Summary Of Continuity Of Care Process
The Holman Group is committed to providing high quality mental health services, and strives toward excellence in customer service. We are truly invested in, and committed to, providing caring and effective treatment to our clients.
Prior to a new account’s benefits beginning, The Holman Group makes every effort to ensure patients currently receiving behavioral healthcare treatment (authorized by the previous behavioral healthcare insurance company) will continue to have access to his/her provider by attempting to contract with as many providers as possible (thereby ensuring there is no disruption in care).
Enrollees New to The Holman Group
A new enrollee inquiring about his/her provider’s status with The Holman Groups may contact the Care Access Department at (800) 321-2843 Monday through Friday, 7:30 AM to 6:30 PM.
If the provider the enrollee is requesting is already on the network, the Care Access Specialist will contact the provider and give them an authorization to see the enrollee.
If the provider the enrollee is requesting is not on the network, every effort will be made to ensure the enrollee utilizing an out-of-network provider, and not experiencing acute or chronic conditions, is provided appropriate continued care. This includes, but is not limited to: attempting to contract with the provider; and/or providing the enrollee with the option of selecting an in-network provider.
In the event the provider is not part of The Holman Group network, a temporary transitional care benefit may be available to new enrollees. The transitional care benefit allows new enrollees to continue to receive services from a provider not on the network for a defined period of time or until the safe transfer of care to a network provider can be arranged. In order to qualify for the transitional care benefit, an enrollee must have utilized medically necessary services provided by a licensed mental healthcare provider within thirty (30) days prior to the effective start date.
Please note: the availability of Transition of Care/Continuity of Care coverage does not mean a treatment is medically necessary, nor does it constitute pre-authorization of the services to be provided. Medical necessity determinations and pre-authorization must still be obtained.
If a new enrollee is currently receiving services at an acute level of care authorized by the current plan prior to the transition to the new plan (e.g. a psychiatric stabilization and detoxification), a benefit determination will be made by The Holman Group’s Behavioral Healthcare Advisor once the prior health plan is no longer providing coverage for the enrollee. Upon transition to benefits provided by The Holman Group, an enrollee who is receiving services at an acute level of care may be eligible for treatment at a different level of care.
Termination of Provider/Facility
When a provider/facility terminates as a contracted provider with The Holman Group, every effort will be made to ensure that the transfer of enrollees to new providers will not disrupt or prevent care, and that the transfers are efficient and cause no unnecessary delays.
When a provider agreement terminates with The Holman Group, the Provider Relations Department will coordinate with the Care Access Department to identify all affected members, inform them of the change and transition them to an in-network provider.
The Holman Group will provide affected enrollees with the continuation of covered services from a terminated provider for a defined period of time (usually 90 days), or until the safe transfer of care to a network provider can be arranged*, as long as the provider’s termination was not for medical or criminal disciplinary action.
*This will be determined by The Holman Group in consultation with the terminated provider.
How to Request an Independent Medical Review (IMR)
In cases where the enrollee believes that health care services have been improperly denied, modified, or delayed by The Holman Group, or by one of its contracting providers, the enrollee has the right to file a complaint (grievance) with the plan. If an enrollee disagrees with the plan’s decision, needs help with a grievance involving an emergency, or a grievance has remained unresolved for more than thirty (30) days, the enrollee may contact The California Department of Managed Health Care (DMHC) for assistance. The Department has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired.
The enrollee may be eligible for an Independent Medical Review (IMR). If the enrollee is eligible for an IMR, the process will provide an impartial review of medical decisions made by the health plan related to the medical necessity of a proposed service, treatment, coverage decision for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical services.
Complaint forms, IMR application forms and instructions can be found online at the DMHC’s website, http://www.hmohelp.ca.gov.
The Holman Group will also furnish Independent Medical Review forms and addressed envelopes to enrollees as appropriate and required.
The DMHC may waive the requirement that the enrollee participate in the Plan's grievance process if they determine that extraordinary and compelling circumstances exist, which include, but are not limited to: serious pain; the potential loss of life, limb or major bodily function; or the immediate, and serious deterioration of the health of the enrollee.
Cancelation of Coverage
Continuing coverage under this Plan is subject to the terms and conditions of the (Employer)’s Group Contract with Holman. If the Group Contract is cancelled, coverage for you and all your Eligible Dependents will end after a written notice of termination of coverage is given and a 30-day grace period has elapsed since the date of the receipt of the last premium payment. Coverage will continue during the grace period.
If an Enrollee’s eligibility is terminated for any of the above reasons, the enrollee will be notified in writing and informed of the effective termination date. Coverage of the enrollee’s dependents will end when enrollee’s coverage ends. Any enrollee who is undergoing treatment in a hospital for acute care at the time of cancellation will continue to be covered under the terms of the Group Contract until discharge.
It is the responsibility of Employer to notify the enrollee of the termination of this group contract. In the event we provide notice of cancellation for non-payment of premium to the Employer, Employer agrees to promptly mail a legible, true copy of the notice of cancellation to all enrollees at their current address. The notice of cancellation will include:
- The date and time coverage will terminate;
- The cause for cancellation, including reference to the applicable clause in this Agreement;
- A statement that the cause for cancellation was not due to the enrollee's health status or requirements for health services;
- That an enrollee who alleges that cancellation was due to the enrollee's health status may request a review of cancellation by the Department of Managed Health Care;
- A written notification reminding members of their rights to request completion of their covered services.
