CSHA Topical Reports

Petitioner Mark Zembsch was employed by the City of Berkeley and eligible for group health insurance coverage under a group hospital and professional service agreement between the city and Health Net of California (“Health Net”). On May 9, 2002, Zembsch signed a form emolling himself, his wife, and his two children in a Health Net HMO plan. Alta Bates Medical Group “Alta Bates”) was the contracting physician group for the Zembsch family’s plan. Health Net’s plan permitted members to receive a standing referral to a specialist without first receiving a specific referral from the member’s primary care physician for each visit. A standing referral is authorized by the plan if it is determined to be necessary by the primary care physician, Health Net’s medical director, and the member.

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