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Information for Cal MediConnect members

The Health Net Difference

You want health insurance you can count on. That's where Health Net comes in.

Experience you can count on

Health Net helps more than a million people on Medicare and Medi-Cal get the benefits they need. We do this by offering better access to your Medicare and Medi-Cal benefits and services, plus a whole lot more:

  • We've been building high quality networks of doctors for more than 20 years. These networks help individuals with Medicare and Medi-Cal get the care they need. We work hard to grow these networks to cover more people in more locations.
  • Award-winning Cultural and Linguistic program - Health Net is the only Cal MediConnect plan to receive the Multicultural Health Care Distinction from the National Committee for Quality Assurance. It no longer matters where you are from or what language you speak. Health Net will make sure you get quality health care that is fair and easy to understand.
  • We're here for your whole family - We offer plans and service that cover individuals and families, through every stage of their lives and health.
  • Your community is our community - We're a California company, so our employees live where you live. We support our local communities with:
    • Health screenings at local health events and community centers
    • No-cost health education classes

Appointing a Representative

To learn more on appointing a representative, please click here

Information last updated 04-04-2014

Prior Authorization for Medical Services and Organization Determination

Prior Authorization for Medical Services

Prior Authorization is a process that is used by your doctor to get you extra care or services. The process is also called a referral request.

Your doctor or Primary Care Physician (PCP) will send in the paper work that is needed to get the Prior Authorization. If you do not have a prior authorization, the cost for the services may not be paid by Health Net.

Please read the Member Handbook to see which services need prior authorization. Some services do not require Prior Authorization, they include:

  • Emergency Care,
  • Urgent Care,
  • Preventive services,
  • Family planning services,
  • Out of area renal dialysis services,
  • Basic prenatal care,
  • Sexually transmitted disease services, and
  • HIV testing

Health Net will notify your doctor when the Prior Authorization services are approved. Health Net will send you a letter to let you know if an Authorization was not approved. The letter will include your appeal rights.

Health Net will usually decide within 14 days or will ask you for more time to make a decision. If you have a very urgent need, you or your doctor can ask Health Net to speed up the review. This is called an expedited decision. The review may be done faster if you think that there could be very serious harm to your health or you may lose maximum function. To request an expedited decision go to contact us.

Your doctor needs to send a request for a Prior Authorization before you can ask Health Net to speed up their decision.

If your Prior Authorization request has been denied by Health Net, you have the right to appeal this decision through the phone, fax or address below.

Contact Information

Health Net
ATTN: Appeals and Grievances Dept.
P.O. Box 10422  
Van Nuys, CA 91410-0422

Health Net Community Solutions, Inc.
Phone: 1-800-977-7282
Monday through Friday, 8:00 a.m. to 5:00 p.m.

Status of Authorization: 1-800-977-7282
Monday through Friday, 8:00 a.m. to 5:00 p.m.

TTY users call 711

Fax: 1-800-793-4473 or 1-800-672-2135

More Information

For more information about coverage determinations and prior authorization, you may refer to chapter 9 of the Member Handbook or you may contact Customer Service.

Information last updated 06-06-2018

Drug and Pharmacy Information

Important Pharmacy Links



2018 DRUG LIST

Our Drug List shows the drugs we cover. Look below to find the drug list in your language. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

PHARMACY DIRECTORY

You can look for network pharmacies with our Pharmacy Search tool.


The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. We also list pharmacies that are in our network but are outside your plan's service area. Generally, you must use network pharmacies except in emergency or urgent care situations. If you want a Provider and Pharmacy Directory mailed to you, or if you need help finding a network pharmacy, please contact us .

Transition Program

The transition program is for new and renewing members who are taking drugs that are not on the Drug List or are on the Drug List with a restriction (not based on safety). This includes both Part D and Medi-Cal drugs.

