Continuity of Care
- Participating Physician Groups (PPG)
Health Net does not delegate the approval and review of requested continuity of care to its participating physician groups (PPGs). Health Net conducts the continuity of care review, and expects delegated PPGs to ensure that members continue to have access to medically necessary items, services, and medical and long-term services and support (LTSS) providers as described below. Health Net and PPGs allow members to maintain their current providers and services authorizations for a period of 6 months for Medicare services and 12 months for Medi-Cal services if the following criteria are met:
- The member has an existing relationship with the provider prior to enrollment by identifying whether the member has seen the requested out-of-network primary care physician (PCP) at least once within the previous 12 months from the date of enrollment and a requested out-of-network specialist at least twice within the previous 12 months from the date of enrollment.
- The out-of-network provider is willing to accept payment from Health Net based on the current Medicare or Medi-Cal fee schedule as applicable.
- If the out-of-network provider does not agree to a rate, or Health Net has a documented quality of care issue with the provider, the member will be offered an in-network alternative, and assisted to an in-network alternative if an offer is not selected.
- Health Net has not excluded the provider from its network due to documented quality of care concerns or state or federal exclusion requirements.
If a member is receiving services that are not covered by Heath Net after the continuity of care period, Health Net notifies the member prior to the end of the continuity of care.