Out-of-Area Dialysis for ESRD

Health Net provides benefits for dialysis services rendered when a member is temporarily outside the Health Net service area under the following conditions:

• When the emergency arises from accident, injury or illness
• Where the health of the member would be endangered if they traveled to return to the Health Net service area
• When it is customary practice in border communities for members to use medical resources in adjacent areas outside the Health Net service area
• When an out-of-area treatment plan has been proposed by the member's primary care physician (PCP) and the proposed plan has been received, reviewed and authorized before services are provided. Health Net may authorized such out-of-area treatment plans only when the proposed treatment is not available from resources and facilities with the Health Net service area

Before leaving the service area, members should contact Health Net's Member Services Department for assistance in coordinating dialysis services when out of area.

If a Medicare Advantage (MA) member has not moved from Health Net's service area, but has left the service area for more than six months, Health Net must disenroll the member from the Health Net MA plan.

Prior Authorization for Out-of-Area Dialysis

Health Net does not require prior authorization or advance notification for dialysis services as a condition of coverage when a member is temporarily absent from Health Net's service area.

For purposes of coordinating member care, Health Net requests that members inform their primary care physician (PCP), participating physician group (PPG) or Health Net when the member needs dialysis services while temporarily outside the provider's or Health Net's service area. Providers may offer medical advice and recommendations of Medicare-approved dialysis facilities in the area for the member. Health Net provides benefits to Medicare-approved dialysis facilities the member independently selects while temporarily outside the PCPs, PPGs or Health Net service area.

Out-of-Country Dialysis

Non-emergency dialysis received outside the United States is not covered. This includes all outpatient dialysis received by members presently diagnosed with end-stage renal disease (ESRD) and already receiving dialysis services.