MassHealth continuity of care transition for Accountable Care Organizations/Managed Care Organization Plans
Effective April, 2018
On April 6, 2018, MassHealth issued a memo extending their Continuity of Care process, changing the Fixed Enrollment date and providing new guidance for service area exceptions.
Continuity of Care (COC) is a term that is used to prevent any disruption of care when people move from one health insurance carrier to another. In this instance, authorizations will allow claims to pay and treatment to continue without disruption even if the provider is out of network and/or the service being provided requires an authorization. Fallon’s COC authorizations will also cover the requirement for PCP referrals during the designated timeframe.
During the COC period, providers are able to meet with new members, complete applicable assessments and put ongoing or new services in place.
Fallon Health’s COC process is different from MassHealth’s process. All of Fallon’s ACO plans provide an extended continuity of care process through May 29 for members with an effective membership date of March 1–31, 2018. This extended COC period through 5/29 will allow network providers time to put into place new referrals and authorizations as required, for any new services your patients may need once they have become effective in one of our ACOs. Please note that the extended COC period through 5/29 only applies to patients effective in an ACO plan between March 1–31. Those with effective dates starting April 1 will follow the usual 30-day continuity of care process.
NO auths are required during either COC period.
Fallon Health is working with our sister payers in Massachusetts to share authorization information, allowing a smoother transition for all MassHealth members, regardless of what plan they are in.
There are certain scenarios that may require a longer period of COC coverage. These scenarios include:
- If a member is pregnant at the time of the health plan effective date, she must be allowed to remain with her OB/GYN provider through her 6 week post-partum visit
- Ongoing ABA therapy when a fragile member has developed a solid relationship with his/her providers
- Ongoing treatment such as chemotherapy and/or radiation, dialysis (with an out-of-network provider), certain drug therapy regimens that must not be interrupted and significant or complex medical needs that are being treated by out-of-network providers
- Ongoing lengthy admissions
Please note that Fallon does not extend the COC period for these scenarios. Instead, we set up completely new COC periods for them.
After March 31, 2018, new requests for coverage of services that require a prior authorization will need to go through the process presently in place with Fallon. This process can be accessed through use of the Standard PA Form. For behavioral health services please contact Fallon Health’s Behavioral Health provider, Carelon Behavioral Health at 1-781-994-7556.
For ongoing, transitional support over the next few months, please feel free to contact the appropriate person in the table below: