of my family go to a different PCP and/or belong to a different Medical Group?
Each family member may select a different PCP and/or Medical Group. You select your PCP/medical group when you enroll in your medical plan.

When can I change my PCP and how do I make that change?
In most cases, you can change your PCP/Medical group at any time during the year. To change your PCP/medical group, contact your medical plan Customer Service using the number on your medical ID card. If you call prior to the 15th of the month, the change will be effective the first of the following month.

How do I see a specialist?
Referrals are usually made to a specialist within your medical group. Your PCP will provide you with a referral form and obtain authorization if needed. No referral is needed for annual OB/GYN exams as long as the provider is part of your medical group.

Can I see a specialist outside my medical group?
If you are enrolled in Health Net, WHA or Kaiser you may not see a specialist outside of your medical group unless you have received authorization from the medical group to see an out-of-network provider. If you are enrolled in the Anthem Blue Cross PLUS plan, you may self-refer to a specialist outside your medical group network, but you will be subject to the higher-cost out-of-network benefits.

What happens if I get care outside my HMO network without my PCP’s referral?
If you get care outside your HMO network without your PCP and medical group’s referral/approval, your insurance will not pay for the cost of care unless it is considered an out-of-area medical emergency. All HMO plans cover emergency care for injury or illness worldwide. You must contact your health plan within 48 hours of getting emergency care. If you have questions about emergency care or getting care when you travel, contact your medical plan’s customer service line using the number on your medical ID card.

The MEDICAL PLAN COMPARISON CHART shows how an HMO compares to other types of medical plans.

What

Brown & Toland and UCSF Medical Group will end their long-standing affiliation on Dec. 31, 2009. A new referral-only agreement is being negotiated with Brown & Toland. That agreement is expected to require prior authorization for referrals from Brown & Toland primary care doctors to UCSF specialists.

Though the contractual relationship between the UCSF Medical Group and Brown and Toland will change, Brown & Toland remains a medical group option for Health Net and Anthem Blue Cross PLUS members. 

Employees enrolled in Kaiser Permanente HMO, Health Net PPO (post-docs), Anthem Blue Cross PPO, Anthem Blue Cross Core or CIGNA will not be affected by this change in affilliation.

Information for the general public, not specific for UC employees, is available at http://www.accessUCSF.org . The Hill Physicians website provider search function has been updated to include physicians at UCSF and many practitioners from St. Mary’s and Saint Francis. As new providers are added to the Hill Physician network, they will be included in the provider search function.

Making Changes - Residents/Fellows

Generally, you can change your medical group and/or PCP throughout the year.  If you contact Health Net and request the change by the 15th of a month, the change will be effective the first of the following month.

The information below outlines the actions Health Net took prior to 1/1/10 to assist employees and retirees affected by the UCSF Medical Group transition to Hill Physicians medical group.

If you have a Brown and Toland PCP that is part of the UCSF Medical Group, Health Net will automatically transfer you and/or your family members to the same UCSF PCP with Hill Physicians effective January 1, 2010.  You will receive a letter in mid-October outlining this information as well as information on transition of care. 

If you would rather stay with Brown & Toland and not follow your PCP to Hill, you need to contact Health Net customer service prior to December 15th, to stop the transfer and to select a new primary care provider for an effective date of January 1, 2010. (1-800-638-3889)

If you are a Health Net Member in Brown and Toland with a non-UCSF PCP, you/your family members will remain with your current PCP(s) in Brown & Toland.

If you prefer to transition to Hill Physicians, contact Health Net customer service to switch to a new PCP in Hill Physicians, (1-800-638-3889).

Making Changes - Postdocs

Generally, you can change your medical group and/or PCP throughout the year.  If you contact Health Net and request the change by the 15th of a month, the change will be effective the first of the following month.

The information below outlines the actions Health Net took prior to 1/1/10 to assist employees and retirees affected by the UCSF Medical Group transition to Hill Physicians medical group.

If you have a Brown and Toland PCP that is part of the UCSF Medical Group, Health Net will automatically transfer you and/or your family members to the same UCSF PCP with Hill Physicians effective January 1, 2010 You will receive a letter in mid-October outlining this information as well as information on transition of care. 

If you would rather stay with Brown & Toland and not follow your PCP to Hill Physicians, you need to contact Health Net prior to December 15th, to stop the transfer and to select a new primary care provider for an effective date of January 1, 2010, (1-800-522-0088). 

