When Coverage Becomes Effective while Member is Hospitalized
Provider Type
- Physicians
- Hospitals
- Participating Physician Groups (PPG)
- Ancillary
Health Net and the participating physician group (PPG) are liable whenever a member is hospitalized either inside or outside the Health Net service area when coverage becomes effective. Health Net plans provide coverage for medical services to all members on the effective date of coverage regardless of health status. Health Net requires adherence to the following guidelines for coverage changes during hospitalization:
Health Net or the PPG must be notified that the newly covered member is confined to a hospital
- The member must be willing to receive care from the selected PPG
- If the member can be transferred, financial responsibility for the cost of transportation is based on terms of the contractual arrangement between Health Net and the PPG
- If the member can be transferred but refuses, Health Net and the PPG are not liable for any expenses relating to the hospitalization. If proper documentation has been completed, Health Net and the PPG pay for the care only when it is not medically prudent to move the member or when it is prudent, but the costs of the move would likely exceed the costs of the member remaining in a hospital where the PPG does not have privileges. Refer to the Transfer and Discharge Refusals by Hospitalized Members section for more information
- The physician from the member's new PPG should discuss the member's treatment plan with the attending non-participating physician. The member's new physician is then responsible for assuming care, and the member is obligated to follow that physician's directions
The conditions that may limit Health Net coverage for new members who are confined to a hospital may not apply if a new member declares they have not received a Health Net identification (ID) card or Health Net Evidence of Coverage (EOC) and therefore, was unaware of the proper procedures to follow when obtaining medical care.