- Participating Physician Groups (PPG)
A Medicare beneficiary must complete and sign the individual election form when enrolling in the Health Net Medicare Advantage (MA) plan. If another person assists the beneficiary in completing the individual election form, that person must also sign the form. If the individual cannot sign, a court-appointed legal guardian or person with durable power of attorney for health care (DPAHC) or designated in a written advance directive, if authorized by state law, must sign. Proof of legal guardian, DPAHC, written advance directive, or proof of authorization by state law is only required when the designated representative is not signing the application that includes the attestation of legal representation. The member's current Medicare coverage continues until the member's coverage with Health Net MA begins.
Generally, the member's enrollment becomes effective the first day of the following month after an election is made. The member's enrollment under any other MA organization or competitive medical plan (CMP) terminates on the effective date of enrollment in the Health Net MA plan. Likewise, enrollment in any other Medicare-contracting health plan or CMP automatically terminates enrollment in the Health Net MA plan.
As long as an individual remains a Health Net MA member, Medicare fee-for-service (FFS) does not process claims for the medical services that the member receives. Health Net MA has financial responsibility for all Medicare-covered health services that the member receives, as long as the member follows the Health Net MA rules stated in these materials and the member's Evidence of Coverage (EOC).
Medicare Advantage HMO
Upon enrollment, Health Net MA members are required to select a Health Net participating primary care physician (PCP) or participating physician group (PPG). The PCP or PPG is responsible for providing or coordinating all of the member's care. By enrolling in the Health Net MA plan, the member agrees to obtain all covered benefits through their Health Net participating PCP or PPG providers, except for emergency, out-of-area urgently needed services, and out-of-area renal dialysis. Additionally, upon enrollment, the member agrees to abide by the rules of Health Net MA.
The Medicare-eligible beneficiary must submit a completed Health Net Medicare Advantage (MA) enrollment application, including the signature of the beneficiary and the signature of anyone who assists the beneficiary in completing the application. If the individual cannot sign, a court-appointed legal guardian or person with durable power of attorney for health care (DPAHC) or designated in a written advance directive, if authorized by state law, must sign. Proof of legal guardian, DPAHC, written advance directive, or proof of authorization by state law is only required when the designated representative is not signing the application that includes the attestation of legal representation. The application must be signed by the Medicare-eligible beneficiary prior to the effective date of coverage. No proof of insurability is required. The Medicare eligible beneficiary may be required to submit proof of Medicare Part A and Part B entitlement.
Before joining the Health Net Medicare Advantage (MA) plan, Medicare-eligible beneficiaries should be aware of the lock-in provision that requires the member to obtain most medical care through Health Net MA. This provision is applicable beginning on the effective date of coverage.
Health Net offers the MA plan through a contract with the Centers for Medicare and Medicaid Services (CMS), the government agency that administers the Medicare program. Under this contract, the government agrees to pay Health Net a fixed monthly amount to provide health care to the member.
While a member is enrolled in a Health Net MA plan, Medicare does not pay anyone other than Health Net for the member's health care. Neither Health Net nor Medicare pays for services provided outside of the Health Net MA plan service area, except emergency or out-of-area urgently needed services.
A member who is a hospital inpatient on the effective date of enrollment does not receive inpatient hospital care through the Medicare plan, but continues to obtain these benefits either through Medicare fee-for-service (FFS) or the Medicare-contracting health plan the member belonged to at the time of admission. In this situation, the plan becomes responsible on the day after discharge. the plan assumes responsibility for all other coverage (except inpatient hospital care) on the effective enrollment date.
Upon enrollment in any plan, members receive an identification (ID) card. All plan member ID cards contain the Health Net logo. Information specific to the member's coverage, may include plan name, plan type, group ID, primary care physician (PCP) office visit copayment, and supplemental benefit information, such as pharmacy coverage, located on the front of the ID card. The member's enrollment form may be used in place of the member ID card when the member requires services prior to receiving the ID card. A member ID card or enrollment form does not constitute eligibility under these plans. Participating providers must always verify eligibility prior to rendering services to any member.
To view a sample of the ID cards, refer to the Identification Cards topic.