Out-of-State Dialysis

If an end-stage renal disease (ESRD) member receiving dialysis informs the participating physician group (PPG) of an intention to travel within the United States, making it impossible for the member to use the customary in-area services or facilities, the PPG must:

• Authorize dialysis services by other providers
• Arrange for the services to be performed by providers in the member's temporary location
• Inform the member that it may be necessary to change the type of setting in which dialysis is performed, because local circumstances may not allow the same type of setting to be used.
• Authorize the services for the length of the planned trip
• Inform the member in writing about the details of what has been authorized and state that, if travel plans change and additional time is needed, the member must inform the PPG. If the member extends the duration of the trip and informs the PPG, a one-time modification of the authorization is made to cover the additional time period

Costs are borne in the same manner as if the member received the services within the PPG service area. Dialysis services are not covered if received outside the United States, except emergency services requiring hospitalization are covered outside the United States in Canada or Mexico.

Medi-Cal members diagnosed with ESRD are eligible for Medicare coverage after a four-month waiting period. If a Medi-Cal member requires dialysis and is under age 21 years, the member must be referred to the California Children's Services (CCS) program. Health Net's care managers assist primary care physicians (PCPs) in ensuring timely referral to the CCS program. Refer to the CCS Program Overview for information on participating providers' responsibilities for referring potential eligible members to CCS and for identifying CCS-eligible conditions.

If the Medi-Cal member is over age 21 for chronic hemodialysis or chronic peritoneal dialysis, the member becomes eligibile for Medicare and the PPG, Health Net or the dialysis center should initiate the Medicare application. Health Net only provides dialysis until Medicare eligibility becomes effective. Given that Medicare is the primary payer before Medi-Cal, PPGs should verify Medicare eligibility and enrollment for any Medi-Cal member diagnosed with ESRD prior to authorizing and billing for dialysis services.