Overview

The Health Net Care Management program involves identifying medical need and allocating resources. The goal of care management is to ensure that all services are medically necessary, not duplicated, safe, provided at the acceptable standard of quality as measured by the professional medical community, and at the correct level of care.

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, creed, ancestry, religion, language, age, gender, marital status, sex, sexual orientation, gender identity, health status, or physical or mental disability, 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:

• Basic care management
• Comprehensive care management

Basic Care Management

At the basic level, care management is the responsibility of the primary care physician (PCP). The PCP is responsible for providing initial primary care management, maintaining continuity of care and initiating specialist care. This means providing care for the majority of health problems, including preventive care services, basic care management, acute and chronic conditions, and psychosocial problems.

Comprehensive Care Management

As a member's health care service needs increase in complexity because of a catastrophic or fragile medical condition, the case is referred to the Health Net Health Services Department, the participating physician group (PPG), or a county or state program for comprehensive care management.

Comprehensive care management is necessary when a member has multiple problems and diagnoses resulting in a high-risk catastrophic or fragile medical condition. Comprehensive care management is a collaborative process through which a Health Net registered nurse (RN) care manager assesses, plans, coordinates, monitors, and evaluates the options and services needed to meet a member's health needs and promote a positive health outcome in cooperation with the entire treatment team.

Care management involves identifying medical needs and allocating resources. The goal of care management is to ensure that all services are medically necessary, not duplicated, safe, provided at the acceptable standard of quality as measured by the professional medical community, and at the correct level of care.

Complex or comprehensive care management is not delegated to Medi-Cal PPGs