Out of Network Coverage (Part C)

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 1-855-464-3571(TTY: 711) for Los Angeles County and 1-855-464-3572 (TTY:711) for San Diego County. Hours are 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.
Members may get Family Planning services from any health care provider licensed to provide these services in or out of Health Net Cal MediConnect'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 primary care provider 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.