Blue Cross updates continuity of care requirements to align with law

In 2020, the president signed the Consolidated Appropriations Act of 2021, or CAA, into law. That legislation had several health care-related provisions. Part of the legislation addresses continuity of care requirements.

Blue Cross Blue Shield of Michigan and Blue Care Network already allow for continuity of care for our members in Michigan as required by state law and the Affordable Care Act, and we are updating our policies to align with the requirements of the CAA.

What is continuity of care?

Sometimes, a contract between a health care provider and a health plan is modified (for example through departicipation, termination, etc.) and results in a loss or reduction of benefits for an individual. Through continuity of care, the individual is still able to see their health care provider under certain circumstances because their health situation requires it. In addition, the care would be provided as if there were no change to the contract.

What does the CAA say about continuity of care? 

According to the legislation, effective Jan. 1, 2022, if a health care provider changes network status, patients with complex care needs have the option of up to 90 days of continued coverage at in-network cost sharing to allow for a transition of care to an in-network health care provider.

Complex care circumstances where you can continue treatment

The circumstances below are similar to our existing continuity of care situations with some changes outlined in the CAA legislation. You can still see your patient if he or she is:

• Undergoing a course of treatment for a “serious and complex condition,” defined as:
• An acute illness — A condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or
• A chronic illness or condition — A condition that is:
• Life-threatening, degenerative, potentially disabling or congenital; and
• Requires specialized medical care over a prolonged period of time
• Getting inpatient care.
• Scheduled to undergo nonelective surgery, including receipt of postoperative care for that surgery
• Pregnant and undergoing a course of treatment for the pregnancy
• Determined to be terminally ill (defined as “a medical prognosis that the individual’s life expectancy is six months or less”) and is receiving treatment for their illness.

Requirements to provide services under continuity of care

If you choose to treat your patient for a continuity of care period of time, you’re required to:

• Accept payment from Blue Cross as payment in full (less any required copays or deductibles).
• Adhere to Blue Cross’ standards for maintaining quality health care and provide Blue Cross with  necessary medical information related to your patient’s care.
• Adhere to Blue Cross’ policies and procedures, including, but not limited to, those concerning  utilization review, referrals, pre-authorizations and treatment plans.

For more information about continuity of care, see our online provider manuals on web-DENIS.