Complex Cancer Care
Provider Type
- Physicians and Practitioners
- Hospitals
- Participating Physician Groups (PPG)
- Ancillary
Medi-Cal members with a qualifying complex cancer diagnosis can request a referral from their provider to get medically needed care from a contracted cancer center (Medi-Cal, CalViva Health, Community Health Plan of Imperial Valley), such as a:
- National Cancer Institute (NCI)-designated comprehensive cancer center,
- Site affiliated with the NCI Community Oncology Research Program (NCORP), or
- Qualifying academic cancer center.
Members also have the option to request treatment at an out-of-network cancer treatment provider.
What is a complex cancer diagnosis?
A complex cancer diagnosis is one for which there is no standard FDA-approved treatment or for which known, highly effective therapy for metastatic cancer has failed, such as the diagnoses listed below. These diagnoses are subject to updates.
- Hematological: Blood disorders/diseases, malignancies.
- Acute leukemia.
- Advanced, relapsed, refractory non-Hodgkin lymphoma and multiple myeloma including blastic plasmacytoid dendritic cell neoplasm (BPDCN) and T-cell leukemias and lymphomas.
- Solid Tumors: Advanced stage (stage IV metastatic cancer), relapsed solid tumors refractory to standard FDA-approved treatment options.
- Rare Cancers: Advanced stage rare solid tumors for which there is no known effective standard treatment options.
How referrals to an out-of-network cancer center work
A member may get medically needed services from an out-of-network provider if all attempts to find an in-network provider have been exhausted. A payment agreement must be in place with Health Net (i.e., letter of agreement or LOA). This includes:
- When a member requests a referral through an out-of-network NCI-designated comprehensive cancer center, out-of-network NCORP-affiliated site, or out-of-network qualifying academic cancer center, or chooses a different type of cancer treatment provider,
or
- When an NCI-designated comprehensive cancer center, NCORP-affiliated site, or qualifying academic cancer center refers a member diagnosed with a complex cancer to an out-of-network specialist.