Written by a parent, not a doctor. Nothing here is medical advice.

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California program

Keep your doctor and get timely plan decisions (California plan rights)

California rules that can help you keep a treating doctor and get plan decisions within set deadlines.

What it is

California rules that can help you keep a treating doctor and get plan decisions within set deadlines.

A plan change or a slow answer can disrupt treatment. These protections can help, but the plan’s regulator and the kind of request matter. Your clinic’s treatment history and request dates help establish which rule applies.

Who can get it
  • State commercial-plan rules apply to fully insured plans regulated by DMHC or CDI. Medi-Cal managed-care plans have their own clocks and continuity rules.
  • Private self-funded employer plans fall outside these state rules. Public-employer and CalPERS plans require a document-specific check.
  • Continuity requires the clinician to accept the plan’s terms. A voluntary change with an option to retain the old plan or use an out-of-network option is excluded.
What you get
  • Continued care with the same doctor in qualifying situations, up to 12 months for a serious chronic condition.
  • Ongoing specialist referrals and deadlines for plan answers.
What you get
  • An acute condition can be covered with the same clinician for its duration. A serious chronic condition can support up to 12 months.
  • Standing specialist referrals support ongoing care. When the network has no suitable specialist, an out-of-network referral can use in-network cost sharing.
  • For medical-service prior approval under the applicable California law, the plan generally has five business days after receiving the reasonably necessary information it requested. An urgent decision is generally due within 72 hours of that receipt, or sooner if your child’s condition or federal law requires it. Missing-information notices and special service rules matter. A missed deadline does not always mean approval.
  • For applicable Medi-Cal rating periods from 2026, the standard deadline is 7 calendar days from request and the urgent deadline is 72 hours.
  • Step-therapy exceptions have 72-hour standard and 24-hour urgent deadlines, with deemed approval when missed. Specified Medi-Cal contracts are excluded from that deemed-approval rule.
If you decide to apply
  1. Ask the plan’s member-services team how to request continued care or an ongoing specialist referral in writing.
  2. Ask the clinic for the treatment information and request dates. Have ready the doctor’s name and the plan document naming its regulator.

Plan member services; DMHC: 888-466-2219; CDI: 800-927-4357 · Official page ↗

What happens next
  • An approval identifies the clinician and the period of continued care.
  • The clinic can confirm what information reached the plan and when. A refusal or missed deadline can support a grievance or regulator complaint.
Good to know

The doctor must accept the plan’s terms. A voluntary switch when you could keep the old plan may not qualify.

What else to know
  • Medi-Cal members moving into managed care can have up to 12 months with an existing clinician under the applicable conditions.
  • A 2025 law phases out prior approval for services approved at least 90% of the time, by 2028 at the latest. It is not a blanket exemption now.
  • CalPERS Kaiser’s 2026 document has its own appeal and fertility-preservation terms. Other CalPERS, school-district and local-government plans need their own review.
Official sources
Ask your social worker

“If our plan changes or a decision is late, what could help our child keep the same team and avoid a gap? What conditions apply? Is a request or complaint worthwhile, and could you help us make it?”

Why I’m asking: I want to keep treatment moving if our plan changes or a decision is delayed.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the new plan in writing for continuity of care and a standing referral, keep the dates of every authorization request, and complain to the regulator when a clock is missed.

Your social worker

The clinic's authorization team knows the clocks and files the requests. The social worker can escalate a stalled one to the plan's case manager.

The care team

The oncologist writes the treatment plan the standing referral and continuity requests rest on.

Who decides
The health plan, with the state regulator enforcing on complaint
Ask your social worker
“If our plan changes, who sends the continuity-of-care request so the same oncologist stays? And when an authorization is late, who calls the plan?”

How to apply

First step: If the plan changed, call member services today and ask for continuity of care with the oncologist and a standing referral. Follow up in writing.

  1. On any plan change, ask the new plan in writing for continuity of care with the oncologist.
  2. Ask for a standing referral to the oncology team.
  3. Note the date the plan received a complete authorization request and count the clock.

Where it starts: Written request to the plan's member services; complaint to the regulator if refused

What to gather

  • The plan document page naming the regulator (DMHC or CDI)
  • The treatment plan and the oncologist's name
  • Dates of each authorization request

How long: Continuity of care is decided by the plan on request. Authorizations: 5 business days, 72 hours urgent. Medi-Cal plans: 7 calendar days, 72 hours urgent.

What a yes looks like

A written continuity-of-care approval naming the doctor and the period, and authorizations back inside the clock.

What a no looks like, and the next move

A refusal or silence past the clock. File the plan grievance and call the regulator the same week.

Watch out

  • Continuity of care starts when you ask the new plan, in writing. Do it before the first appointment on the new plan.
  • A voluntary switch, where you could have kept the old plan, does not get continuity. An employer-forced change does.
  • The authorization clock starts when the plan has everything it asked for. Ask the clinic what was sent and when.
  • A 2025 law makes plans drop prior authorization for services they approve 90% of the time, by 2028 at the latest. Not yet.
  • CalPERS Kaiser’s 2026 plan has its own appeal and fertility-preservation terms. Other CalPERS, school-district and local-government plans need their own document check. Ask the administrator before applying the private self-funded-plan exclusion.

Dates that change this

2025-10-06: SB 306 (2025): plans report authorization data by December 31, 2026 and must stop requiring prior authorization for services approved at 90% or more by January 1, 2028. Medi-Cal plans are exempt.

2026-01-01: Medi-Cal plan standard authorization decisions within 7 calendar days of the request for rating periods starting January 1, 2026.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

Same oncologist through an ongoing treatment after a plan change (up to 12 months for a serious chronic condition). Standing specialist referrals. Authorization answers in 5 business days, 72 hours urgent.

  • $12 (maximum; an acute condition for its whole duration) — Continuity of care, serious chronic condition
  • $5 (from the plan having the information it asked for) — Standard prior-authorization decision
  • $72 — Urgent prior-authorization decision
  • $72 (counts as approved if missed) — Step-therapy exception decision, nonurgent
  • $24 (counts as approved if missed) — Step-therapy exception decision, urgent
  • $7 (from the request, rating periods from 2026) — Medi-Cal plan standard authorization decision
  • $72 — Medi-Cal plan urgent authorization decision

Legal protection: Continuity of care with the same doctor after a plan change or a network exit: acute condition for its duration, serious chronic condition up to 12 months · Standing referral to a specialist for continuing care; out-of-network referral at in-network cost when the network has no suitable specialist · Step-therapy exception decided in 72 hours, 24 when urgent, or it counts as approved · A Medi-Cal member moved into a managed care plan can keep an existing provider for up to 12 months

What it costs the family: None.

The eligibility facts, as published

Plan type
fully insured plans regulated by DMHC or CDI; Medi-Cal managed care plans for the Medi-Cal clocks and continuity
Self funded
outside state rules; ask the plan for its own terms
Continuity conditions
the provider must accept the plan's terms; a voluntary plan change with an option to keep the old plan or an out-of-network option is excluded
Step therapy medi cal
the deemed-approval rule does not apply to specified Medi-Cal contracts

Decisions this site cannot make: Regulator and plan type · Plan's continuity-of-care review

Expect friction on: Requests must be in writing · The provider must agree to the plan's terms

The trap: Not asking. Continuity of care starts when you request it from the new plan, in writing, on day one.

Where I read this

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