Continuity of Care in California: Qualifying Conditions and Requests

Continuity of care in California lets you keep seeing your current doctor for a limited time when that doctor leaves your health plan’s network, or when you switch to a plan the doctor doesn’t take. The right is not automatic. You have to request it, you have to be treated for one of six qualifying conditions, and your doctor has to accept the plan’s terms. How long you get depends on the condition, ranging from the length of an acute episode to the full duration of a terminal illness.

What Triggers the Right

Two events open the door. The first is when your provider’s contract with your plan ends, whether the plan dropped them, they left voluntarily, or their medical group lost its contract. The second is when you become a new enrollee in a plan that doesn’t include your current provider, which usually happens at open enrollment, when you change jobs, or when you’re assigned to a Medi-Cal managed care plan.

In either case, the plan must arrange for you to finish your course of treatment with that provider, so long as you meet the health condition requirements and the provider agrees to the plan’s terms. The right belongs to you, and plans are not required to volunteer it. Knowing to ask is half the protection.

Which Plans Have to Honor the Request

California’s rules cover two kinds of regulated coverage. HMOs fall under the Department of Managed Health Care (DMHC) through the Knox-Keene Health Care Service Plan Act. PPO and indemnity coverage falls under the California Department of Insurance (CDI). Both types carry the same core obligation.

The important gap involves self-insured employer plans. Many large employers fund claims directly and hire an administrator to process paperwork rather than buying insurance from a carrier. These arrangements are governed by the federal Employee Retirement Income Security Act (ERISA), which preempts state insurance mandates. California cannot force a self-insured employer plan to follow its continuity of care rules, even if the administrator is a California carrier you’d recognize. Check your plan documents or ask HR whether your coverage is “fully insured” or “self-funded” before you file anything. If you’re self-funded, skip ahead to the federal section — the No Surprises Act gives you a shorter but real safety net.

Qualifying Conditions and How Long You Get

Six categories qualify, each with its own time limit. The plan sets the exact duration in consultation with you and your provider, but the statute sets ceilings.¹

Acute Conditions

Sudden-onset conditions of limited duration — pneumonia, a broken bone, a post-surgical infection — qualify for continued care through the full duration of the acute episode. There is no fixed month cap.¹

Serious Chronic Conditions

For diabetes, heart disease, autoimmune disorders, and similar ongoing conditions, you can continue seeing your provider long enough to complete a course of treatment and arrange a safe transfer to a new in-network doctor. The ceiling is 12 months from the contract termination date or the effective date of your new coverage, whichever applies.¹

Pregnancy

Pregnant patients keep their provider through all three trimesters and the immediate postpartum period.² If you’re diagnosed with a maternal mental health condition during pregnancy, care for that specific condition extends up to 12 months from the diagnosis or the end of pregnancy, whichever is later. The extension requires written documentation from your treating provider.¹

Terminal Illness

An incurable or irreversible condition with a high probability of causing death within one year or less qualifies you to stay with your provider for the duration of the illness. The statute explicitly allows this to run past 12 months.¹

Newborn Care

Children between birth and 36 months who are receiving ongoing care from an affected provider can continue that care for up to 12 months from the contract termination date or the start of new coverage.²

Scheduled Surgery or Procedure

If your provider has documented a surgery or procedure to occur within 180 days of the contract termination date or within 180 days of your new coverage taking effect, you can complete it with that provider, including post-operative follow-up. For HMO coverage, the procedure must also be authorized by the plan as part of a documented course of treatment.¹

How to Make the Request

File a formal request with your health plan. The statute doesn’t set a filing deadline, but DMHC regulations and plan contracts typically require you to act within 30 days of learning your provider is leaving the network or of your new coverage taking effect. Treat 30 days as the outer limit even if your plan materials are silent. The safest move is to submit the request the same week you find out.

Include your provider’s name, the medical condition being treated, a description of the current treatment, and documentation supporting the qualifying category. If it matters whether your condition is acute or a serious chronic condition, ask your provider for notes that make the case clearly.

California regulations require the plan to weigh urgency when it responds.³ Plan contracts and regulatory guidance generally require a decision within 30 days for standard requests and within 72 hours for urgent ones. If the plan approves the request, you continue treatment under the same in-network cost-sharing you had before.

