CurrentHealth NetPolicy N/A

Continuity of Care (COC) and Long-Term Services and Supports (LTSS)

Governs member rights and provider/PPG responsibilities for Continuity of Care in California, and provides an overview of Long-Term Services and Supports programs and eligibility for Health Net members.

Policy Summary

PayerHealth Net

PolicyContinuity of Care (COC) and Long-Term Services and Supports (LTSS)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 20, 2019

Next Review DateN/A

Key ActionPPGs and Health Net must inform members of their right to request Continuity of Care and process COC requests in a timely manner.

SourceLink

12 monthsmax COC duration

3 daysrisk-of-harm timeframe

15 daysurgent appointment timeframe

30 daysstandard review timeframe

2+ ADLsCBAS ADL criterion

~6 months

Continuity of Care and LTSS Coverage Criteria

Continuity of Care coverage criteria

Covered when ALL of the following conditions and operational criteria are met:

Member experiences a provider network change beyond their control or transitions into Health Net (disruption that may place member at risk).

Member has a qualifying condition that meets statutory or regulatory standards (evaluated under Health and Safety Code §1373.96, All Plan Letter 18-008, or Dual Plan Letter 16-002).

Pre-existing relationship exists with the requested out-of-network provider: member saw that PCP or specialist at least once for a non-emergency visit within 12 months prior to initial enrollment (self-attestation is insufficient).

Proof of an in-network relationship required; one non-emergency visit in prior 12 months

Requested provider meets acceptance criteria: willing to accept contracted rates, California‑approved, no quality of care concerns, and supplies all relevant treatment information and current treatment plan to determine medical necessity.

ALL of the following

Pregnancy: continue for duration of pregnancy and immediate postpartum period.
Surgery or procedure scheduled as part of a documented course of treatment to occur within 180 days of provider termination or coverage effective date.
Care of newborn: birth to 36 months, up to 12 months of continuation.
Acute sudden‑onset conditions: continuation through completion of the acute condition.
Serious chronic conditions and terminal illness: may qualify for continuation (terminal illness continuation may exceed 12 months per policy).

ALL of the following

RISK OF HARM: Complete request within 3 calendar days if there is risk of harm to the member.
Urgent with upcoming appointment: Complete within 15 calendar days if beneficiary's medical condition requires more immediate attention (e.g., upcoming appointments).
Standard review: Start review within 5 working days of receipt for non‑risk requests; complete all other requests within 30 calendar days from receipt.

Exceptions and exclusions: continuation is not required when the provider was terminated for medical disciplinary reasons, fraud, or criminal activity as specified in applicable law (e.g., Business & Professions Code §805).

LTSS coverage description

Long‑Term Services and Supports (LTSS) programs, eligibility overview, and examples of covered supports:

Member eligibility: active enrollment in a Health Net Medi‑Cal or Cal MediConnect (CMC) plan; no age requirement for most LTSS programs (age requirements noted per program); member must live in a permanent home setting (residents of long‑term care facilities are not eligible for home‑based LTSS).

Core LTSS programs included: In‑Home Supportive Services (IHSS), Community Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), Connect the Needs (CTN), and Respite Care (temporary caregiver relief up to 24 hours every 6 months).

IHSS program description and examples of services: state‑funded program that pays for in‑home services for Medi‑Cal beneficiaries who need assistance with ADLs/IADLs based on assessed level of need; examples include house cleaning, meal preparation, laundry, grocery shopping, personal care (toileting, bathing, grooming), accompaniment to medical appointments, and protective supervision.

LTSS purpose: federally funded waiver programs intended to support people living in a home environment to prevent or avoid institutionalization.

Eligibility and Services Criteria

Program‑specific eligibility and services criteria for Health Net Medi‑Cal/CMC members:

ALL of the following

Active enrollment in a Health Net Medi‑Cal or CMC plan.
No age requirement; hours and eligibility are based on functional need as determined by a DPSS social worker assessment.
Member must live in a permanent home setting (residents of long‑term care facilities are not eligible).
Service examples: house cleaning, meal preparation, laundry, grocery shopping, personal care services, accompaniment to medical appointments, protective supervision.

