Continuity of Care Must Be Maintained

Dual eligibles often have long-standing relationships with primary care, specialty and durable medical equipment providers; many are stabilized on complex treatment or drug regimes. Even brief disruptions can have a serious impact on the health of this medically vulnerable population. Policies must be put in place to ease transitions into the model by maintaining access to current providers and services, treatments and drug regimes.

Care continuity rights can be broken into two categories. The first is the right to maintain access to current services, including prescription drugs, during a defined transition period.

The second type of care continuity right provides continued access to a current provider who is not part of the integrated model’s network. During a defined transition period, new enrollees should be permitted to receive services from non-network providers with whom they have an existing relationship. The integrated model needs to have processes for paying these non-network providers and for reaching out to them to encourage enrollment in the network. If these outreach efforts are unsuccessful, a process should exist for the enrollee to secure approval to continue seeing that provider.

NSCLC created a tool for advocates on continuity of care in the Dual Eligible Demonstrations.


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