- Participating Physician Groups (PPG)
The Plan offers Ambetter HMO plans through Covered California and directly through the Plan to residents of Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino and San Diego counties. The Ambetter 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. The Ambetter HMO product also includes bronze and minimum coverage plans in Kern County only.
Members who enroll in a Ambetter HMO plan are assigned to a primary care physician (PCP) and obtain professional and institutional services through the tailored network of Ambetter HMO participating providers. A key difference between Ambetter HMO plans and other Plan HMO plans is that many physicians participating in the Ambetter HMO network are directly contracting with the Plan.
Members Assigned to Direct Network
Some Ambetter 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." or “Health Net Direct FFS Commercial”. 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 directly contracted provider in the Ambetter HMO network.
Members Assigned to a PCP Affiliated with a PPG Participating in Ambetter HMO
Some Ambetter HMO members may select and be assigned to a PCP affiliated with a PPG that is participating in the Ambetter HMO network. The member ID card reflects a specific PPG name. The PPG is responsible for medical management for these Ambetter 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.