Important: Prior to enrollment, refer to the Summary of Benefits for specific plan benefits.
2013/2014 Plan Details
Selecting an HMO or POS "Tier 1" Primary Care Physician
Health Net requires the designation of a Primary Care Physician on HMO and POS plans. A Primary Care Physician provides and coordinates your HMO and POS "Tier 1" medical care. You have the right to designate any Primary Care Physician who participates in our network and who is available to accept you or your family members, subject to certain requirements described in the Evidence of Coverage. For children, a pediatrician may be designated as the Primary Care Physician. Until you make this designation, Health Net designates one for you. For information on how to select a Primary Care Physician and for a list of the participating Primary Care Physicians, contact Health Net's Member Services Department at 1-888-893-1598.
Obstetrician and Gynecologist (OB/GYN) and POS "Tier 1" Self-Referral
If you are a female member you may obtain HMO or POS "Tier 1" OB/GYN physician services without first contacting your Primary Care Physician. If you need OB/GYN preventive care, are pregnant or have a gynecology ailment, you may go directly to an OB/GYN specialist or a physician who provides such services in your HMO or POS "Tier 1" Physician Group. If such services are not available in your Physician Group, you may go to one of the contracting Physician Group's referral Physicians who provides OB/GYN services. (Each contracting Physician Group can identify its referral physicians.) The OB/GYN Physician will consult with the member's Primary Care Physician regarding the member's condition, treatment and any need for follow-up care. Copayment requirements may differ depending on the service provided.
The coverage described above meets the requirements of the Patient Protection and Affordable Care Act (PPACA), which states:
You do not need prior authorization from Health Net or from any other person (including a Primary Care Physician) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Health Net's Member Services Department at (888) 893-1598.
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