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Employee Health Systems – Multicultural Medical Group

Employee Health Systems – Multicultural Medical Group

Due to direction from the California Department of Managed Health Care, Health Net is moving members who receive care from Employee Health Systems Medical Group (EHS) and Multicultural Medical Group to new Participating Medical Groups and (in some cases) to new Primary Care Physicians. The reason for the move is to ensure uninterrupted access to care.

Health Net is committed to helping ensure a smooth transition. Please see below for answers to commonly asked questions that may apply to you if you currently receive care from an EHS or Multicultural physician.

If you need additional help, please call 1-844-442-5047.

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  • Will I keep my EHS or Multicultural primary care physician?
    • In most cases, EHS and Multicultural physicians are available to Health Net members through other contracted participating provider groups (PPGs), clinics and Health Net’s Direct Network.

      In some cases, EHS and Multicultural members will be moved to new primary care physicians (PCPs) so they have uninterrupted access to care.

      The notification letter you received from Health Net in early January explains whether you will be able to continue seeing your current PCP. (If you have Medi-Cal coverage and live in either Riverside or San Bernardino counties, your notification letter came from Molina Healthcare.)

      If you would like to select a PCP other than the one we moved you to, please call us at 1-844-442-5047.

      If you have Medi-Cal coverage and live in either Riverside or San Bernardino counties, you may call Molina Healthcare at 1-888-665-4621 to select a new PCP.

  • Will I retain my specialists?
    • Many specialists contract with more than one PPG – or they may have a Direct Network relationship with Health Net – so there is a good chance the specialist you now see is contracted with Health Net.

      However, if the specialists you currently see are not contracted with the new PPG you were assigned to, they may be contracted with other PPGs. That may mean you would have to change PCPs so that you can continue to see your specialists.

      For help in determining whether a particular specialist is contracted with your new PPG, please call our dedicated phone representatives at 1-844-442-5047.

  • Will I continue using the same hospital as before?
    • The hospital you use will depend on what hospitals your new PPG and your PCP use.

  • What if I have doctor visits or other services (such as specialist care, hospitalization, pregnancy, or treatment for ongoing, chronic conditions) authorized and scheduled by EHS/Multicultural after January 31, 2018? Can I keep those appointments?
    • Yes, for certain services that meet our “transition of care” guidelines. The notification letter you received from Health Net had a Transition of Care form in it. You may fill it out and return it to us, or you may call us at:

      Medi-Cal: 800-675-6110
      CalViva Health: 1-888-893-1569
      Medicare: 1-800-275-4737
      Commercial: 1-800-522-0088

  • Where will I go for laboratory or radiology services?
    • Please contact the PCP we assigned you to for direction on which laboratories and radiology services to use.

  • Will my new doctor have access to my medical records?
    • Yes. If you are assigned to a new doctor, you can request your previous doctor send him or her your medical records. You may contact your previous PCP for more information.

  • Will this network change cost me anything in copayments or other charges?
    • No, your benefits are not changing.

  • I have several prescriptions that are covered by Health Net. Will that change?
    • There will be no change in your medication coverage. If you use a self-injectable medication, you should contact your PCP to see if there is any change in how this medication is provided to you. If you have any prescriptions that need to be renewed after January, you will need to contact your new PCP and ask him or her to order the medications.

  • Who is responsible for paying claims prior to January 31, 2018?
    • EHS and Multicultural are responsible for services and claims up to January 31, 2018.

  • Who can I call at Health Net to discuss my personal situation?
    • You may call our dedicated phone representatives at 1-844-442-5047.

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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