The QIHEC is led by Health Net’s Chief Medical Director for Medi-Cal and Chief Health Equity Officer and is overseen by Health Net’s Governing Board. The QIHEC meets quarterly.

External practitioners (network providers, including but not limited to hospitals, clinics, county partners, physicians, subcontractors, and downstream subcontractors) must reflect the composition of the Health Net Community Solutions’ provider network.

These members of the QIHEC must be representative of the composition of Health Net’s network providers and include, at a minimum, network providers who deliver health care services to members affected by health disparities, limited English proficiency (LEP), chronic conditions, and member populations such as children and youth with special health care needs (CYSHCN), seniors, and persons with disabilities (SPDs).

The committee must also include Health Net representatives from Behavioral Health, the Pharmacy Department, Network Management, Medical Affairs, Customer Service Operations, Credentialing, Peer Review, and Population Health & Clinical Operations (PHCO), including Utilization Management (UM) and Care Management.

QIHEC performs the following functions:

• Annually assess UM, Quality Improvement (QI), and Health Equity activities, including areas of success and needed improvements in services rendered within the QI and Health Equity program at the regional and/or county level. Conduct a quality review of all services rendered, provide results of required performance measure reporting, and report on efforts to reduce health disparities.
  • Address activities and priorities related to the Quality Improvement and Health Equity Transformation Program (QIHETP).
  • Analyze and evaluate the results of QI and Health Equity activities, including an annual review of the results of performance measures, utilization data, and consumer satisfaction surveys.
  • Institute actions to address performance deficiencies, including policy recommendations.
  • Ensure follow-up on identified performance deficiencies or gaps in care.
• Support efforts to align resources, strategies, and partners by place in order to reduce identified inequities (e.g., via use of Health Equity Improvement Zones).
• Identify differences in quality of care and utilization of physical and behavioral health care services for members who are directly managed or delegated to providers.
• Ensure that all interventions to address differences in quality of care and utilization have an equity focus, including addressing underlying factors such as social determinants of health (SDoH).
• Review performance measure results and address deficiencies, including results and deficiencies of all fully delegated subcontractors.
• Review progress summaries from Joint Operating Meetings.
• Ensure connectedness to the findings, recommendations and actions from the Quality Improvement Committee, Community Advisory Committees (CAC) and Public Policy Committee to drive aligned decisions and programming.
• Ensure member confidentiality is maintained in QI discussions and avoid conflict of interest among the QIHEC members.
• The QIHEC shall provide input and advice on the following non-exclusive list of topics:
  • Population Health Management.
  • Health Delivery System Reform to improve health outcomes.
  • Coordination of Care.
  • Clinical quality of physical and behavioral health care.
  • Access to primary and specialty health care providers and services.
  • Member experience with respect to clinical quality, access, availability, and culturally and linguistically competent health care and services, continuity and coordination of care.
  • Non-Specialty Mental Health Services (NSMHS) member and PCP outreach and education plan.
• QIHEC is responsible for adequately addressing recommendations put forth by the CAC and providing feedback through a dashboard that outlines progress and decisions on recommendations.
  • For recommendations that the QIHEC is unable to reasonably address, a CAC may opt to escalate its recommendation to the Health Net Community Solutions (HNCS) Board of Directors for further review and consideration.
• Form and delegate authority to subcommittees when appropriate; and
• Review and reassess the adequacy of the charter annually and recommend any proposed changes to the Board for approval. The Committee shall annually review its own performance.

Refer to the Community Advisory Committee section.

The Credentialing/Peer Review Committee verifies practitioners and organizational providers who contract to provide services to Health Net members, ensuring they meet established standards for training, licensure, competency, and qualifications.

The Credentialing Committee ensures that Health Net's credentialing and recredentialing criteria for participation in the network are met and maintained across all lines of business, as defined by the regional health plans.

QIHEC delegates authority and responsibility for credentialing and recredentialing peer review activities to this committee.

