Health Net of California
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About Health Net of California

One of the largest provider networks in the state
Health Net is one of the largest health plans in California. We have an extensive network of more than 50,000 physicians, and 4,600 pharmacies - all working together to serve more than 2.3 million members. You can use our Doctor Search feature to see if your doctor or physician group is listed in Health Net's statewide care network.

NCQA accreditation
The National Committee for Quality Assurance (NCQA) has awarded its highest accreditation status of "Excellent" to Health Net's commercial and Medicare lines of business. Excellent accreditation status is awarded for service and clinical quality that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement. HEDIS®* results are in the highest range of national performance. The NCQA is an independent, not-for-profit organization that evaluates health plans' quality.

Extra advantages
Depending on the Health Net plan you join, you could take advantage of a wide array of programs and services designed to help keep you well. Here's just a select sampling:

  • WellRewards**
    This program offers discounts of 10% to 60% on many products and services designed for your good health, including eye exams, eyewear and contact lenses, fitness club memberships, Jenny Craig® and Weight Watchers® programs. Also, save 30% on ongoing massage therapy, chiropractic and acupuncture with participating providers.
History of quality care
Health Net, Inc. is one of the nation's largest publicly traded managed health care companies. Its mission is to help people be healthy, secure and comfortable. The company's HMO, POS, insured PPO and government contracts subsidiaries provide health benefits to approximately 6.4 million individuals in 27 states and the District of Columbia through group, individual, Medicare, Medicaid and TRICARE programs. Health Net's behavioral health services subsidiary, MHN, provides behavioral health, substance abuse and employee assistance programs (EAPs) to approximately 7.4 million individuals in various states, including the company's own health plan members. The company's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.

 

* HEDIS is a registered trademark of the National Committee for Quality Assurance. **The WellRewards program offers discounts on health products and reduced-fee health services. It is not part of Health Net members' benefit programs and is not intended to take the place of any covered benefits and is offered to the members in addition to, rather than instead of, covered benefits.

Preferred Provider Organizations (PPOs)
A Preferred Provider Organization (PPO) provides a list of contracted "preferred" providers from which to choose. You receive the highest monetary benefit when you limit your medical care services to those providers on the list. If you go to a doctor or hospital that is not on the preferred provider list referred to as going "out-of-network", then the plan covers a smaller percentage of your medical care expenses or may cover none of your medical care expenses based on the contract wording of the plan. Always check with your PPO or consult your list of preferred providers before you seek medical care services to make certain your physician or hospital is a contracting provider (part of the network). Make sure that your doctor refers you to medical care providers within your PPO network, if applicable.

PPOs in California can be regulated by either the CDI or the Department of Managed Medical Care (DMHC) depending on whether the underwriting company (the company backing the policy) is a licensed insurance company or a managed care company. The DMHC has sole jurisdiction over Blue Cross/Blue Shield PPO medical plans. If you are confused about whom to call regarding a PPO problem or concern, then consult your plan documents for regulatory information. If there is still some question, then you can reach the CDI or the DMHC for assistance at the contact information given in the "Resources" section of this brochure.

Important Points to Remember About Preferred Provider Organizations:

  • You receive the highest monetary benefit when staying within the PPO network.
  • You may have the option to go outside the PPO network at a higher monetary cost to you.
  • You should consider checking if your doctor or any specialist referred to you is part of the PPO network before utilizing covered services.
  • You can seek the assistance of the DMHC on all Blue Cross/Blue Shield PPO medical plans.
  • You can contact either the CDI or the DMHC for clarification regarding PPO issues.

 

Health Maintenance Organizations (HMOs or Managed Care)
Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their medical care services from doctors and hospitals affiliated with the HMO. It is common practice in HMOs for the plan member to choose a primary care physician who treats and directs medical care decisions and who coordinates referrals to specialties within the HMO network. The doctors and hospital personnel may be employees of the HMO or contracted providers. Since HMOs operate in restricted geographic regions, this may limit coverage for plan members if medical treatment is obtained outside the HMO network or coverage area. California HMOs are required to cover medically necessary emergency services even when outside of their coverage area. The intent of managed care products is to create less costly delivery of medical care services while maintaining quality medical care by specifying provider choice. HMOs offer access to a comprehensive package of covered medical care services in return for a prepaid monthly amount (premium). Most HMOs charge a small copayment depending upon the type of service provided.

All HMOs in California are regulated by the Department of Managed Medical Care (DMHC). If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint/grievance process in place. If you file a grievance and it has not been resolved within 30 days or there is some question as to the HMOs decision, then you may contact the DMHC for assistance. Please see contact information listed for the DMHC in the "Resources" section of this brochure.

Important Points to Remember About Health Maintenance Organizations:

  • You must obtain medical care services from HMO providers, except in certain emergency situations.
  • Your choice of primary care physician is important because he/she directs your care. Also, your primary care physician often coordinates referrals to specialties within the HMO.
  • Your options may be limited by the geographic restrictions of the HMO network.
  • You may be charged a small copayment each time you utilize an HMO covered service.
  • You can seek assistance from the DMHC on all HMO and managed care questions.

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