We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of our plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We may cover a 30-day supply of your drug if:

  • you are taking a drug that is not on our Drug List, or
  • health plan rules do not let you get the amount ordered by your prescriber, or
  • the drug requires prior approval by Health Net Cal MediConnect, or
  • you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the first 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception.


Emergency Supply

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.


Level of Care Changes

If your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.

  • If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply.
  • If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply.

Transition Letter

You will be sent a transition letter when we cover a transition supply of your drug. You can ask for the transition letter in another format or language. To ask for the letter in another format or language, please contact us .

EXPLANATION OF BENEFITS

When you use your Part D prescription drug benefits, we will send you an Explanation of Benefits (EOB). The EOB helps you keep track of drug costs. You can get the EOB in another format or language. To get the EOB in another format or language, please contact us.

Out-of-Network Pharmacies

We have thousands of pharmacies in our network to make it easy to get your drugs at a network pharmacy. But we know there may be times when you can't use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:

  • There is no network pharmacy that is close to you and open.
  • You need a drug that you can't get at a network pharmacy close to you.
  • You need a drug for emergency or urgent medical care.
  • You must leave your home due to a federal disaster or other public health emergency.

Always contact us first to try finding a network pharmacy close to you.

Pharmacy Claims

In most cases, network pharmacies send your claim to us when you pick up your drugs. Out-of-network pharmacies may not send the claim to us. In these cases, you must pay the full cost of your drugs up front. You can ask us to pay you back for our share of the cost.


Submitting a claim

Mail the form and receipt to:

Health Net Community Solutions, Inc.
Attn: Pharmacy Claims
PO Box 419069
Rancho Cordova,
California 95741-9069


Once we receive your claim form, we'll respond within 14 days.

For questions about your benefits, check your Member Handbook or contact us.

Prescription Claim Form (pdf)

Information last updated 12-20-2017

Information last updated 04-27-2018

Quality Assurance Programs

Quality Assurance Programs

The goal of our Quality Assurance programs is to make sure our members are getting drugs that are safe for them. These programs are important for members who:

  • take more than one drug,
  • use more than one pharmacy, or
  • have more than one prescriber

Drug and Utilization Review Programs

When a pharmacy sends a prescription claim, we look at the claim for:

  • Age related problems
  • Gender related problems
  • Overuse and underuse
  • Issues with other drugs you take
  • Issues with a disease you have
  • Wrong drug dosage
  • Wrong length of therapy
  • Drug/allergy issues
  • Abuse or misuse

We also review your past pharmacy claims to check for drug errors and improve patient safety.

Information last updated 04-27-2018

Best Available Evidence (BAE) for Low-Income Subsidy (LIS) Members

Best Available Evidence (BAE) for Low-Income Subsidy (LIS) Members

There are times when Centers for Medicare and Medicaid Services (CMS) does not have the right information about a Medicare beneficiary's LIS status. This means that the wrong information can be given to Health Net or your plan sponsor.

CMS created the Best Available Evidence (BAE) policy in 2006 to deal with this issue. The policy requires plan sponsors to offer the right amount of cost sharing for low-income beneficiaries when CMS reports the wrong LIS information.

Go to the CMS.gov website

Information last updated 04-27-2018

Appeals and Grievances

Many issues or concerns can be promptly resolved by our Customer Service Department. If you have not already done so, you may want to first contact Customer Service before submitting one of the forms below.


Appeals

An "appeal" is a request that you make when you want us to change a decision we have made about what is covered or what we will pay for. You need to send an appeal request regarding medical care by 60 calendar days from the date on the denial letter that you get from us. After 60 days, Health Net can take an appeal request if you give us a good reason. This also applies for Part D; you need to send an appeal request regarding Part D prescription drugs by 60 calendar days from the date on the denial letter that you get from us. After 60 days, Health Net can take an appeal request if you give us a good reason.