ALL of the following

CTN and Respite Eligibility and Service Criteria

Eligibility and service criteria for CTN and Respite Care (short‑term, caregiver relief services):

ALL of the following

Member must be actively enrolled in Cal MediConnect.
Member must have unmet needs in a minimum of 3 ADL/IADL.
Member must be willing to have an in‑person assessment completed.
CTN availability: CTN is a Health Net specific short‑term program generally available in Los Angeles County; member must be enrolled in Cal MediConnect in Los Angeles or San Diego County as noted.
Member must have an active caregiver (formal or informal) and be willing to allow a temporary caregiver into the home.

Provider Acceptance, Forms, and Coding

COC provider acceptance criteriamixed

Requested provider must accept contracted rates and be California approved with no quality concerns and supply relevant treatment information

Required state formsmixed

SOC 873	Health Care Certification Form to be completed by Licensed Health Care Professional
SOC 295	Application for In-Home Supportive Services (IHSS) to be completed by PPS

mixed

No codes listed

inv-08: Pre-existing relationship timeframe

Pre-existing relationship timeframeMember must have seen the requested out-of-network PCP or specialist at least once for a non-emergency visit within the 12 months prior to the date of initial enrollment in Health Net; self-attestation is not sufficient.

Proof requiredHealth Net or its delegate must be able to determine the pre-existing relationship; documentation of the non-emergency visit is required; self-attestation alone does not meet the requirement.

ScopeApplies to both primary care providers and specialists when evaluating Continuity of Care requests based on a pre-existing relationship.

inv-09: ADL/IADL impairment thresholds — CBAS and CTN minimums

CBAS ADL thresholdEligibility requires impairments in two or more Activities of Daily Living (ADLs) and/or need for assistance or supervision performing ADLs.

Provider and Public Program Actions & Referrals

Note

Provider and PPG Responsibilities for Continuity of Care

Providers and PPGs must inform members of their right to request Continuity of Care (COC) and assist with arranging services. If Health Net receives the application, Health Net will assess likely COC eligibility per Health and Safety Code §1373.96, APL 18-008, or DPL 16-002 and refer qualifying requests to the member's PPG. The current or receiving PPG must render a decision to approve or deny the COC request, negotiate payment terms with out-of-network treating providers when applicable, and authorize services as appropriate.

Approved out-of-network COC providers must coordinate with Health Net or the delegated PPG and may not refer the member to another out-of-network provider without prior authorization.
If a secondary referral to an out-of-network provider is requested, Health Net or the PPG will review the request for medical necessity and determine whether an in-network provider is available before making an initial determination.
Services need not continue if the out-of-network provider does not accept Health Net or PPG terms and conditions.

Documentation Required

Key Definitions

inv-15: Serious chronic condition — definition and context

DefinitionA serious chronic condition is a medical condition due to a disease, illness, or other medical disorder that is serious in nature and either persists without full cure or worsens over an extended period, or requires ongoing treatment to maintain remission or prevent deterioration.

Context for COCSerious chronic conditions qualify as an automatic condition under Health and Safety Code §1373.96 for consideration of Continuity of Care until completion of covered services for the duration of the condition.

Care implicationsMembers with serious chronic conditions may be eligible to continue care from an out-of-network provider while treatment is ongoing to maintain remission or prevent deterioration.

inv-16: Terminal illness — definition and coverage note

DefinitionTerminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less.

Policy Summary

PayerHealth Net

PolicyContinuity of Care (COC) and Long-Term Services and Supports (LTSS)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 20, 2019

Next Review DateN/A

Key ActionPPGs and Health Net must inform members of their right to request Continuity of Care and process COC requests in a timely manner.

SourceLink

On This Page

Member must be actively enrolled in a Health Net Medi‑Cal or CMC plan and be 18 years of age or older.

Impairments in two or more ADLs and/or require assistance or supervision performing ADLs; require ongoing or intermittent protective supervision, skilled observation, assessment, or intervention by skilled health or mental health professional.

Core services include professional nursing and medication management, therapeutic activities, social services/personal care, and one meal per day.

Additional services may include PT/OT/ST, mental health/psychiatric services, registered dietician services, and transportation to/from the center.

Operational notes: eligibility determined by RN using CDET during face‑to‑face assessment; if eligible, CBAS multidisciplinary team creates an Individualized Plan of Care (IPC) reviewed every 6 months.

ALL of the following

Member must be an actively enrolled Health Net Medi‑Cal or CMC member and be 65 or older.
Member must be certified or certifiable for nursing home placement, wish to remain in the community, reside within an MSSP service area, and be appropriate for care management services determined by MSSP site staff.
Services include care management, personal care assistance via IHSS, environmental adaptations (ramps, grab bars, PERS), housing assistance/minor repairs, money management, and protective supervision; limited spaces with waiting list ~6 months.

