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As a member of Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”), you will get your health care from providers in Health Plan’s network. In some cases, you may be able to go to providers who are not in the Health Plan network. This is called continuity of care. Call Health Plan and tell us if you need to see a provider that is out of network. We will tell you if you have continuity of care. You are able to use continuity of care, for up to 12 months, or more in some cases, if all of the following are true:
- You have an ongoing relationship with the non-plan provider, prior to enrollment in Health Plan
- The non-plan provider is willing to work with Health Plan and agrees to Health Plan’s requirements
- You were seen by the non-plan provider at least once during the twelve (12) months prior to your enrollment with Health Plan for a non-emergency visit
- You were seen by the non-plan provider at least once during the six (6) months prior to the transition of services from a Regional Center to Health Plan
- Health Plan does not have a documented quality of care concern with the non-plan provider
If your providers do not join the Health Plan network by the end of 12 months, do not agree to HPSJ payment rates or do not meet quality of care requirements, you will need to switch to providers in the Health Plan network or call Customer Service at 1-888-936-7526 (PLAN) TTY 711 to discuss your options.
If you are being treated by a provider for certain health conditions who is not a HPSJ provider or your provider stops working with HPSJ, you may be able to keep getting services from that provider. This is another form of continuity of care. Services Health Plan provides for continuity of care include but are not limited to:
- Acute conditions (a medical issue that needs fast attention) – for as long as the condition lasts.
- Chronic physical and behavioral conditions (a medical issue you have for a long time)– for an amount of time required to finish the course of treatment and to arrange for a safe transfer to a new doctor in Health Plan.
- Pregnancy – during the pregnancy and the immediate postpartum period.
- Maternal mental health services
- Care of a newborn child between birth and age 36 months for up to 12 months from the start date of the coverage or the date the provider’s contract ends with Health Plan.
- Terminal illness (a life-threatening medical issue) – for as long as the illness lasts. Completion of covered services may exceed twelve (12) months from the time the provider stops working with
- Performance of a surgery or other medical procedure from a non-plan provider as long as it is covered, medically necessary and is authorized by Health Plan as part of a documented course of treatment and has been recommended and documented by the provider – surgery or other medical procedure to take place within 180 days of the provider’s contract termination date or 180 days from the effective date of coverage of a new member.
For other conditions that may qualify, contact Customer Service at 1-888-936-7526 (PLAN) TTY 711.
If the non-plan provider is not willing to continue to provide services, does not agree on payment or other terms for providing care, then you will not be able to receive continued care from the provider. Call Customer Service at 1-888-936-7526 (PLAN) TTY 711 for help selecting a contracted provider to continue with your care or if you have any questions or problems in receiving covered services from a provider who is no longer part of Health Plan.
Health Plan is not required to provide continuity of care for services not covered by Medi-Cal, durable medical equipment, transportation, other ancillary services and carved-out service providers. To learn more about continuity of care and eligibility qualifications, and to hear about all available services, call Customer Service at 1-888-936-7526 (PLAN), TTY 711.
View your rights to Continuity of Care on the Department of Health Care Services (DHCS) website