To ask for an appeal, you can call, mail, fax, or submit a request online as outlined in the "How to File an Appeal or Grievance" section below. If you submit via Mail or Fax, please put dates, times, names of people and places in your letter. Or you can fill out the Medical Services – Reconsideration Form (below). You do not need to use the form if you do not want to. Please include copies of any information about your appeal in the letter and mail to:


Medical Services:

Health Net
Attn: Appeals & Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422


Prescription Services:

Health Net
Attn: Appeals & Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422

You may also call us at 1-855-464-3571 (Los Angeles); 1-855-464-3572 (San Diego County). Send your letter by mail, e-mail or fax to the address(s) and/or fax number listed below in the How to File section.

How soon we decide on your appeal depends on the type of appeal:

For a decision to authorize medical care and payment (including Tier 3 drugs) of services: For Medicare and Medi-Cal covered services, we will give you a written decision within 30 calendar days after we get your appeal. For Medicare covered services, a decision about payment for services and claim payment will be provided within 60 calendar days after we get your appeal. For Medi-Cal covered services, a decision about your payment for services and claim payment will be provided within 30 calendar days after we receive your appeal. We will make it sooner if your health requires. If we need more information to review your appeal for services you have not received, we may ask you for more time. You may ask us for more time for services you have not received (an extension) if you need to get more information to send to us. We will tell you if we are taking extra time and we will explain why we need more time.

For a decision about payment for Part D prescription drugs you already received: After we get your appeal request, we have 7 calendar days to make a decision. If we decide in your favor, we have 30 days from the date of your appeal to send payment.

For a standard decision about Part D prescription drugs: After we get your appeal, we have up to 7 calendar days to decide. We will make it sooner if your health requires.

You, any doctor, or your representative can ask us to give you an expedited ("fast") appeal. We can give you a fast appeal only for drugs or services that you have not received yet. You can ask for a fast appeal if you or your doctor think that waiting could seriously harm your health. If we give you a fast decision, we will decide no later than 72 hours of getting your request. For a fast appeal, contact us by telephone or fax at the number listed below in the How to File section.

For denials of medical appeals for Medicare covered services (including services that are covered by both Medicare and Medi-Cal): If we deny any part of your medical appeal, your case will be sent to an independent review organization. This independent review organization contracts with the Federal government and is not part of our Plan.

For denials of medical appeals for Medi-Cal covered services: You may request a State Fair Hearing at anytime without asking us (health plan) to review our decision first. Your request must be submitted in writing. The request must include:

  • Your name
  • Address
  • Member number
  • Reasons for appealing
  • Any evidence you want us to review, such as medical records, doctor's letters, or other information that explains why you need the item or service. Call your doctor if you need this information.

Send your request to:

State Hearings Division
Department of Social Services
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

You may be able to get an IMR right away without filing an appeal first. This is in cases where your health is in immediate danger or the request was denied because treatment was considered experimental or investigational. If you disagree with our decision, you can request an IMR. You cannot ask for an IMR if you already asked for a State Fair Hearing on the same issue. The paragraph below will provide you with information on how to request an IMR. Note that the term “grievance” is talking about both "complaints" and "appeals." To request an IMR:

  • Fill out the Complaint/Independent Medical Review (IMR) Application Form available at dmhc.ca.gov - Independent Medical Review Application Form or call the DMHC Help Center at 1‑888‑466‑2219. TDD users should call 1‑877‑688‑9891.
  • Attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
  • Mail or fax your form and any attachments to:

    Help Center
    Department of Managed Health Care
    980 Ninth Street, Suite 500
    Sacramento, CA 95814-2725
    FAX: 916-255-5241

For denials of Part D appeals: If we deny any part of your Part D appeal, you or your representative can mail or fax your written appeal request to the independent review organization. Send a written appeal request to:

MAXIMUS Federal Services
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302

Fax number for enrollees: 1-585-425-5390

The independent reviewer will look at our decision. If any of the medical care or service you asked for is still denied, you can appeal to an Administrative Law Judge (ALJ). You will be notified of your appeal rights if this happens.