ALL of the following

Must be actively enrolled in Cal MediConnect and have unmet needs in a minimum of 3 ADL/IADL.
Must be willing to have an in‑person assessment completed; CTN is only available in Los Angeles County (member must be enrolled in Cal MediConnect in Los Angeles or San Diego County).
Member must have an active caregiver (formal or informal) and be willing to allow a temporary caregiver in their home.
CTN services include short‑term supports such as emergency utility assistance, non‑Medi‑Cal covered home equipment and installation, assistive devices, referrals to home‑delivered meals, medication management, transportation referrals, and emergency response system; typical length of service ~3 months.

ALL of the following

Applicants may be subject to unannounced home visits and program requirement letters; substantiated fraud may lead to prosecution and can be reported via fraud hotline 800‑822‑6222.
Members may hire family/friends as IHSS providers; registries are available (PASC 1‑877‑565‑4477, SEIU registry 1‑866‑544‑5742).

CTN services included (examples): emergency utility assistance; non‑Medi‑Cal covered home equipment and installation; assistive devices; referrals to home‑delivered meals; medication management; transportation referrals; emergency response system; length of service approximately 3 months.

ALL of the following

Caregiver matched must be able to meet member needs and be available at the requested time for respite.
Services provided by respite caregiver may include meal preparation, bathing, and dressing; services excluded from caregiver‑provided respite include transportation and housekeeping.
Respite visit limits: each visit has a minimum of 4 hours; cumulative respite not to exceed 24 hours every 6 months.4 hours minimum; 24 hours maximum per 6 months

ALL of the following

Referral submission options: fax to 1‑866‑922‑0783 or email Help_Referral@healthnet.com (also provided as HELP_referral@healthnet.com); complete Cal MediConnect Respite Care Referral Form with member and caregiver details and requested dates/hours.
Public Programs Department contact: phone 1‑800‑526‑1898; assistance available for referral submission.

Operational note: CTN is intended as a short‑term (~3 months) program to address immediate, complex, unmet LTSS needs and to bridge members to longer‑term services where available.

CTN ADL/IADL thresholdCTN eligibility requires unmet needs in a minimum of three ADL/IADL.

Assessment basisCBAS eligibility and service needs are determined by a Registered Nurse using the CBAS CDET during a face-to-face assessment; CTN requires willingness to have an in-person assessment.

inv-10: Respite visit minimum and maximum — minimum 4 hours; cumulative limits

Minimum visit lengthEach respite visit must be a minimum of 4 hours.

Cumulative limitRespite care cumulative limit is 24 hours not to exceed every 6 months.

Referral details requiredReferrals must indicate how many hours and specify which dates respite is needed, and include caregiver name and phone number.

IHSS Referral Form Requirements (Los Angeles County)

Los Angeles County IHSS referrals require two forms: a Licensed Health Care Professional (LHCP) must complete SOC 873 and the Public Authority / Provider Payment System (PPS) must complete SOC 295. Ensure all required fields are completed as noted below when submitting.

SOC 873 (Health Care Certification Form): Complete applicant name, DOB, address, and county of residence in Section A (page 1). Leave Section B (page 1) blank for member signature. Fill in applicant name on top of page 2. Sections C & D (page 2) must be completed by the LHCP.
SOC 295 (IHSS application): Complete page 1 with available information. Form must include the member's social security number. It is acceptable to send page 2 without the member's signature. Use page 3 to complete sections 6a and 6b (Ethnicity & Language Codes) on the bottom of page 1.

Note

MSSP and IHSS Referral Process (San Diego County)

For San Diego County, MSSP and IHSS referrals are submitted online through the Aging and Independent Services (AIS) website. It is recommended to have the member available by phone when completing the online referral to answer questions and provide necessary information.

Use the AIS online submission portal for MSSP and IHSS referrals in San Diego County.
Have the member on the phone during referral completion when possible to confirm details.

Prior Authorization

Referral Submission and Public Programs Contact

For Cal MediConnect Respite Care referrals and general Public Programs contact, use the channels below to submit completed forms or ask questions. Providers should include Case Manager name and contact information, reason for referral, and specific tasks/services requested on the referral form. If assistance is needed completing forms, contact Health Net for support.

