Coverage Provided By Your Employer
ELECT Open Access
What are the Basics?
Health Net ELECTSM Open Access is a two-tiered Point of Service (POS) plan. You choose between two tiers of benefits - HMO or Open Access - whenever you need care.
- With the HMO tier, all your care is provided through or overseen by your Primary Care Physician.
- With Open Access you can, without a referral, make an appointment with any specialist within the Health Net provider network, but only for consultations or evaluations.
How Does it Work?
When you need care, you can choose your HMO portion of this plan:
- Call your physician group and make an appointment to see your Primary Care Physician.
- Your copayment for office visits, emergency room visits, hospitalization and prescriptions depend on the plan your employer chooses.
- You'll know your copayment amounts in advance - there are no surprises.
- There's no paperwork so you won't have to submit claims for reimbursement.
- Your Primary Care Physician must authorize all referrals to specialists.
Or, choose Open Access:
- Without a referral, call any doctor or specialist in the Health Net network.
- Arrange office visits, consultation, evaluation and treatment - most procedures that can be performed in the doctor's office only - for a single copayment.
- Your costs will be higher and you may need claim forms for certain services.
- Certain services requiring hospitalization, outpatient surgery, maternity care and other therapeutic care must be coordinated and authorized by your Primary Care Physician in order to be covered by Health Net.
- If your Open Access specialist recommends hospitalization or surgery, you must inform your Primary Care Physician. Only your Primary Care Physician can get such treatment authorized for you.
What are my Benefits?
HMO level - The following are common to many of our plans:
- Office visits
- Hospitalization coverage
- Emergency room service
- X-ray and laboratory procedures
- Vision and hearing examinations
- Prenatal, postnatal and newborn care office visits
- Outpatient mental health consultation and treatment
Open Access level
- Health Net offers a variety of ELECT Open Access plans.
- Benefit plans may vary by deductibles, copayments, coinsurance and out-of-pocket maximum amounts.
- Your amount of coverage is generally higher and your out-of-pocket costs are lower with HMO benefits than they are with Open Access benefits.
- In general, you'll pay more for care that has been provided by a doctor other than your Primary Care Physician.