Common use of Continuity of Care for Former Qualified Health Plan Members Clause in Contracts

Continuity of Care for Former Qualified Health Plan Members. For a transitional period of at least ninety (90) days following an Enrollee's effective date of enrollment with the Contractor, when that member can demonstrate that he or she was covered by a Qualified Health Plan (the “member’s QHP") for at least one day during the ninety (90) days preceding enrollment with the Contractor, the Contractor must take the following steps to ensure continuity of that member’s care: • The Contractor must accept any prior authorizations authorized by the member’s QHP and for which the provider shows evidence of the prior authorization and which would still be in effect if the member were still covered by the member’s QHP. • The Contractor must allow Enrollee to see an out-of-network provider on an in-network basis if (1) that provider was a part of the member’s QHP network, and (2) the member had been in the care of that provider for a period of at least six months. Whether or not such provider agrees to accept the Contractor’s in-network rates, the balance-billing of the Medicaid beneficiary is prohibited. • The Contractor must make a formulary exception to allow the member to refill or renew any prescription which the member had received through the member’s QHP as part of its formulary and which is not on the Contractor’s formulary. • To the extent allowable by HIPAA and other law, the Contractor must coordinate with the member’s QHP to ensure a smooth transition of medical management responsibilities and must abide by further continuity of care policies which may be adopted by EOHHS.

Continuity of Care for Former Qualified Health Plan Members. For a transitional period of at least ninety (90) days following an Enrollee's effective date of enrollment with the Contractor, when that member can demonstrate that he or she was covered by a Qualified Health Plan (the “member’s QHP") for at least one day during the ninety (90) days preceding enrollment with the Contractor, the Contractor must take the following steps to ensure continuity of that member’s care: •  The Contractor must accept any prior authorizations authorized by the member’s QHP and for which the provider shows evidence of the prior authorization and which would still be in effect if the member were still covered by the member’s QHP. •  The Contractor must allow Enrollee to see an out-of-network provider on an in-network basis if (1) that provider was a part of the member’s QHP network, and (2) the member had been in the care of that provider for a period of at least six months. Whether or not such provider agrees to accept the Contractor’s in-network rates, the balance-billing of the Medicaid beneficiary is prohibited. •  The Contractor must make a formulary exception to allow the member to refill or renew any prescription which the member had received through the member’s QHP as part of its formulary and which is not on the Contractor’s formulary. •  To the extent allowable by HIPAA and other law, the Contractor must coordinate with the member’s QHP to ensure a smooth transition of medical management responsibilities and must abide by further continuity of care policies which may be adopted by EOHHS.