Complex Cancer Care

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), 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 includes those listed below. These diagnoses are subject to updates.

• 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;
• Advanced stage (stage IV metastatic cancer), relapsed solid tumors refractory to standard FDA-approved treatment options; and
• 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 can get medically needed services from an out-of-network provider but there must be a payment agreement 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 a member 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.