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Plan Exclusions and Limitations

Refer to your plan's Evidence of Coverage, go to Chapter 4, Section 3  to read about benefit limitations and items or services that are not included in your coverage with our plan.

While you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are: emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers.

Health Net Provider Network Coverage Limitations

HMO Plans

In-network providers are those providers who are contracted with Health Net. Out-of-network providers are those who do not have a contract with Health Net and who accept Medicare. Members enrolled in Health Net Medicare Advantage (MA) HMO plans must receive all routine care from in-network plan providers, except in emergency or urgent care situations or for out-of-area renal dialysis. If Health Net MA HMO members obtain routine care from out-of-network plan providers, neither Medicare nor Health Net will be responsible for the costs. In most cases, you will need to be referred by your primary care physician to receive services from a specialist. If you do not have a referral before you receive services from a specialist, you may have to pay for these services yourself.

 

If you have any questions about your plan coverage, call Member Services. We are here to help!