Also see:
Medical Insurance
Kaiser
HealthNet PPO
Description
This
is a general summary of
Health Net benefits. A more
complete description of
benefits and the terms under
which they are provided,
including limitations and
exclusions, are contained in
the
Evidence of Coverage.
If there are any
discrepancies between the
information contained in
this summary and the
provisions of the Evidence
of Coverage, the Evidence of
Coverage is the controlling
document.
Remember, the Health Net
contract determines the
exact terms and
conditions of coverage.
Health Net ELECT Open
Access is a Health
Maintenance Organization
(HMO) with a
Point-of-Services (POS)
provision. The HMO
provision requires that
you select a Primary
Care Physician (PCP)
from one of the Health
Net Participating
Physician Groups. The
POS component gives you
the option of seeking
consultations and
evaluations from any
specialist within the
Health Net network
without a referral from
your PCP. The HMO
provision is referred to
as Tier 1 and the POS
provision is referred to
as Tier 2.
Under Tier 1 (the HMO),
you receive all of your
care from within your
PCP’s network of
participating
physicians, hospitals,
and other health care
providers. Under Tier 2
(the POS option), you
are allowed
consultations with a
doctor outside of your
Participating Physician
Group, but within Health
Net’s Preferred Provider
Organization (PPO)
network, without a
referral from your PCP.
How the Plan Works
You must choose a PCP
from a Health Net
Participating Physician
Group when you enroll.
If you enroll
dependents, each
dependent can choose
their own Participating
Physician Group and
PCP. You may not choose
a specialist as a PCP.
If you are a new Health
Net enrollee and you do
not select a PCP, you
will be defaulted to a
PCP.
Your PCP will treat you
for many medical
conditions, perform
preventative care
services and coordinate
all of your health care,
including making
referrals to specialists
and hospitals within
your Participating
Physician Group. Also,
under the HMO (Tier 1)
component, you are
allowed to self-refer to
one annual OB/GYN
appointment. You must
select an OB/GYN
provider who is in the
same Participating
Physician Group as your
PCP for the visit to be
covered at the HMO
benefit level. Using
your PCP and using the
HMO option is the most
cost effective, lowest
out-of-pocket cost way
to use the plan.
However, with the Tier 2
component, you may see
any doctor or specialist
in the Health Net
Preferred Provider
Organization network
without a referral from
your PCP. When you use
this option, your costs
will be higher and you
may have to file claim
forms for certain
services. This direct
access feature only
covers office visits,
consultation,
evaluation, and
treatment procedures
that that can be
performed in the
doctor’s office. Some
services may require
certification from
Health Net. Services
requiring
hospitalization,
outpatient surgery,
maternity care and other
therapeutic care must be
coordinated and
authorized by your PCP
under the Tier 1 option.
If you need a Health Net
HMO or PPO Provider
Directory, please call
Health Net’s Member
Services at
1-800-676-6976 or
1-800-331-1777
(Spanish), or use Health
Net’s web site at
www.healthnet.com.
The directory lists
physicians and medical
groups accepting new
patients. If your
current physician or
medical group accepts
Health Net but is not
listed in the Directory,
call Health Net’s Member
Services for assistance.
Once enrolled in Health
Net, you can also call
Member Services to
change your PCP.
Call Health Net’s Member
Services at
1-800-676-6976 if you:
|
· |
Need to choose a
PCP |
|
· |
Have a benefits
question |
|
· |
Need hospital
certification |
|
· |
Need a Provider
Directory |
|
· |
Need a member
identification
(ID) card |
|
· |
Have an
eligibility
question |
Elect Open Access
The Elect Open access
plan is a traditional
HMO plan with no
deductibles and $10
copayments for most
services.
Copayments
For
most routine HMO care,
you pay a $10 copayment.
For other services,
copayments range from
$10 to 50% of actual
charges. For TIER2,
copayments for covered
benefits are normally
$30.
Deductible
Under
Health Net, you pay no
deductibles.
Hospitalization
You are covered for all
medically necessary
hospitalization when
admitted by your PCP.
Emergency Care
If you need emergency
services, you should
call 911 or go directly
to the nearest medical
facility for treatment.
Emergency Care is any
otherwise covered
service that a
reasonable person with
an average knowledge of
health and medicine
would seek if he or she
was having serious
symptoms (including
symptoms of Severe
Mental Illness and
Serious Emotional
Disturbances of a
child), and believed
that without immediate
treatment, any of the
following would occur:
|
· |
His or her
health would be
put in serious
danger (and in
the case of a
pregnant women,
the health of
her unborn
child) |
|
· |
His or her
bodily
functions,
organs or parts
would become
seriously
damaged |
|
· |
His or her
bodily organs or
parts would
seriously
malfunction |
Health Net will make any
final decisions about
Emergency Care. If you
seek Emergency Care,
please inform Health Net
of the locations,
duration and nature of
the services provided.
Out-of-Area Care
If you need urgent
medical care and cannot
get to your PCP, call
your PCP for guidance.
If you are unable to
contact your PCP,
you
should seek care for
Urgently Needed Services
from a licensed medical
professional where you
are located and notify
your Participating
Physician Group as soon
as possible afterwards.
Claim Forms
Under the Health Net HMO
component you do not
have to file claim
forms. You may have to
file claim forms when
using your TIER 2
benefits or following
Emergency Care or
out-of-area Urgent Care
services.
Medical Transition of Care
Benefit
As a new member you are
entitled to a medical review
that may allow you to
continue your current
treatment plan due to a
specific diagnosis for a
specified time frame with
your prior provider. Some
examples of circumstances
for you or a member of your
family:
|
· |
You are in the
second or third
trimester of
pregnancy or a
high-risk pregnancy
and are currently
established with an
Obstetrician |
|
· |
You are scheduled
for surgery within 3
weeks after your
effective date of
coverage |
|
· |
You have documented
follow-up care for
surgery that was
completed within 6
weeks prior to your
effective date of
coverage |
|
· |
You have
complications
resulting from
surgery performed
within the month
prior to your
effective date of
coverage |
|
· |
You are presently
undergoing a course
of chemotherapy or
radiation therapy |
|
· |
You are approved for
or on a waiting list
for a transplant |
|
· |
You have an acute or
serious chronic
condition |
|
· |
You are currently
receiving outpatient
mental health
treatment or you are
currently in a
chemical dependency
treatment program |
If any of these examples
apply, please complete a
Health Net Transition of
Care Assistance Request Form.
How to Get in Touch with
Health Net HMO
Call Health Net’s Member
Services at
1-800-676-6976,
1-800-331-1777 (Spanish) or
go to Health Net's web site
at
www.healthnet.com
for more information.
