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.
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
- 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.