- Participating Physician Groups (PPG)
The Department of Health Care Services (DHCS) is responsible for accepting enrollment and opt-out requests related to Cal MediConnect. DHCS may accept enrollment via telephone, mail, fax, online, or during face-to-face interviews where the applicant completes a paper form, or through other mechanisms defined by DHCS and approved by the Centers for Medicare & Medicaid Services (CMS). DHCS may encourage the use of mechanisms other than a paper form, but must accept paper enrollment requests (which may be received in person, by mail or fax) if beneficiaries choose to use one. Regardless of mechanism, DHCS must collect certain information necessary for CMS to process related transactions, and to notify beneficiaries of certain rights.
For voluntary enrollment requests, an enrollee or his or her legal representative must complete an enrollment form or other CMS-approved enrollment request mechanism to enroll in a Cal MediConnect plan and must submit the enrollment request to the DHCS. Voluntary is used to mean beneficiary-initiated elections.
Cal MediConnect plans must accept enrollment and opt-out requests it receives through DHCS. Cal MediConnect plans may not accept enrollment and opt-out requests directly from the enrollee and process such requests themselves, but instead, must forward the request to DHCS, unless DHCS has deferred enrollment activities to Cal MediConnect. Generally, beneficiaries may not request their enrollment effective date when voluntarily requesting enrollment. Furthermore, the effective date is generally not prior to the receipt of an enrollment request by DHCS. Enrollment cannot be effective prior to the date the beneficiary or his or her legal representative signed the enrollment form or submitted the enrollment request. The effective date may not be earlier than the first day of the enrollee's entitlement to Medicare Part A and Part B and Medicaid, as well as the date of eligibility for Part D and other demonstration eligibility criteria.
As long as an individual remains a Health Net Cal MediConnect member, Medicare fee-for-service (FFS) does not process claims for the medical services that the member receives. Health Net Cal MediConnect has financial responsibility for all Medicare-covered health services that the member receives, as long as the member follows the Health Net rules stated in these materials and the Cal MediConnect Member Handbook.
If a member does not select a primary care physician (PCP), Health Net uses FFS utilization data, or other data sources, including electronic data, to establish existing provider relationships for the purpose of PCP assignment a specialist or clinic, if the member indicates a preference for either. If there is no match on all of the sources that Health Net utilizes, the beneficiary is assigned a PCP closest to their residence. Health Net also uses the Health Risk Assessment (HRA) process to ensure members are informed about their ability to choose a PCP. Health Net complies with all federal and state privacy laws in the provision and use of this data.
Health Net notifies the PCP that a member has selected him or her, or the member has been assigned to the PCP by Health Net, within 10 calendar days from when selection or assignment is completed by the member or Health Net, respectively.
Health Net maintains procedures that proportionately include contracting traditional and safety-net providers in the assignment process for members who do not choose a PCP.
If, at any time, a member selects a PCP and notifies Health Net of his or her selection, the member's choice overrides Health Net's PCP assignment.
A member who is a hospital inpatient on the effective date of enrollment does not receive inpatient hospital care through the Cal MediConnect plan, but continues to obtain these benefits either through Medicare fee-for-service (FFS) or the Medicare-contracting health plan the member belonged to at the time of admission. In this situation, the plan becomes responsible on the day after discharge. The plan assumes responsibility for all other coverage (except inpatient hospital care) on the effective enrollment date.
Upon enrollment in any Health Net plan, members receive an identification (ID) card. All plan member ID cards contain the Health Net logo. Information specific to the member's coverage, may include plan name, plan type, group ID, primary care physician (PCP) office visit copayment, and supplemental benefit information, such as pharmacy coverage, located on the front of the ID card. The member's enrollment form may be used in place of the member ID card when the member requires services prior to receiving the ID card. A member ID card or enrollment form does not constitute eligibility under these plans. Participating providers must always verify eligibility prior to rendering services to any member. To verify eligibility, contact the Cal MediConnect Provider Services Department or access the website at provider.healthnet.com.
To view a sample of the ID cards, refer to the Identification Cards topic.