A new member who is currently receiving treatment, or an existing member whose physician is leaving or left the Sutter Health Plus network, may request to temporarily remain with their current treating physician for certain medical conditions.
New members can send completed forms to Sutter Health Plus within 30 days before or 60 days after their Sutter Health Plus effective enrollment date, or within 30 days of the date their physician left the network. Completed requests can be submitted via mail, fax or email to:
Sutter Health Plus
P.O. Box 160305
Sacramento, CA 95816
Fax: 916-736-5421 or toll-free fax: 1-855-759-8752
Email: [email protected] (email must include attached, completed copy of the COC Form)
Sutter Health Plus will notify the member by mail or phone if they qualify for continuity of care. For questions regarding COC, please call Sutter Health Plus Member Services at 1-855-315-5800. For protected health information (PHI) reasons, COC details cannot be shared with brokers or employers.
Important: COC does not apply to a new member who had the option to continue coverage with his or her previous health plan or provider (including through an out-of-network option) and instead voluntarily changed health plans.
|Category:||Sutter Health Plus|
|Date:||September 16, 2016|
WHAT IS CONTINUITY OF CARE?
In certain circumstances (described below), you may temporarily continue care with a physician who is not part of Sutter Health Plus’ network (a “non-participating provider”). Y ou may continue care with a provider if you are being treated by a provider who has been terminated from Sutter Health Plus’ network, or you are a new member who has been receiving care from a non-participating provider if you meet the continuity of care requirements explained below.
CONTINUITY OF CARE REQUIREMENTS
In order for you to be eligible for continued care, the non-participating provider must have been treating you for one of the conditions listed below. Individual circumstances will be evaluated by a Sutter Health Plus medical director on a case-by-case basis.
An acute condition: a medical condition that involves a sudden onset of symptoms due to an illness, injury or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition
A serious chronic condition: a serious chronic condition is a medical condition due to disease, illness or other medical problem or medical disorder that is serious in nature and that persists without full cure, worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Covered services will be provided for the period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by Sutter Health Plus in consultation with the member and the terminated provider or non-participating provider, consistent with good professional practice. Completion of covered services under this paragraph shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly enrolled member
A pregnancy. Care will be continued for the duration of the pregnancy and the immediate postpartum period
A terminal illness. An incurable or irreversible condition that has a high probability of causing death within one year. Care shall be continued for the duration of the terminal illness
Care of a newborn child whose age is between birth and 36 months. Care shall be continued for up to 12 months from contract termination of provider or from effective date of coverage for a newly covered member
Performance of surgery or other procedure that has been authorized by Sutter Health Plus (or its contracted medical group) as part of a documented course of treatment that is to occur within 180 days of the provider’s termination date or the effective date of coverage for a new member
Provider Requirements: Non-participating providers are required to agree to Sutter Health Plus’ credentialing, hospital privileging, utilization review, peer review, quality assurance and compensation terms. If non-participating providers do not agree to these contractual terms and conditions, you are not eligible to continue care with that provider. Participating providers who are terminating are compensated pursuant to the terms of the terminated provider agreement for the statutorily required period of time when such arrangements are specified in the particular Participating Provider Contract.
A non-participating provider and a provider whose terminated contract does not specify that compensation for continuity of care services will be compensated under the terms of the terminated contract, will be compensated at the same rate that is paid to similar participating providers that are noncapitated providers for similar services in the same geographic region, unless otherwise agreed by the Plan and the non-participating provider.
Neither Sutter Health Plus nor the participating medical group is required to continue the provider’s services if the non-participating provider or terminated provider does not agree to comply or does not comply with the contractual terms and conditions as to similarly situated providers as described above.
Member/Subscriber Voluntary Change in Coverage: Continuity of care does not apply to a new member who had the option to continue with his or her previous health plan or provider (including through an outof-network option), and instead voluntarily changed health plans.
IMPORTANT: Language assistance services, including translations of vital documents and interpreter services are available for our members who have a limited or no ability to speak English. These language assistance services are available to you at no cost. To get an interpreter or to ask about written information in your language, please contact Member Services at 1-855-315-5800 (TTY users call 1-855-830-3500).
IMPORTANTE: Los servicios de asistencia en idiomas, incluyendo traducciones de documentos importantes y servicios de interpretación, están disponibles para nuestros miembros que tienen una limitación o no son capaces de hablar inglés. Estos servicios de asistencia de idiomas están disponibles para usted sin ningún costo. Para obtener a un intérprete o para solicitar información por escrito en su idioma, por favor comuníquese con servicios al miembro al 1-855-315-5800 (usuarios de TTY deben llamar al 1-855-830-3500).