There is another special type of appeal that is only for when coverage will end for SNF (Skilled Nursing Facility), HHA (Home Health Agency) or CORF (Comprehensive Outpatient Rehabilitation Facilities) services. If you think your coverage is ending too soon, you can appeal at once to Livanta. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta is an independent organization. It is not connected with our plan. See "How to File" section below to contact Livanta.

  • If you get the notice 2 days before your coverage ends, you must appeal no later than noon of the day after you get the notice.
  • If you get the notice and you have more than 2 days before your coverage ends, then you must appeal no later than noon of the day before the date that your Medicare coverage ends.

Important Appeals Information

If you have questions about these appeal procedures, you may refer to the sections of the Member Handbook for your plan as outlined below. You can also call Health Net Customer Service at the phone number listed below in the How to File section.

Plan Name Appeals Member Handbook Section
Health Net Cal MediConnect (MMP) Chapter 9, section 5 (Medical Care) & section 6 (Part D Prescription Drugs)

As a Health Net member, you have the right to:

  • Tell Medicare about your complaint by calling 1‑800‑MEDICARE (1‑800‑633‑4227; TTY/TDD Hearing Impaired 1‑877‑486‑2048), which is the national Medicare help line, 24 hours a day, 7 days a week. Or you may fill out the Complaint Form available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx
  • Tell Medi-Cal about your complaint by calling the Cal MediConnect Ombuds Program at 1‑855‑501‑3077. The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program
  • Obtain a total number of Health Net's complaints, appeals and exceptions, please call Health Net Customer Service at the phone number listed below in the How to File section.

If you want to ask about the status of an appeal, please call Health Net Customer Service at the phone number listed below in the How to File section.

Grievances

A grievance is a complaint that you give to your health plan. You can file a complaint when you are unhappy with any service or benefit that you get from Health Net's Cal MediConnect Program. For example, you would file a complaint if you had a problem with:

  • waiting times for appointments
  • wait time in the waiting room
  • the way your doctors or staff behave
  • being able to reach someone by phone
  • getting information you need from the doctor's office
  • the cleanliness of the doctor's office

You can file your complaint with us or the provider at any time.

The Appeals and Grievances Department can only work on complaints filed against Health Net and our contracted providers.

You can send us a complaint using one of the ways below:

  • Call Health Net's Customer Service Department
    Los Angeles: 1-855-464-3571    TTY 711
    San Diego: 1-855-464-3572       TTY 711
  • Send a letter, fax (facsimile) or e-mail to Health Net at address listed below in the How to File section
  • You may file a complaint through Cal MediConnect Ombuds Program
  • For Medicare services, you may also file a complaint through 1-800-Medicare

The Customer Service Center will try to find an answer for your complaint right away. You can ask them to send you a letter that tells you what the answer was for your complaint. If the Customer Service Center can't help you right away, they will send the complaint to be researched.

We must get back to you with what we found out about your complaint as quickly as possible. We will send you a letter no later than 30 calendar days after we get your complaint.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," or we decided we need more time to review your request for a medical care or appeal of denied medical care we will automatically give you a "fast complaint" and respond to your complaint within 24 hours. If you have an urgent problem that involves an immediate and serious risk to your health, you can request a "fast complaint" and we will respond within 72 hours. We may take up to 14 more calendar days if we need more information from you or your doctor for medical appeals on services you have not received. You can ask us for more time to send in information also.

If you have questions about these complaint procedures you may refer to the applicable sections of the member handbook. You can call Health Net Customer Service at the phone number listed below in the How to File section.

Plan Name Grievance Member Handbook Section
Health Net Cal MediConnect (MMP) Chapter 9, section 10

If you want to inquire about the status of a complaint, please call Health Net Customer Service at the phone number listed below in the How to File section.

