Statewide Medicaid Managed Care: Continuity of Care Provisions

Feb 9, 2024
The Agency for Health Care Administration (AHCA) contracts with Medicaid health and dental plans to provide services to health plan enrollees in the Statewide Medicaid Managed Care (SMMC) program. AHCA recently entered into new contracts with health and dental plans. As part of those contracts, the ACHA achieved program changes that greatly benefit enrollees and providers.

AHCA will transition to the new contracts through a regional phased rollout. The first regional rollout occurred on Saturday, Dec. 1, 2018. The rollout for phase two will occur on Tuesday, Jan. 1, 2019.

Health and dental plans are required to ensure continuity of care (COC) during the transition period for Medicaid recipients enrolled in the SMMC program. COC requirements ensure that when enrollees transition from one health plan to another, one service provider to another or one service delivery system to another (i.e., fee-for-service to managed care), their services continue seamlessly throughout their transition. AHCA has instituted the following COC provisions:

• Health care providers should not cancel appointments with current patients. Health plans must honor any ongoing treatment that was authorized prior to the recipient’s enrollment into the plan for up to 60 days after the rollout date in each region.

• Providers will be paid. Providers should continue providing any services that were previously authorized, regardless of whether the provider is participating in the plan’s network. Plans must pay for previously authorized services for up to 60 days after the rollout date in each region and must pay providers at the rate previously received for up to 30 days.

• Providers will be paid promptly. During the COC period, plans are required to follow all timely claims payment contractual requirements. AHCA will monitor complaints to ensure that any issues with delays in payment are resolved.

• Prescriptions will be honored. Plans must allow recipients to continue to receive their prescriptions through their current provider, for up to 60 days after the rollout date in each region, until their prescriptions can be transferred to a provider in the plan’s network.

More information about COC provisions can be referenced on the COC program highlight document, which is posted on the AHCA’s website. Once on the page, click “Program Changes,” then the “Outreach and Presentations” link.

News Bites - December 2018