- Participating Physician Groups (PPG)
The plan offers CommunityCare HMO plans through Covered California and directly through the plan to residents of Kern, Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties. The CommunityCare HMO product consists of platinum, gold and silver benefit plans provided through a tailored network of select providers to offer an affordable product for California residents in these counties.
Members who enroll in a CommunityCare HMO plan are assigned to a primary care physician (PCP), and obtain professional and institutional services through the tailored network of CommunityCare HMO participating providers. A key difference between CommunityCare HMO plans and other plan HMO plans is that many physicians participating in the CommunityCare HMO network are directly contracting with the plan.
Acupuncture services are administered by American Specialty Health Plans of California, Inc. (ASH). Behavioral health and substance abuse services are administered by MHN Services.
Members Assigned to Direct Network: Southern California
Some CommunityCare HMO members may select and be assigned to a directly contracting PCP for primary care services. In these cases, the member identification (ID) card reflects the participating physician group (PPG) name: "Direct Network: So. Calif." For these members, the plan is responsible for medical management, providers are required to adhere to plan prior authorization requirements and request prior authorization from the plan, and providers are required to submit claims directly to the plan. Direct Network PCPs and Essential Community Providers (in-network clinics) may refer members to any provider in the CommunityCare HMO network.
Members Assigned to a PCP Affiliated with a PPG Participating in CommunityCare HMO
Some CommunityCare HMO members may select and be assigned to a PCP affiliated with a PPG that is participating in the CommunityCare HMO network. The member ID card reflects a specific PPG name. The PPG is responsible for medical management for these CommunityCare HMO members, and providers are required to adhere to prior authorization requirements and contact the PPG for prior authorization requests. With the exception of select PPGs participating in the CommunityCare HMO network, the provider is required to submit claims directly to Health Net.