Member Cost-Sharing Protections
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
- Pursuant to The Social Security Act section 1932(b)(6) and 42 USC section 1396u-2(b)(6), Health Net and all of its subcontractors must not hold a member liable for any of the following:
- Debts of Health Net in the event of Health Net’s insolvency;
- Payment for covered services provided by Health Net if Health Net has not received payment from the Department of Health Care Services (DHCS), or if a provider, under an agreement or other arrangement with Health Net, fails to receive payment from either DHCS or Health Net; or
- When payments to a provider that furnishes covered services under an agreement or other arrangement with Health Net are in excess of the amount that normally would be paid by the member if the service had been received directly from Health Net.
- Health Net, including its network providers and subcontractors, must not bill a member for any covered services provided under this contract. Health Net must assure that all network provider agreements include requirements whereby the member must be held harmless for charges for any covered services.
- Health Net and its network providers are prohibited from imposing on members cost-sharing requirements. Health Net’s subcontractor agreements and network provider agreements must specify that a provider agrees to accept Health Net’s reimbursement as payment in full for services rendered to members.