Coverage
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Durable medical equipment (DME), including respiratory equipment and wheelchairs as defined by Health Net using Medicare guidelines, is covered when determined to be medically necessary and ordered or approved through the participating physician group (PPG) or Health Net in accordance with policies established by the PPG, Health Net and Medicare.
To ensure appropriate coverage of medical services for Health Net members, Health Net requires that members be provided with timely responses and accurate information. If prompt and accurate information is not provided, a member may misuse the program, resulting in non-coverage of medical items or required coverage of unnecessary items.
Capitation is applicable to certain membership assigned to select PPGs. The Division of Financial Responsibility (DOFR) allows a PPG to participate in ancillary DME capitation with Apria Healthcare for most DME items.
DME benefits include but are not limited to:
- Braces - Orthopedic appliance or apparatus used to support, align, prevent, or correct deformities, or to improve the function of moveable parts of the body. Coverage includes leg, arm, back, and neck braces, and trusses. Back braces include special corsets and sacroiliac, sacrolumbar and dorsolumbar corsets and belts
- Canes
- Crutches
- Insulin pumps, when specific medical criteria are met. For more information, refer to Health Net's medical policy on insulin pumps, available on the Health Net provider website
- Orthopedic shoes, if they are an integral part of a leg brace
- Oxygen
- Seat lift (only the seat-lift mechanism is covered, not the chair itself); when specific medical criteria are met
- Custom footwear and custom shoe inserts; for members with diabetes and members with the extra foot orthotic benefit. Includes one pair of extra depth or custom molded shoes (including non-customized removable inserts provided with the shoes) and/or three pairs of inserts each calendar year
- Orthotics, as defined as rigid or semi-rigid device affixed to the body externally and required to support or correct a defect of form or function of a permanently inoperative or malfunctioning body part or to restrict motion in a diseased or injured part of the body
- Walkers
- Wheelchairs, including manual and motorized vehicles
- Whirlpool bath equipment - Covered if member is homebound and has a condition for which the whirlpool bath would provide substantial therapeutic benefits. Requests are reviewed case-by-case
- Power-operated vehicle (POV) or scooter
Diabetic supplies
Health Net Medicare Advantage members can obtain diabetic supplies, including blood glucose test strips and lancets, through any Health Net network pharmacies. Diabetic supplies require a prescription.
For Medicare only, please note, certain Health Net Employer Group plans may have a different benefit start date. Contact Pharmacy Services for more details for Employer Group plans.
Health Net network pharmacies can provide the following preferred brands:
Blood glucose meters:
- OneTouch® by LifeScan, Inc.
- OneTouch Verio Flex® Meter
- OneTouch Verio Reflect® Meter
- OneTouch® UltraMiniTM Meter
- OneTouch® Ultra® 2 Meter
- OneTouch® Verio Meter
- OneTouch® Verio® IQ Meter
- Accu-Chek® by Roche Diabetes Care, Inc.
- Accu-Chek® Guide Me Meter
- Accu-Chek® Guide Meter
- Accu-Chek® Aviva Plus Meter
- Accu-Chek® Nano SmartView Meter
Test Strips:
- OneTouch®:
- OneTouch Verio®
- OneTouch Ultra®
- Accu-Chek®:
- Accu-Chek® SmartView
- Accu-Chek® Guide
- Accu-Chek® Compact Plus
- Accu-Chek® Aviva Plus
Note: All other non-preferred brand blood glucose meters and test strips require prior authorization. Continuous glucose monitoring systems and supplies require prior authorization.
An updated list of covered diabetes testing supplies can be found on our website.
Non-covered items include:
- Exercycles
- Elastic stockings, job stockings and support hose; garter belts and similar devices, as they are not considered braces
- Foot supportive devices, whether custom-made (orthotics) or stock pre-made (arch supports, inserts, heel and sole lifts, and heel wedges or pads), unless they are an integral part of a leg brace
- Ambulatory blood pressure monitoring with automatic or semi-automatic (patient-activated) portable monitors - Not covered for hypertensive members, but may be covered if prescribed by a physician for use as part of home dialysis delivery system
- Modification of automobiles/or other highway motor vehicles
- Books or other items of a primarily educational nature
- Air conditioners, air filters or heaters
- Food blenders
- Reading lamps, or other lighting devices
- Bicycles, tricycles or exercise equipment (generally)
- Televisions
- Orthopedic mattresses, recliners, rockers, seat lift chairs, or other furniture items
- Waterbeds
- Household items
- Other items not generally used primarily for health care and which are regularly and primarily used by persons who do not have a specific medical need for them
Durable medical equipment (DME), including blood glucose monitors, test strips and lancets, as defined by Health Net using Medicare guidelines, is covered when determined to be medically necessary.
DME includes:
- Brace - Orthopedic appliance or apparatus used to support, align, prevent, or correct deformities, or to improve the function of moveable parts of the body. Coverage includes leg, arm, back, and neck braces and trusses. Back braces include special corsets and sacroiliac, sacrolumbar and dorsolumbar corsets and belts
- Canes
- Crutches
- Blood glucose monitoring devices, if authorized. Blood glucose test strips and lancets are covered under the pharmacy benefit. Insulin-dependent and non-insulin-dependent diabetics may receive these supplies:
- Members are offered blood glucose monitoring devices and supplies as listed in the Health Net Recommended Drug List (RDL). New members may change their current blood glucose monitoring device for one of the preferred brands at no charge
- Medicare Advantage (MA) and Medicare Advantage Part D (MA-PD) members may obtain blood glucose monitoring equipment and supplies by contacting the Health Net Medicare Advantage (MA) Member Services Department. For Medicare Prescription Drug Plan (PDP) members, pharmacies should bill Medicare directly for blood glucose monitoring equipment and supplies
For the MA population assigned to participating physician groups (PPGs) with ancillary capitation, glucose monitors are covered under ancillary capitation, since coverage is via the DME benefit.
- Insulin pumps; when specific medical criteria are met. Refer to Health Net's medical policy on insulin pumps, available on provider.healthnet.com, for more information
- Orthopedic shoes, if they are an integral part of a leg brace
- Oxygen
- Power-operated vehicle (POV) or scooter
- Seat lift (only the seat lift mechanism is covered, not the chair itself); when specific medical criteria are met
- Custom footwear and custom shoe inserts - For members with diabetes and members with the extra foot orthotic benefit. Includes one pair of extra depth or custom molded shoes (including non-customized removable inserts provided with the shoes) and/or three pairs of inserts each calendar year
- Orthotics, as defined as rigid or semi-rigid device affixed to the body externally and required to support or correct a defect of form or function of a permanently inoperative or malfunctioning body part or to restrict motion in a diseased or injured part of the body
- Walkers
- Wheelchairs - Manual and motorized vehicles are included
- Whirlpool bath equipment - Covered if member is homebound and has a condition for which the whirlpool bath would provide substantial therapeutic benefits. Requests are reviewed case-by-case
Non-covered items include:
- Exercycles
- Elastic stockings, job stockings and support hose; garter belts and similar devices, as they are not considered braces
- Foot supportive devices, whether custom-made (orthotics) or stock pre-made (arch supports, inserts, heel and sole lifts, and heel wedges or pads), unless they are an integral part of a leg brace or the member is a diabetic or has the extra foot orthotic benefit
- Ambulatory blood pressure monitoring with automatic or semi-automatic (patient-activated) portable monitors - Not covered for hypertensive members, but may be covered if prescribed by a physician for use as part of home dialysis delivery system
- More than one piece of the same equipment at a time