This committee oversees peer review activities and makes decisions regarding quality improvement follow-up on service and clinical matters, including quality of care cases. It also provides a forum for instituting corrective actions, as needed, and assesses the effectiveness of these interventions through systematic follow-up across all lines of business, including inpatient and outpatient care and services.

This committee reports quarterly to the QIHEC and provides a summary of activities to the Health Net Board of Directors and DHCS.

Membership includes practicing medical directors or practitioners (representing primary and specialty disciplines) from PPGs across each region (Northern, Central and Southern California).

The corporate pharmacy division of Centene Corporation, Centene Pharmacy Services, and the Health Net Pharmacy Department provide pharmacy management and administration of prescription and medical drug benefits for Health Net members.

Health Net Pharmacy Directors manage the organizations pharmaceutical services.

The Health Net Pharmacy Advisory Committee (PAC) provides feedback to the Corporate Pharmacy and Therapeutics (P&T) Committee.

The Corporate P&T committee includes a Medical Director, Director of Pharmacy, practicing network physicians from various specialty areas, and community pharmacists.

The Health Net PAC reports to the Quality Improvement/Health Equity Committee which reports to the Health Plan Board of Directors.

The Health Net PAC meets at least quarterly. Responsibilities include reviewing the quality, effectiveness and safety of new medications, therapeutic classes and conversion programs, as well as the review and adoption of Corporate P&T guidelines.

Health Net policies and procedures determine whether medications are added to formularies or drug lists, the level of benefit, and any applicable limitations.

These guidelines also establish a standardized process for requesting and approving additions to the drug lists at the request of a provider or committee member.

California may have Corporate P&T-approved variations based on state and product differences in benefit design and pharmacy coverage.

A summary of drug list (Formulary) provisions is available in the Provider Policy Manuals. Members may obtain a copy by contacting Member Services or online.

Centene Pharmacy Services processes prior authorization requests for medication and formulary exceptions.

The Director of Pharmacy, a registered pharmacist, or their registered pharmacist designee, reviews all denials.

A Medical Director may be consulted to review requests that do not meet clinical guidelines, medical necessity criteria, or involve experimental or investigational determinations.

Programs are developed to ensure safe and appropriate utilization of pharmaceuticals.

Health Net may delegate responsibility for activities associated with utilization management (UM) and administrative services to its PPGs.

The Health Net Delegation Oversight Committee (DOC):

The Specialty Network Committee sets standards for Health Net participating transplant performance centers and bariatric performance centers, guides members to specialty network providers, monitors performance, issues requests for CAPs, and reports to HNQIC.

Theis committee meets at least six times per year and reports annually to HNQIC.

Behavioral Health Medical Directors consider a number of resources in this process, including internal research on the effectiveness of guideline elements, a review of relevant literature, and guidelines from professional organizations.

Guidelines are drafted and then reviewed by Medical Directors. The Medical Directors then submit the guidelines to the Medical Affairs Committee (MAC) with a recommendation that it approve them. The MAC makes the final decision to approve and adopt the guidelines.

• Medication Assisted Treatment Guidelines for Substance Use Disorders
• Criteria and Guidelines for Authorization of Psychological and Neuropsychological Testing
• Criteria and Standards for Utilizing Single Case Agreements
• Harm Reduction in Substance Use Disorder Treatment
• Ketamine Use for Treatment Resistant Depression or Post-Traumatic Stress Disorder
• Treatment of Highly Specialized Populations
• Utilization of Intranasal Spray of Spravato (esketamine) for the Treatment of Treatment- Resistant Depression
• Wilderness Program Treatment

• Medical necessity
• When a therapist is seeing more than one family member at a time in outpatient treatment
• When a therapist is seeing a member more than once weekly in outpatient treatment
• Dual/multiple relationships with patients
• CMS national and local coverage determinations

A hard copy of these documents may be obtained by calling Behavioral Health Provider Services or by accessing the Health Net website.