As a Health Net member, you have the right to:

  • Tell Medicare about your complaint by calling 1‑800‑MEDICARE (1‑800‑633‑4227; TTY/TDD Hearing Impaired 1‑877‑486‑2048), which is the national Medicare help line, 24 hours a day, 7 days a week. Or you may fill out the Complaint Form available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx
  • Tell Medi-Cal about your complaint by calling the Cal MediConnect Ombuds Program at 1‑855‑501‑3077. The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program
  • Obtain a total number of Health Net's complaints, appeals and exceptions, please call Health Net Customer Service at the phone number listed below in the How to File section.

For quality of care complaints, you may also complain to the Quality Improvement Organization (QIO)

Complaints about the quality of care received under Cal MediConnect can be reviewed by Health Net under the complaint process, by an independent organization called the QIO, or by both. For example, if a member believes he/she is being discharged from the hospital too soon, the member may file a complaint with the QIO in addition to a complaint filed under Health Net's grievance process. For any complaint filed with the QIO, Health Net will work with the QIO in resolving the complaint.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. A member who files a quality of care complaint with a QIO does not need to file the complaint within a specific time period. Please see below in the 'How to File an Appeal or Grievance' section for specific contact information.

How to file an Appeal or Grievance

You may file an appeal or grievance using the following methods:


  • Call our Customer Service Department
    Monday through Friday, 8:00 a.m. to 8:00 p.m.
    At other times, including Saturday, Sunday and Federal Holidays, you can leave a voicemail.
    Health Net Cal MediConnect (MMP)- Los Angeles: 1-855-464-3571
    TTY 711
    Health Net Cal MediConnect (MMP)- San Diego: 1-855-464-3572
    TTY 711

    For Quality Improvement Organization (QIO) Complaints, please contact:

    Livanta
    BFCC-QIO Program
    9090 Junction Drive, Suite 10
    Annapolis Junction, MD 20701

    Toll-free Number: 1-877-588-1123
    TTY: 1-855-887-6668
    Appeals (Fax): 1-855-694-2929
    All other reviews (Fax): 1-844-420-6672

  • By Submitting an Online Form (Use of Online Form is optional)

    Medical Appeal Form

    REQUEST FOR RECONSIDERATION (APPEAL) Part C
    Your request for reconsideration (appeal) must be made within 60 calendar days from the date of the initial denial decision. If your request for reconsideration (appeal) is submitted beyond 60 calendar days, please submit an explanation why you were unable to make your request within this timeframe.

    Health Net will make its reconsidered determination as expeditiously as your health requires, for Medicare and Medi-Cal covered services, we will give you a written decision within 30 calendar days after we get your appeal. For Medicare covered services (including services that are covered by both Medicare and Medi-Cal), a decision about payment for services and claim payment will be provided within 60 calendar days after we get your appeal. For Medi-Cal covered services, a decision about your payment for services and claim payment will be provided within 30 calendar days after we receive your appeal. We will make it sooner if your health requires. If we need more information to review your appeal for services you have not received, we may ask you for more time. You may ask us for more time for services you have not received (an extension) if you need to get more information to send to us. We will tell you if we are taking extra time and we will explain why we need more time.

    Prescription Drug Appeal Form

    Important Note: Expedited Decisions

    If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. We will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

    Grievance Form

    Use this form to formally express your dissatisfaction with the care or service(s) you have received. It will be submitted to the Appeals and Grievances Department for review and response back to you.

  • By Mail or Fax

    You may mail your appeal or grievance via a written letter or by using one of our forms found below. Please mail or fax to:

    Prescription Drug Services and Medical Services:

    Health Net Community Solutions, Inc.
    Attn: Appeals & Grievances Dept.
    P.O. Box 10422
    Van Nuys, CA 91410-0422

    Fax: 1-877-713-6189

  • Forms
    Medical Services – Reconsideration Form (pdf)
    Prescription Drugs – Redetermination Form (pdf)

Appointing a Representative

An appointed representative is a person who can act on your behalf to request an exception appeal or complaint. This person can be a relative, friend, advocate, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Please note that your physician or other prescriber is not required to submit a signed Appointment of Representative (AOR) form CMS-1696 or other equivalent notice. Physicians and other prescribers may request a redetermination on your behalf at any time without completing an AOR form.