Fax completed Cal MediConnect Respite Care Referral Form to Public Programs: 1-866-922-0783.
Email completed Cal MediConnect Respite Care Referral Form to Public Programs: HELP_referral@healthnet.com.
Telephone for Public Programs: 1-800-526-1898 (for assistance completing forms and general inquiries).
COC inquiries email: SHP_TOC-COC_SPD@healthnet.com.
LTSS referrals email: HELP_referral@healthnet.com.
Include on the referral form: Health Net or Medical Group Case Manager name and contact information, reasons for referral, and which tasks/services are being requested (note that transportation is not included).

COC duration noteFor current Health Net members, completion of covered services for a terminal illness may exceed 12 months from the provider termination date; similar extension may apply for newly enrolled members from the effective date of coverage.

Coverage implicationMembers diagnosed with a terminal illness are covered for continuation of services for the duration of the terminal illness under Continuity of Care rules.

inv-17: LTSS — Long-Term Services and Supports definition

DefinitionLong-Term Services and Supports (LTSS) are an array of federally funded waiver programs providing services designed to support people living in a home environment to prevent or avoid institutionalized care.

GoalLTSS programs aim to support community living and delay or avoid placement in nursing homes or other long-term care facilities.

Core programsCore LTSS programs referenced include IHSS, CBAS, MSSP, CTN, and Respite Care.

inv-18: IHSS — In-Home Supportive Services definition

DefinitionIn-Home Supportive Services (IHSS) is a state-funded program that pays for in-home services for Medi-Cal beneficiaries who need assistance with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) based on assessed need.

Examples of servicesExamples include house cleaning, meal preparation, laundry, grocery shopping, personal care services (toileting, bathing, grooming), accompaniment to medical appointments, and protective supervision.

Assessment basisIHSS hours are determined by assessed functional need (typically by DPSS social worker); members must live in a permanent home setting to be eligible.

inv-19: CBAS — Community-Based Adult Services definition

DefinitionCommunity-Based Adult Services (CBAS), formerly Adult Day Health Care (ADHC), are centers providing a variety of medical and social services to improve functioning and delay or avoid placement in a nursing home or other long-term care facility.

Eligibility noteCBAS members must be actively enrolled in Health Net Medi-Cal or CMC, be 18 or older, and have impairments in two or more ADLs and/or require assistance or supervision performing ADLs.

Core servicesServices include professional nursing and medication management, therapeutic activities, social services/personal care, and one meal per day, with additional services such as PT/OT/ST and transportation as available.

inv-20: MSSP — Multipurpose Senior Services Program definition

DefinitionMultipurpose Senior Services Program (MSSP) provides case and healthcare management for frail, elderly members who are certifiable for placement in a nursing facility but wish to remain in the community.

Eligibility criteriaMembers must be actively enrolled in Health Net Medi-Cal or CMC, be 65 or older, be certifiable for a nursing home, reside within an MSSP service area, and not reside in a long-term care facility.

Services and limitationsServices include care management, personal care via IHSS, environmental adaptations, housing assistance, money management, and protective supervision; spaces are limited and waiting list is approximately 6 months.

inv-21: CTN — Health Net specific program definition and typical length

DefinitionCTN is a Health Net–specific short-term program for members with immediate, complex, unmet LTSS needs providing services and referrals not covered by Medi-Cal.

Typical lengthLength of service is approximately 3 months.

Eligibility notesCTN requires active Cal MediConnect enrollment, unmet needs in a minimum of 3 ADL/IADL, willingness to have an in-person assessment, and availability in Los Angeles County (member must be enrolled in Cal MediConnect in Los Angeles or San Diego County).

inv-22: Activities of Daily Living (ADL) — basic self-care tasks

DefinitionActivities of Daily Living (ADL) are basic self-care tasks needed for daily living, learned in early childhood and necessary to get through the day.

Common ADLsExamples include ambulation/walking, bathing, dressing, self-feeding, toileting, and transferring (in/out of bed or chair).

Functional relevanceADL impairments are used as eligibility criteria for LTSS programs such as CBAS and influence the level of assistance required.

inv-23: Instrumental Activities of Daily Living (IADL) — tasks supporting independent living

DefinitionInstrumental Activities of Daily Living (IADL) are tasks that support independent living once a person is up and dressed for the day.

Common IADLsExamples include accessing resources, meal preparation, medication management, money management, and transportation.

Use in eligibilityUnmet needs in IADLs, combined with ADLs, factor into eligibility for programs like CTN which requires unmet needs in a minimum of three ADL/IADL.