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Introduction to Health Net Please see the "Schedule of Benefits and Copayments" section for covered services.Health Net and SIMNSA will distribute ProviderDirectories at the time of enrollment. Please callHealth Net’s Customer Contact Center orSIMNSA if you need a Provider Directory or ifyou have questions involving reasonable access tocare. SIMNSA Members may contact SIMNSA at(011-52-664) 683-29-02 or 683-30-05 or 1-619407-4082. Some Hospitals and other providers do notprovide one or more of the following services thatmay be covered under your Evidence of Coverageand that you or your family member might need:family planning; contraceptive services, includingemergency contraception; sterilization, includingtubal ligation at the time of labor and delivery;Infertility treatments; or abortion. You shouldobtain more information before you enroll. Callyour prospective doctor, medical group, independent practice association, or clinic, or callHealth Net’s Customer Contact Center at 1-888926-4921 to ensure that you can obtain the HealthCare Services that you need.For definitions of Acute Condition, SeriousChronic Condition and Terminal Illness see the"Definitions" section.Health Net may provide coverage for completionof services from such a provider, subject toapplicable Copayments and any exclusions andlimitations of this Plan. You must request thecoverage within 60 days of your Group’s effective date unless you can show that it was notreasonably possible to make the request within 60days of your Group’s effective date, and youmake the request as soon as reasonably possible.The non-participating provider must be willing toaccept the same contract terms applicable toproviders currently contracted with Health Net,who are not capitated and who practice in thesame or similar geographic region. If the providerdoes not accept such terms, Health Net is notobligated to provide coverage with that provider.Health Net Salud Service AreaThe Health Net Salud Service Area encompassescertain regions in Southern California and Mexico(Baja California within fifty miles of the California – Mexico Border).Please refer to the "Health Net Salud Plan Service Area"section at the end of the EOC for more information on theapproved areas of California and Mexico where this SaludCon Health Net Plan is available.To request continued care, you will need tocomplete a Continuity of Care Assistance RequestForm. If you would like more information on howto request continued care, or request a copy of theContinuity of Care Assistance Request Form or ofour continuity of care policy, please contact theCustomer Contact Center at the telephone numberon your Health Net ID Card.Transition of Care for New EnrolleesYou may request continued care from a provider,including a Hospital, that does not contract withHealth Net or SIMNSA if, at the time of enrollment with Health Net, you were receiving carefrom such a provider for any of the followingconditions: A newborn up to 36 months of age notto exceed twelve months from yourEffective Date of coverage under thisPlan;A Terminal Illness (for the duration ofthe Terminal Illness); orA surgery or other procedure that hasbeen authorized by the Member’sprior health plan as part of adocumented course of treatment.Selecting a Primary Care PhysicianHealth Net requires the designation of a PrimaryCare Physician. A Primary Care Physicianprovides and coordinates your medical care. Youhave the right to designate any Primary CarePhysician who participates in our network andwho is available to accept you or your FamilyMembers, subject to the requirements set outbelow under “Selecting a Contracting PhysicianGroup.”An Acute Condition;A Serious Chronic Condition not toexceed twelve months from the yourEffective Date of coverage under thisPlan;A pregnancy including the duration ofthe pregnancy and immediatepostpartum care;92020 Salud HMO y Más Basic Plan

Introduction to Health NetSelecting a Participating Mental HealthProfessionalFor children, a pediatrician may be designated asthe Primary Care Physician. Until you make thisPrimary Care Physician designation, Health Netdesignates one for you. Information on how toselect a Primary Care Physician is available onthe Health Net website at www.healthnet.com. Alist of the participating Primary Care Physiciansin the Health Net Service Area is also availableon the Health Net website at www.healthnet.com.You can also call the Customer Contact Center atthe number shown on your Health Net ID Card torequest provider information.Mental Disorders and Chemical Dependencybenefits are administered by MHN Services, anaffiliate behavioral health administrative servicescompany (the Behavioral Health Administrator),which contracts with Health Net to administerthese benefits. When you need to see a Participating Mental Health Professional, contact theBehavioral Health Administrator by calling theHealth Net Customer Contact Center at the phonenumber on your Health Net ID card. The Behavioral Health Administrator will help you identifya Participating Mental Health Professional, aparticipating independent Physician or a subcontracted provider association (IPA) within thenetwork, close to where you live or work, withwhom you can make an appointment.Selecting a Contracting Physician GroupAt the time of enrollment, Subscribers and FamilyMembers who live in California