You can use the AOR form or you can make your own statement.

The signed AOR form or other equivalent notice must be included with each oral or written request for an appeal or grievance. Unless revoked, an appointment is considered valid for one year from the date that the representative form is signed by both the member and representative. Also the representation is valid for the duration of the appeal or grievance. A photocopy of the signed representative form must be submitted with future appeals or grievances on behalf of the Member in order to continue representation. However the original or photocopied form is only valid for one year after the date of the member's signature.

You can use the form or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, Cal MediConnect may also accept other forms of legal documentation.

The required information of an 'equivalent written notice' is one that:

  • Includes the name, address, and telephone number of enrollee;
  • Includes the enrollee's HICN [or Medicare Identifier (ID) Number];
  • Includes the name, address, and telephone number of the individual being appointed;
  • Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
  • Is signed and dated by the enrollee making the appointment; and
  • Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment

Send your AOR form or equivalent written notice to:

Appeals and Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422

Information last updated 04-27-2018

Long Term Services and Support

Long-Term Services and Supports (LTSS)

If you have a serious health condition, these services can help you stay in your home and community. These programs help many people with their daily activities. You can use these services and programs in your community through Health Net.

The services you can use are:

IHSS – In Home Support Services

If you have Medi-Cal, the way you get in-home services will not change. Please call Member Services if you need help getting IHSS services.

MSSP – Multipurpose Senior Services Program

Multipurpose Senior Services Program (MSSP) helps seniors in poor health keep living on their own. Health Net contracts with many of these programs in your community. Contact Member Services for information or help using the programs.

CBAS – Community Based Adult Services

Community Based Adult Services (CBAS) offers day care programs to frail, older persons. You may be able to use these programs instead of a nursing facility. Health Net contracts with these programs in your community. Contact Member Services for information and help using the programs.

Long Term Care – Skilled Nursing Facilities (SNF)

Health Net arranges and covers extended stays for members that need long-term nursing care.

Information last updated 04-27-2018

Care Coordination

Care Coordination

Health Net's Cal MediConnect Case Management

Health Net's Case Management service is here to help you with your health care needs.

This is called "care coordination".

Goals of the service include:

  • Improving care coordination for your Medicare and Medi-Cal health needs.
  • Giving you resources to help you make decisions about your health care.
  • Supporting quality care that helps you stay in your home. This gives many people the chance for a better quality of life.

Sometimes you may want to stay in a care center close to home.

Your care coordinator

You have access to a care coordinator. They are here to:

  • Help you understand your health.
  • Show you what you can do to improve your health and stay healthy.
  • Help you understand why certain treatments are important.
  • Work with you, your doctor and everyone involved in your care.
  • Set up a care plan to satisfy your health care needs.
  • Keep track of your health progress.

Their main goal is to make sure you get the care you need.

Information last updated 04-27-2018

Medication Therapy Management

Medication Therapy Management

Health Net's Medication Therapy Management (MTM) program is offered at no cost to eligible members. The MTM program helps members learn how to get the most from their medication.

2018 Medication Therapy Management

Who is eligible?

To be eligible for the MTM program, members must:

  • Have three or more of the following diseases:
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Depression
    • Diabetes
    • End-Stage Renal Disease (ESRD)
    • High cholesterol
    • Osteoporosis
  • Take eight or more drugs that treat chronic conditions
  • Have expected drug costs of at least $3,967 per year

How do I enroll?

All eligible members are automatically enrolled in the program. Though this program is not called a benefit, it's offered at no charge to our members.

Once members are enrolled in the program, a pharmacist reviews each member's pharmacy records. Members get a Welcome letter about any issues found by the pharmacist. The Welcome letter invites members to call a pharmacist to ask questions about their drugs. The Welcome letter also tells members how to call and ask for a comprehensive medication review (CMR).