If you are a Health Net Member in Brown and Toland with a non-UCSF PCP, you/your family members will remain with your current PCP(s) in Brown & Toland.  If you prefer to transition to Hill Physicians, contact Health Net customer service to switch to a new PCP in Hill Physicians, (1-800-522-0088).

When Should I Make Changes?

If you wish your Medical Group change to be effective 1/1/10, you will need to make the change prior to 12/15/09. And note, in general you can change your PCP and/or medical group throughout the year by contacting your medical plan. Both Anthem Blue Cross PLUS and Health Net require the member to call prior to the 15th of the month to change their medical group if they want the change effective the first of the following month.

Health Net members will be automatically moving members who have a UCSF PCP from B&T to Hill Physicians effective 1/1/10.

Blue Cross Plus members must call BC Customer Service to switch from B&T to Hill Physicians medical group in order to keep their UCSF PCP. When you call please make clear that you want the change to be effective 1/1/10. You will also have to indicate you are a current patient of the provider as many provider practices are closed.

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Making Changes - Employees/Retirees

Generally, you can change your medical group and/or PCP throughout the year.  If you contact Health Net or Anthem Blue Cross and request the change by the 15th of a month, the change will be effective the first of the following month.

The information below outlines the actions both Health Net and Anthem Blue Cross took prior to 1/1/10 to assist employees and retirees affected by the UCSF Medical Group transition to Hill Physicians medical group.

Health Net Members

Health Net will be automatically transferring members who currently have a UCSF PCP with Brown & Toland to the same UCSF PCP with Hill Physicians effective 1/1/10. Members with a non-UCSF PCP will remain with Brown & Toland unless they call Health Net (1-800-539-4072) to switch to Hill Physicians. If a current member with a UCSF PCP would rather stay with Brown & Toland and not follow their current PCP, you will need to contact Health Net Customer service. You may call Health Net beginning the week of October 5, 2009 to initiate medical group or provider changes to be effective 1/1/10.

In mid-October Health Net will send a letter to all members currently assigned to a UCSF PCP with Brown & Toland informing them of the automatic transfer. Members will be provided with information on what to do if they wish to make another selection. Transition of Care information will also be included in this mailing.


Anthem Blue Cross PLUS Members

Anthem Blue Cross will not automatically transfer members who have a UCSF PCP to Hill Physicians. Members must call Anthem Blue Cross (1-888-209-7975) beginning October 1, 2009, to request a change to Hill Physicians medical group. If your PCP has a closed practice you will need to indicate you are a current patient of that provider.

In early October, Anthem Blue Cross will be sending out a letter to all affected members who have a UCSF B&T PCP. Information will be provided on how to change your medical group to Hill Physicians effective 1/1/10. Anthem Blue Cross PLUS members who are using a UCSF specialist will receive a transition of care letter. Members who plan to stay with Brown & Toland will need to call Anthem Blue Cross to get an authorization to complete their treatment with their current UCSF specialist.

Are You Affected?

Employees/retirees enrolled in the UC-sponsored Health Net HMO, Health Net Seniority Plus or Anthem Blue Cross PLUS (non-Medicare and Medicare members) may be affected if your current medical group is Brown & Toland.

Residents/Fellows enrolled in the UC-sponsored Health Net HMO may be affected if your current medical group is Brown & Toland.

Postdocs enrolled in UC-sponsored Health Net HMO may be affected if your current medical group is Brown & Toland.

Is your PCP a UCSF provider? - If yes, you must change your medical group from B&T to Hill Physicians to keep your current PCP.

If neither your PCP or specialists are UCSF providers, you do not need to make any changes. In the future, should you wish to receive care (primary or specialty) at UCSF you will need to switch to Hill Physicians Medical group and select a Hill Physician PCP.

Anthem Blue Cross PLUS members may use their out-of-network benefits to self-refer to specialists who are not part of their medical group. Please review the plan Evidence of Coverage or call Anthem Blue Cross Customer Service to obtain information on how your out-of-network benefits work. Keep in mind you will incur more out-of-pocket expenses for these benefits.

Employees/retirees enrolled in Anthem Blue Cross PPO, Kaiser Permanente-CA, CIGNA, Western Health Advantage, High Option (retirees only) and Core ARE NOT affected by this change.

Residents/Fellows enrolled in Anthem Blue Cross PPO ARE NOT affected by this change.

Post-docs enrolled in Health Net PPO ARE NOT affected by this change.

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