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Continuity of Care

If you or your Dependent(s) have an Acute Condition, a Serious Chronic Condition, a Pregnancy, a terminal illness, or your newborn child between birth and age 36 months is under medical care, you may be eligible to continue to receive treatment from your provider (e.g. physician or hospital):

  • ​if your treating Plan Provider terminates as a VHP Plan Provider, or

  • if you are receiving care from a non-participating provider at the time of your enrollment in VHP Plan.

This section describes the Covered Services of this continuity of care. You have the right to request copy of the Plan’s continuity of care policy. To request a copy of this policy, call Member Services at 1.888.421.8444 (toll-free).

Continuity of care Covered Services will be provided to qualified Members from their provider. Treatment will be provided in a timely and appropriate basis as determined by the Plan Physician. In the case that the Member is pregnant, continuity of care Covered Services will be provided until postpartum services related to the delivery are complete or until such time as it is deemed appropriate. Plan Providers will consult with the Member’s provider to determine when it is safe to transfer.

Completion of Covered Services following termination of a Plan Provider or enrollment in the Plan:

  • ​for an Acute Condition shall be provided for the duration of the Acute Condition.

  • for a Serious Chronic Condition shall be provided for a period of time necessary to complete the course of treatment and to arrange for a safe transfer to a Plan Provider. Completion of Covered Services shall not exceed 12 months.

  • for a Pregnancy shall be provided for the duration of the Pregnancy.

  • for a terminal illness shall be provided for the duration of the terminal illness. Terminal illness for continuity of care is defined as an incurable or irreversible condition that has a high probability of causing death within one (1) year or less. Completion of Covered Services shall be provided for the duration of a terminal illness, which may exceed 12 months from the Plan Provider contract termination date or 12 months from the effective date of Coverage for a new Member.

  • for the care of a newborn child between birth and age 36 months. Completion of Covered Services shall not exceed 12 months.

  • for the performance of a surgery or other procedure that is authorized by the Plan as part of a documented course of treatment and has been recommended and documented by the current provider at the time of enrollment or Plan Provider termination. Completion of such surgical Covered Services must occur within 180 days.

To receive continuation of care from your provider or Plan Provider, you must obtain a written Prior Authorization from VHP. This authorization shall state the predetermined amount of time you will be able to continue to receive care from your current provider.

A written referral for continuity of care is only provided if you are a new Enrollee or your provider is a terminated VHP Provider, when:

  • ​the delay in the provision of services will result in loss of continuity of care,

  • the services for the condition are otherwise Medically Necessary covered Benefits under the terms of your Coverage with VHP when provided by Plan Providers,

  • the services are provided within the Service Area,

  • your Coverage with VHP is in effect,

  • the terminated Provider or Out-of-Network Provider signs a new temporary contract with VHP, and the terminated Provider was not terminated by VHP for reasons other than medical disciplinary cause, criminal activity, or the provider’s voluntary termination, and

​Your Coverage with VHP does not include an Out-of-Network option.

To apply for continuity of care Covered Services, call Member Services at 1.888.421.8444 (toll-free) within 30 days from your Effective Date of Coverage with VHP, or within 30 days from the date you received notice from VHP that your Plan Provider has terminated or when your Plan Provider notifies you = that he/she is terminating from VHP. For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality.​

Last updated: 12/14/2018 2:36 PM