What is a Comprehensive Medication Review?

A CMR is a complete review of all of the drugs each member takes. This includes prescription and over-the-counter drugs, vitamins and herbal supplements. A CMR takes about 30 - 60 minutes. Pharmacists work with members to create a plan for any problems found in the review. Pharmacists may discuss any problems found during the CMR with doctors or other prescribers when needed. A member can call us and ask for a CMR or a pharmacist may call a member to offer a CMR.

As part of a CMR, pharmacists create a personal list of medications for members. Members can also print and fill out a blank personal medication list (PDF) at any time.


Follow up review

Every three months or so, our pharmacists review every MTM members’ pharmacy records for any new problems. After each review, we send a letter to the member that lists any issues. The letter also suggests ways to help improve medication use.

To find out more about our MTM program or to get copies of MTM documents, you may contact us .

Information last updated 04-27-2018

Out of Network Coverage

Out of Network Coverage

You must get your care from network providers. Usually, the plan will not cover care from a provider who does not work with the health plan. Here are some cases when this rule does not apply:

  • The plan covers emergency or urgently needed care from an out-of-network provider. To learn more and to see what emergency or urgently needed care means, see below.
  • If you need care that our plan covers and our network providers cannot give it to you, you can get the care from an out-of-network provider. If you are required to see a non-network provider, prior authorization will be required. Once the authorization is approved, you, the requesting provider and the accepting provider will be notified of the approved Authorization. In this situation, we will cover the care at no cost to you. To learn about getting approval to see an out-of-network provider, see below
  • The plan covers kidney dialysis services when you are outside the plan's service area for a short time. You can get these services at a Medicare-certified dialysis facility.
  • When you first join the plan, you can make a request to us to continue to see your current providers. We are required to approve this request if you can show an existing relationship with the providers with some exceptions (see the Member Handbook for a list of exceptions). If your request is approved, you can continue seeing the providers you see now for up to 6 months for services covered by Medicare and up to 12 months for services covered by Medi-Cal. During that time, our care coordinator will contact you to help you find providers in our network. After the first 6 months for Medicare services and 12 months for Medi-Cal services, we will no longer cover your care if you continue to see out-of-network providers. For help with transitioning your Medicare or Medi-Cal covered services as a new member of our plan, you can call Member Services at 1‑855‑464‑3572 (TTY: 711), 24 hours a day, seven days a week.
  • Members may get Family Planning services from any health care provider licensed to provide these services in or out of Health Net's network, and the services can be provided outside of your county of residence.

How to get care from out-of-network providers

If there is a certain type of service that you need and that service is not available in our plan's network, you will need to get prior authorization (approval in advance) first. Your PCP will request prior authorization from our plan or your Medical Group.

It is very important to get approval in advance before you see an out-of-network provider or receive services outside of our network (with the exception of emergency and urgently needed care, family planning services, and kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area). If you don't get approval in advance, you may have to pay for these services yourself.

Please note: If you go to an out-of-network provider, the provider must be eligible to participate in Medicare and/or Medicaid. We cannot pay a provider who is not eligible to participate in Medicare and/or Medicaid. If you go to a provider who is not eligible to participate in Medicare, you must pay the full cost of the services you get. Providers must tell you if they are not eligible to participate in Medicare.

How to get covered services when you have a medical emergency or urgent need for care

Getting care when you have a medical emergency

What is a medical emergency?

A medical emergency is a medical condition with symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn't get immediate medical attention, you or any prudent layperson with an average knowledge of health and medicine could expect it to result in:

  • Placing the person's health in serious risk; or
  • Serious harm to bodily functions; or
  • Serious dysfunction of any bodily organ or part; or
  • In the case of a pregnant woman, an active labor, meaning labor at a time when either of the following would occur:
    • There is not enough time to safely transfer the member to another hospital before delivery.
    • The transfer may pose a threat to the health or safety of the member or unborn child.

What should you do if you have a medical emergency?

