Adding and Deleting Members

Adding Members

Health Net discourages employer groups from retroactively adding members after the applicable monthly billing is reconciled. Only unavoidable administrative errors by the group or its agent may form a basis for retroactively adding a new member after the monthly billing has been reconciled. Health Net may make exceptions for groups that pay a super-composite rate or when a newly eligible dependent must be added to an existing family contract.

If Health Net must retroactively assign a new member to a participating physician group (PPG), capitation payment for that member is made and the PPG is responsible for all services due to the member from the date the member became eligible.

The Evidence of Coverage (EOC) issued to members upon enrollment informs them that they have 30 days from the date of acquiring a dependent to add the dependent to the contract (certain employer groups have exceptions to the 30-day enrollment time limit). After 30 days, the subscriber must wait until the employer's open enrollment or other qualifying event to make the addition. It may take up to three months before the dependent appears on the PPG Eligibility Report, due to the employer group's Health Net billing cycle.

The EOC also instructs subscribers to add dependents within the required time. Health Net encourages the PPG to urge the subscriber to add the member officially through the employer's human resources office (or Health Net, if a non-group conversion) as soon as possible in order to avoid problems that can arise if the member is not timely added.

Exceptions to this time limit exist. The 30-day requirement is waived when subscribers are already on a family contract or are employed by an employer group that pays a super-composite rate.

The PPG must continue to provide care to the dependent even if that individual does not appear on the Eligibility Report after 30 days. Members must sign an Eligibility Certification before services are provided. Contact the Health Net Provider Services Center for assistance in determining whether the contract provision applies in a particular case.

Deleting Members

If Health Net terminates the coverage of any member covered under the group agreement, the prepaid subscription charges received by Health Net applicable to periods after the cancellation date are refunded within 30 days. Neither Health Net nor any participating provider has any further responsibility to the member.

In the event of a retroactive cancellation, retroactive capitation adjustments are made in accordance with the Provider Participation Agreement (PPA).