Health Net complies with applicable federal civil rights laws and ensures that all medically necessary covered services are available and accessible to all members regardless of race, color, national origin, age, mental disability, physical disability, sex (including pregnancy, sexual orientation, and gender identity), religion, ancestry, ethnic group identification, medical condition, genetic information, marital status, or gender or identification with any other persons or groups defined in Penal Code 422.56, and that all covered services are provided in a culturally and linguistically appropriate manner.

Care management is not episodic or restricted to a single practice setting, but occurs across the continuum of care and addresses ongoing individual needs.

There are two different levels of care management:

1. Care Coordination – Appropriate for with primarily social determinants of health (SDOH) needs, such as housing, financial, etc., with the need for referrals to community resources for assistance with accessing health care services. Care coordination typically involves non-clinical activities performed by non-clinical staff; clinical staff may aid if minor health concerns arise. Services at this level of coordination include outreach to member, assistance scheduling appointments, assistance securing authorizations and follow up to ensure follow through. In addition, this level of care management is used for continuity of care transitions and supplemental support for Members managed by the county.
2. Care Management – Appropriate for members needing a higher level of service, with clinical needs. Members in care management may have a complex condition or multiple co-morbidities that are generally well-managed. Members in care management typically have adequate family or other caregiver support and need moderate to minimal assistance from a care manager. Services at this level include those provided at the level of care coordination along with identification of member agreed-upon goals, identification of actions needed to meet the goals, and necessary support to meet those goals.

CCM provides both ongoing chronic care coordination and interventions for episodic, temporary needs with a goal of regaining optimum health or improved functional capability, in the right setting and in a cost-effective manner.

CCM is for members with complex needs, including members classified as children or adults with special health care needs; those with catastrophic, high-cost, high-risk, or co-morbid conditions; those who have been non-adherent in less intensive programs; or those that are frail, elderly, disabled, or at the end of life.

CCM is provided by Health Net for members who need additional support to avoid adverse outcomes, and/or those who have experienced a critical event or have a complex diagnosis requiring oversight and coordination to ensure the member receives appropriate services and care.

Services at this level include all coordination and care management services described above, along with more frequent member contact to assess continued appropriateness and adherence with their treatment plan, and progress toward meeting goals.

Care managers monitor members’ key indicators of disease progress, e.g., hemoglobin A1c levels and medication adherence. Care managers also evaluate members for referral to enhanced care management (ECM) services as appropriate.

Some services, such as major organ transplant for members under 21, have been carved-out of the health plan and are not covered by Health Net under its Medi-Cal managed care contract with the California Department of Health Care Services (DHCS). Transplant cases for members under age 21 are managed by the state of California. County care management programs include California Children's Services (CCS), waiver and regional service programs. Refer to the Public Health topic for additional information on these programs. For a complete list of carve-out services refer to Member Handbook.

Disagreements that arise between Health Net's care management and public health case management are resolved by the Health Net Medical Management Department.