Termination of Benefits. If your Employer fails to pay Holman the appropriate premiums for you and/or your dependents, Holman may terminate the benefits for you and/or your dependents if the Employer has been duly notified with the Notice of Cancellation for Nonpayment of Premiums and Grace Period and billed for the charge and at least a 30-day grace period has elapsed since the date of the receipt of the last premium payment. The notice of cancellation for nonpayment of premiums and grace period shall include the language in California Title 28, Section 1300.65(c)(3)(B)(ii) in be in at least 12 point font:
“You are receiving this Notice of Cancellation because your Holman coverage is being cancelled or not renewed because you have not paid your premium. Even though you have not paid your premiums, you are being provided a “grace period” to allow you time to make your past due premiums payment(s) without losing your health care coverage. “Grace period” means a period of at least 30 days beginning no sooner than the first day after the last day of paid coverage and lasts at least 30 days. Your grace period ends on (insert month, day, year). You may avoid losing your coverage if you pay the premium(s) owed to Holman before the end of the grace period. If you do not pay the required premium amount by the end of the grace period, your coverage will be terminated effective the day after the last day of the grace period. Your grace period ends on (insert month, day, year). Coverage will continue during the grace period; however, you are still responsible to pay unpaid premiums and any copayments, coinsurance or deductible amounts required under the plan contract. For information about individual health care coverage and health care subsidies that may be available to you, contact Covered California at (800) 300-1506 or TTY at (888) 889-4500 or online at www.CoveredCa.com. If you wish to end your coverage immediately, please contact Holman as soon as possible.”
Coverage will continue during the grace period; however, the Employer will be still responsible to pay unpaid premiums and the Enrollee will be responsible for any copayments, coinsurance or deductible amounts required under the group plan contract. Grace period means a period of at least 30 days beginning no earlier than the first day after the last date of paid coverage to allow the Employer to pay an unpaid premium amount without losing healthcare coverage. At a minimum this grace period shall extend through the thirtieth (30th) day after the last date of paid coverage.
If Holman withdraws a health benefit plan from the market, Holman will notify the Employer, enrollees and the director at least 90 days prior to the discontinuation of the group contract. Notice of the decision to cease new or existing health benefit plans in the state is provided to the director, the Employer and the enrollees covered under this group plan contract at least 180 days prior to the discontinuation of this contract.
Holman has the right to terminate your coverage under this Plan in the following situations:
- Failure to Pay. Your coverage may be terminated for employer’s nonpayment of required premiums owed to Holman if your employer has been duly notified and billed for the charge and at least a 30-day grace period has elapsed since the date. of the receipt of the last premium payment.. Coverage will continue during the grace period; however, the Employer will be still responsible to pay unpaid premiums and the Enrollee will be responsible for any copayments, coinsurance or deductible amounts required under the group plan contract.
- Fraud or Misrepresentation. Your coverage may be terminated if you knowingly provide false information (or misrepresent a meaningful fact) in the enrollment process or fraudulently or deceptively use services or facilities of Holman and/or its contracted providers s (or knowingly allow another person to do the same). If coverage is terminated for the above reasons, you forfeit all rights to enroll in the COBRA Plan and lose the right to re-enroll with Holman in the future.
Right to Submit Request for Review of Cancellation, Rescission, or Nonrenewal of Your Plan Contract, Enrollment, or Subscription.
If you believe your plan coverage has been, or will be, improperly cancelled, rescinded, or not renewed, you have the right to file a Request for Review. You have the options of going to the plan and/or the Department if you do not agree with the plan decision to cancel, rescind or not renew your plan coverage.
Option (1) - You may submit a Request for Review to your plan. * You may submit a Request for Review to Holman by calling 1-800-321-2843 or submitting a request at www.HolmanGroup.com, or by mailing your written Request for Review to Holman, 9451 Corbin Ave., Suite 100, Northridge, CA 91324. * You may want to submit your Request for Review to Holman first if you believe your cancellation, rescission or nonrenewal is the result of a mistake. Requests for Review should be submitted as soon as possible after you receive the Notice of Cancellation, Rescission, or Nonrenewal. * Holman will resolve your Request for Review or provide a pending status within three (3) days. If the plan upholds your cancellation, rescission or nonrenewal, it will immediately transmit your Request for Review to the Department of Managed Health Care and you will be notified of the plan's decision and your right to also seek a further review of the plan's decision by the Department as detailed under
Option 2, below. Option (2) - You may submit a Request for Review to the Department of Managed Health Care. * You may submit a Request for Review directly to the Department of Managed Health Care without first submitting it to the plan or after you have received the plan's decision on your Request for Review. * Requests for Review by the Department of Managed Health Care may be submitted:
DEPARTMENT OF MANAGED HEALTH CARE
980 NINTH STREET, SUITE 500
SACRAMENTO, CALIFORNIA 95814-2725
OR ONLINE: WWW.HEALTHHELP.CA.GOV