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20-737 Get Ready for Changes to the Medi-Cal Subnetwork Certification Assessment and Attend Upcoming Webinar

Date: 09/18/20

This information applies to Participating Physician Groups (PPGs).

For Medi-Cal, this information applies to Kern, Los Angeles, Sacramento, San Diego, San Joaquin, Stanislaus, and Tulare counties.

The assessment of subnetworks starts in August 2020 through January 2021

In accordance with regulatory requirements set forth by the Department of Health Care Services (DHCS), Health Net is required to assess and certify our participating physician groups (PPGs) for network adequacy and certify the network by March 2021, and annually thereafter.

Health Net’s capitated delegated PPGs must demonstrate that they maintain a network adequate to service adult and pediatric members within the PPG’s service area based on the number of providers, provider types and geographic location of providers.

Health Net will conduct the annual network adequacy assessment of its PPGs for the scope of at-risk services for which they are contracted to provide based on their service area.

Assessment categories include:

  • Provider to Member Ratios - PPG must meet provider to member ratios for Primary Care Physicians (PCP) and total network physicians.
  • Mandatory Provider Types - PPG must offer to contract with Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) and Indian Health Facilities (IHF) in their service areas where available, and must contract with at least one (1) of each FQHC, RHC, certified nurse midwife (CNM) and licensed midwife (LM) in their service areas, where available.
  • Time and Distance - PPG must meet time and distance to care for required adult and pediatric primary care and specialty care.
  • Timely Access - PPG must meet appointment access standards for primary care, specialty care, after-hours access and instruction as relevant to provider types.

PPGs are required to ensure members are receiving timely appointments per state requirements, and that services can be obtained within the applicable time and distance standards.

In areas where the network may not be adequate, the PPG must allow members to access services out of network (OON) for any deficient network components.

If deficiencies exist, physician or provider cannot restrict members’ access to practitioners within its own provider network, and must authorize services for OON providers when medically necessary.

Prepare for the upcoming assessment

To prepare for the assessment, reference Provider Update 19-678 sent on September 30, 2019 for Review Access to Care Standards, available on the Provider Library under Medi-Cal > Updates and Letters.

The Provider Update covers topics such as medical appointment access standards, required specialties and time and distance to care. PPGs are encouraged to review its network and ensure the provider information is correct when rosters are sent to Health Net. This includes the correct adult and pediatric provider types as well as the patient age range. This information will be displayed in the online and hard-copy provider directories for members.

Impact of not meeting standards

PPGs are subject to a corrective action plan and possibly an impact to network participation if one or more network adequacy standards are not met. Providers can work with their Health Net Provider Relations Contracting Specialist if they have questions or concerns about their ability to meet these standards.

Upcoming provider webinar

Join our upcoming webinars to learn about access requirements, and get tips on how to meet performance goals.  The webinars are scheduled for the dates listed.

  • Friday, September 25, 2020 at 1 p.m.
  • Wednesday, September 30, 2020 at 1 p.m.

The registration links will also be available on the Health Net Provider Portal.

Additional information

Providers are encouraged to access the Provider Portal online for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 1-800-675-6110.



Last Updated: 09/22/2020