If you have a medical emergency:

  • Get help as fast as possible. Call 911 or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
  • As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care. You or someone else should call to tell us about your emergency care, usually within 48 hours. Contact Member Services at 1-855-464-3572 (TTY: 711), 24 hours a day, seven days a week.

What is covered if you have a medical emergency?

You may get covered emergency care whenever you need it, anywhere in the United States or its territories. If you need an ambulance to get to the emergency room, our plan covers that. To learn more, see the Benefits Chart in Chapter 4.

Coverage is limited to the United States and its territories: the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

There are some exceptions under Medicare as follows:

There are three situations when Medicare may pay for certain types of health care services you get in a foreign hospital (a hospital outside the U.S.): 1. You're in the U.S. when you have a medical emergency, and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury. 2. You're traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as "without unreasonable delay" on a case-by-case basis. 3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it's an emergency. In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.

Medi-Cal coverage is limited to the United States and its territories, except for Emergency Services requiring hospitalization in Canada or Mexico.

After the emergency is over, you may need follow-up care to be sure you get better. Your follow-up care will be covered by us. If you get your emergency care from out-of-network providers, we will try to get network providers to take over your care as soon as possible.

What if it wasn't a medical emergency after all?

Sometimes it can be hard to know if you have a medical emergency. You might go in for emergency care and have the doctor say it wasn't really a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care.

However, after the doctor says it was not an emergency, we will cover your additional care only if:

  • You go to a network provider, or
  • The additional care you get is considered "urgently needed care" and you follow the rules for getting this care. (See the next section.)

Getting urgently needed care

What is urgently needed care?

Urgently needed care is care you get for a sudden illness, injury, or condition that isn't an emergency but needs care right away. For example, you might have a flare-up of an existing condition and need to have it treated.

Getting urgently needed care when you are in the plan's service area

In most situations, we will cover urgently needed care only if:

  • You get this care from a network provider, and
  • You follow the other rules described in this chapter.
  • However, if you can't get to a network provider, we will cover urgently needed care you get from an out-of-network provider.

    In serious emergency situations: Call "911" or go to the nearest hospital.

    If your situation is not so severe: Call your PCP or Medical Group or, if you cannot call them or you need medical care right away, go to the nearest medical center, urgent care center, or hospital.

    If you are unsure of whether an emergency medical condition exists, you may call your Medical Group or PCP for help.

    Your Medical Group is available 24 hours a day, seven days a week, to respond to your phone calls regarding medical care that you believe is needed immediately. They will evaluate your situation and give you directions about where to go for the care you need.

    If you are not sure whether you have an emergency or require urgent care, please contact a clinician by calling Nurse24 toll free at 1-800-893-5597 (TTY: 1-800-276-3821) 24 hours a day, 7 days a week.

    Getting urgently needed care when you are outside the plan's service area

    When you are outside the service area, you might not be able to get care from a network provider. In that case, our plan will cover urgently needed care you get from any provider.

    Our plan does not cover urgently needed care or any other care that you get outside the United States.

Information last updated 04-27-2018

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Important Notice

General Purpose
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.


Policy Amendment without Notice.
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.


No Medical Advice.
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.


Reconstructive Surgery
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:


1. To improve function; or
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
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.

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This Schedule of Benefits is a brief list of benefits, with applicable copayments, coinsurance and deductibles information for your health plan. It does not list the exclusions and limitations or other important terms applicable to your plan.

For more information, please review carefully the disclosure form for your plan. It includes additional terms and information on certain exclusions and limitations.

The Evidence of Coverage (EOC) for your plan contains the complete terms and conditions of your Health Net coverage. It is important for you to thoroughly review the disclosure form and EOC for your plan, especially those sections that apply to those with special health care needs. You may view your Evidence of Coverage by: closing the current window and clicking on MY MEDICAL BENEFITS.

You may request copies of the forms referenced above for your health plan by: closing this window and clicking on Contact Us at the top of any web page.
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