Medi-Cal Managed Care
- Participating Physician Groups (PPG)
The Department of Health Care Services (DHCS) administers the state's Medi-Cal managed care programs. Medi-Cal managed care differs from commercial managed care in that it integrates private health care with publicly funded health programs.
Health Net's Medi-Cal managed care service area includes the counties of Kern, Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare. In Riverside and San Bernardino counties, Health Net is a subcontracting health plan to Molina Healthcare. Additionally, Health Net is a subcontracting health plan for CalViva Health in Fresno, Kings and Madera counties.
In Kern, Los Angeles, San Joaquin, Stanislaus, and Tulare counties, Medi-Cal beneficiaries have the option of enrolling in Health Net, the mainstream or commercial plan in the state's Two-Plan Managed Care Program. In Los Angeles County, Health Net subcontracts with Molina Healthcare to provide care for approximately one-third of Health Net's Medi-Cal beneficiaries. All of these members have Health Net identification cards. Providers must follow the prior authorization and utilization management (UM) procedures of Molina for its assigned Health Net fee-for-service (FFS) members, or the procedures of the participating physician group (PPG) for capitated members.
CalViva Health is the local initiative health plan for the Medi-Cal managed care counties in Fresno, Kings and Madera. CalViva Health is partnering with Health Net to serve Medi-Cal beneficiaries in these counties. Under the direction of the Fresno-Kings-Madera Regional Health Authority, CalViva Health selected Health Net as its contractor to provide administrative and network services under the Two-Plan model expansion in the three-county region. Health Net continues to hold most provider network contracts in Fresno, Kings and Madera counties as CalViva Health's subcontractor.
Health Net Medi-Cal members in Sacramento and San Diego counties are participants in the Geographic Managed Care (GMC) program. The benefits under the GMC program are very similar to the Two-Plan Managed Care program benefits with a few minor variations.
In Riverside and San Bernardino counties, Health Net is a subcontracting health plan to Molina. These members have Molina identification cards. Providers must follow the prior authorization and UM procedures of Health Net for FFS members or the procedures of the PPG for capitated members in these two counties.