The Provider Has to Agree

This is where continuity of care requests often collapse. Your provider must accept the arrangement; the plan cannot force it. Under the statute, the plan can require the provider to accept the same contractual terms that were in place before termination, including credentialing, utilization review, and quality standards. If the provider refuses, the plan has no obligation to continue the arrangement.¹

Payment works the same way. Absent a different agreement, the provider is paid at rates comparable to what the plan pays similar in-network providers in the same geographic area. Most providers who recently had a contract with the plan will accept these terms because they were already working under similar conditions. A provider who left the network over a payment dispute may not. Call the office and ask before you file.

The same rules apply if you’re a new enrollee whose provider has never contracted with the plan. Standard terms, comparable rates, and the provider’s refusal ends it.

If Your Plan Denies the Request

Start with an internal grievance to the plan. If the plan upholds the denial or 30 days pass without a resolution, escalate to the DMHC for an HMO or the CDI for PPO and indemnity coverage.

For DMHC-regulated plans, the strongest tool is Independent Medical Review. An IMR sends your case to doctors with no connection to your plan. They review the records and the plan’s rationale, then decide. If the IMR sides with you, the plan must authorize the services within five business days. The review is free, and the decision is binding on the plan.⁴

Standard IMR decisions typically come within 45 days after the DMHC receives supporting documentation. If your condition is urgent, with a serious and immediate threat to your health backed by written documentation from your doctor, an expedited IMR is usually decided within seven days.⁴

Some patients cannot use the IMR process. Members of self-insured employer plans, Medicare enrollees, and Medi-Cal fee-for-service members (those not in managed care) are not eligible.⁴ If that’s you, use your plan’s internal process, federal external review, or a Medi-Cal state fair hearing, depending on which category applies.

If You’re on a Self-Insured Employer Plan

Federal law provides a shorter safety net. The No Surprises Act, in effect since 2022, requires all group health plans and health insurance issuers, including self-insured plans, to offer transitional care when a provider’s contract is terminated while you’re mid-treatment.⁵

Eligibility is narrower than California’s. You have to be a “continuing care patient,” meaning you’re undergoing treatment for a serious and complex condition, receiving institutional or inpatient care, scheduled for nonelective surgery, pregnant, or terminally ill. The plan must notify you of the provider’s departure and your right to elect continued care.⁵

The transition period lasts up to 90 days from the notice date, or until you’re no longer a continuing care patient, whichever comes first.⁶ During that window you keep the same benefits, cost-sharing, and terms you had before the termination. The provider must accept the plan’s payment as payment in full and continue following the plan’s quality standards.

The 90-day cap is a hard ceiling regardless of your condition, which makes it significantly shorter than California’s protections for chronic conditions, terminal illness, or pregnancy. Use the window to find a new in-network provider and transfer records and treatment plans.

To appeal a denial under a federal plan, you have four months from the denial notice to file a written request for external review. Standard federal external reviews must be completed within 45 days. Expedited reviews for medically urgent situations must be decided within 72 hours. Your doctor or another medical professional can file the external review on your behalf.⁷

Mistakes That Cost People Their Rights

Not asking. Continuity of care is a right you have to exercise. Plans don’t grant it automatically when your provider leaves, and many patients assume they have no options and start over with a new doctor mid-treatment.

Waiting too long. Even without a statutory deadline, plan contracts and regulations build one in, and 30 days is the practical outer limit. File as soon as you learn your provider is leaving or that your new plan doesn’t cover them.

Assuming the provider will participate. Some patients get approved by the plan only to find the provider has declined. If your doctor left over a payment dispute, ask their office directly whether they’d continue treating you under the plan’s terms. Knowing the answer early lets you pivot to an urgent transfer if needed.

Filing with the wrong agency. Members of self-insured employer plans sometimes complain to the DMHC and get turned away because the agency has no jurisdiction. Confirm your plan type first so your appeal goes to the right place from the start.

1
California Legislative Information. California Health and Safety Code HSC 1373.96
2
California Legislative Information. California Insurance Code 10133.56
3
Legal Information Institute. California Code of Regulations Title 28, Section 1300.67.1 – Continuity of Care
4
Department of Managed Health Care. Frequently Asked Questions
5
Office of the Law Revision Counsel. 42 U.S. Code 300gg-113 – Continuity of Care
6
Centers for Medicare and Medicaid Services. The No Surprises Act Continuity of Care, Provider Directory, and Public Disclosure Requirements
7
HealthCare.gov. External Review