Transfer Reinsurance
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
Health Net's member transfer policy allows members undergoing medical treatment to transfer to an alternate participating physician group (PPG). The Transfer Reinsurance program is designed to mitigate PPG and hospital financial risk under the member transfer policy. This program is offered in Los Angeles, Riverside, and San Bernardino counties. Health Net reserves the right to discontinue this program after any calendar year. Unless otherwise provided in the Provider Participation Agreement (PPA), the terms of the Transfer Reinsurance program are described below.
Hospitalized members are required to wait until they are discharged before Health Net approves a transfer, and members must work or live within the service area of the selected PPG.
Cost
The cost of transfer reinsurance is stated in each PPG's and hospital's PPA. The cost is split with capitated hospitals, if applicable. Shared-risk PPGs and hospitals have the cost of transfer insurance deducted equally from professional capitation and the shared-risk pool.
Exclusions
The Transfer Reinsurance program does not include members enrolled in Medicare Supplement, Flex-Funded, and Point-of-Service (POS) benefit programs. Requests for payment of costs related to claims of treating providers for services to members assigned to a PPG through new member or open enrollment or due to a change of home or work address, are not eligible for payment under the Transfer Reinsurance program.
Members covered under the Special-Risk Reinsurance program do not qualify for coverage under this program.
If a member qualifies for coverage under the Transfer Reinsurance program and another Health Net reinsurance program, the other reinsurance program applies.
Thresholds
The PPG's cost for services provided to the member must reach the threshold amounts stated in the hospital or PPG PPA before the Transfer Reinsurance program covers costs for treating providers' claims related to any service. These threshold amounts must be incurred within 180 days of the effective date of the member's transfer and assignment to the PPG in order for transfer reinsurance to take effect.
Requests for Payment Submission
Submit requests for payment on a Health Net PPG professional Batch form (PDF), with Transfer Reinsurance written at the top, to the Health Net Reinsurance Unit. Requests for payment must be submitted within 120 calendar days after meeting the threshold.