Health Maintenance Organization
With Health Maintenance Organization (HMO) plans, members choose a primary care physician (PCP) from our network of providers and pay a fixed monthly fee. Their PCP will then oversee all health care related services, including referrals and authorizations. HMOs are ideal for employees who would like one doctor to coordinate all their medical care at predictable costs. Hmo health insurance.
If you select an HMO plan, your employees can depend on basic, inpatient, and emergency services. Many plans include office visits, hospitalization, X-ray and lab services, prenatal and postnatal services, mental health services and more. Copays may vary according to plan.
Health Net HMO Plans
We know HMOs! Health Net has a variety of plan designs for businesses of all sizes. Our Full Network HMO gives you and your employees access to thousands of physicians and pharmacies across the state.
If you select an HMO plan, your employees can depend on basic, inpatient, and emergency services. Many plans include office visits, hospitalization, X-ray and lab services, prenatal and postnatal services, mental health services and more. Copays vary according to plan.
Elect Open Access (EOA) Plans
Elect Open Access (EOA) is an HMO plan with set copays, unlimited lifetime benefits, and a primary doctor to coordinate all of your care. However, an EOA also offers the flexibility of seeing any provider within Health Net's PPO provider network without needing a referral. For this added convenience, members who visit a PPO provider will have slightly higher copays per visit.
EOA products are also available with our ExcelCare Network, a subset of our full HMO network (see Tailored Network HMO plans below), available in Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Santa Clara, Stanislaus and Ventura counties. For more information on EOA plans, call your broker or Health Net representative.
Point-of-Service (POS) Plans
A POS plan combines aspects from both HMO and PPO plans, offering more freedom than a traditional HMO. Members choose a primary care physician from our network of providers, but our POS also offers limited coverage for members who choose to see an out-of-network provider.
Health Net POS is a two-tiered point-of-service plan. Members have the option to use benefits at an HMO benefit level or PPO benefit level whenever they need care. HMO benefits include primary care physician, referral to see a specialist, predictable payments and no claim paperwork. PPO benefits include the option to see any doctor or specialist in the Health Net network without a referral, payment of deductible and coinsurance and possibly filing claim forms.
SmartCare offers a streamlined collection of HMO options to give you meaningful plan choices that are easy to understand, compare and select.
Health Net SmartCare puts together all the pieces you and your employees value, so you can offer them a single solution that works today and tomorrow. Now you and your employees can prosper with:
Simple, more flexible plan choices that meet budgets and exceed expectations.
A popular and proven network expanded for greater access and value.
Whole person health - benefits that make employees feel valued, support their well-being and sustain productivity.
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Health Net's ExcelCare Network combines all the best benefits from our HMO and Elect Open Access (EOA) plan with a select network of affordable providers. The ExcelCare Network was designed to be a cost-effective health plan that offers quality coverage.
Salud con Health Net
Salud con Health Net is a system of health care designed to specifically address the cultural preferences of the Hispanic community. Members enjoy a health care experience that's affordable, local and culturally competent.
Salud plans make it possible to get what's really important when it comes to benefits - comprehensive coverage, plan choice and low, predictable copays. Plan members and insureds also have access to participating SIMNSA1 providers in Mexico.
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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.
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.
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.
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:
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
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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.
Contact Enrollment Services
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Here is the contact information for:
CalViva: 1-888-893-1569 (for those living in Fresno, Kings, Madera Counties)
About Plan Types
We offer several types of plans. There are HMO and HSP plans offered by Health Net of California, Inc. PPO and EPO insurance plans are offered by Health Net Life Insurance Company.
With an HMO, you have one main doctor called a primary care physician who coordinates all your care. You see your PCP for checkups, advice and care when sick or hurt. Your doctor refers you to other services when you need them. You get all services from the HMO network. There is no coverage if you see doctors who are not in the network, except in an emergency.
EPO and HSP plans have one network to use for all covered services. There is no coverage for services received outside of the network, except in an emergency or for urgent care. With EPO and HSP plans, you are required to pick a primary care physician (PCP) – a main doctor to see for checkups, advice and care when sick or hurt. Members can go directly to any doctor or specialist in the network without the need for a referral.
PPO plans give you the choice to go directly to any doctor. You can see a doctor in the PPO provider network. Or you can visit a doctor outside our network. You generally pay less out-of-pocket when you go to a doctor that is in the PPO network.