must select aSalud Network Physician Group close enough totheir residence or place of work to allow reasonable access to medical care. Family Members mayselect different Participating Physician Groups.Certain services and supplies for Mental Disorders and Chemical Dependency may require priorauthorization by the Behavioral Health Administrator in order to be covered. Please refer to the“Mental Disorders and Chemical Dependency”provision in the “Covered Services and Supplies,”section for a complete description of MentalDisorders and Chemical Dependency services andsupplies, including those that require priorauthorization by the Behavioral Health Administrator.A Subscriber who resides outside the Health NetSalud Service Area may enroll based on theSubscriber’s work address that is within theHealth Net Salud Service Area. Family Memberswho reside outside the Health Net Salud ServiceArea may also enroll based on the Subscriber’swork address that is within the Health Net SaludService Area. If you choose a Physician Groupbased on its proximity to the Subscriber’s workaddress, you will need to travel to that PhysicianGroup for any non-emergency or non-urgent carethat you receive. Additionally, some PhysicianGroups may decline to accept assignment of aMember whose home or work address is not closeenough to the Physician Group to allow reasonable access to care. Subscribers and FamilyMembers who live in California may also obtaincovered services from SIMNSA Providers inMexico.Specialists and Referral CareSometimes, you may need care that your Physician cannot provide. At such times, in order to seea Specialist or other Health Care Provider for thatcare, you will need to have a referral. Refer to the“Selecting a Participating Mental Health Professional” section above for information aboutreceiving care for Mental Disorders and ChemicalDependency.When enrollment is allowed by the Employergroup, family Members living in Mexico, may goto any contracting Physician Group in theSIMNSA Network and are not required to select aparticular SIMNSA Physician Group for coveredservices. Such Family Members may not obtainany services in California, except in the case ofEmergency Care or Urgently Needed Care.If you are a California Member and you needmedical care that your Salud Network PhysicianGroup cannot provide, your Physician Group mayrefer you to a Specialist or other Health CareProvider for that care. Your Salud NetworkPhysician Group must authorize all treatmentsrecommended by such provider.102020 Salud HMO y Más Basic Plan

Introduction to Health NetChanging Contracting Physician GroupsFacilitiesMembers Mexico may self-refer to any providerin the SIMNSA Network in Mexico without priorauthorization. You must receive authorizationfrom SIMNSA to receive care from providersoutside the SIMNSA Network, except in case ofEmergency or Urgently Needed Care.Subscribers and Dependents residing in California may, depending on the circumstances, transferto another contracting Physician Group in theSalud Network. These transfers must be according to the conditions explained in the "Transferring to Another Contracting Physician Group"portion of the "Eligibility, Enrollment andTermination" section.THE CONTINUED PARTICIPATION OF ANYONE PHYSICIAN, HOSPITAL OR OTHERPROVIDER CANNOT BE GUARANTEED.THE FACT THAT A PHYSICIAN OR OTHERPROVIDER MAY PERFORM, PRESCRIBE,ORDER, RECOMMEND OR APPROVE ASERVICE, SUPPLY OR HOSPITALIZATIONDOES NOT, IN ITSELF, MAKE ITMEDICALLY NECESSARY OR MAKE IT ACOVERED SERVICE.If enrollment is allowed Members residing inMexico will not be required to select a contracting Physician Group; they may obtain care fromany Physician provided he or she contracts toparticipate in the SIMNSA network.Your Financial ResponsibilityStanding Referral to Specialty Care forMedical and Surgical ServicesYour Salud Network or SIMNSA Provider willauthorize and coordinate all your care, providingyou with medical services or supplies. You arefinancially responsible only for any requiredCopayment described in the "Schedule of Benefits and Copayments" section.A standing referral is a referral to a participatingSpecialist for more than one visit without yourPrimary Care Physician having to provide aspecific referral for each visit. You may receive astanding referral to a Specialist if your continuingcare and recommended treatment plan is determined Medically Necessary by your Primary CarePhysician, in consultation with the Specialist,Health Net’s Medical Director and you. Thetreatment plan may limit the number of visits tothe Specialist, the period of time that the visits areauthorized or require that the Specialist provideyour Primary Care Physician with regular reportson the health care provided. Extended access to aparticipating Specialist is available to Memberswho have a life threatening, degenerative ordisabling condition (for example, Members withHIV/AIDS). To request a standing referral askyour Primary Care Physician or Specialist.You are completely financially responsible formedical care that is not provided or authorized byyour Salud Network or SIMNSA Provider exceptfor Medically Necessary care provided in alegitimate emergency. However, if you receivecovered services at a contracted network healthfacility at which, or as a result of which, youreceive services provided by a non-contractedprovider, you will pay no more than the same costsharing you would pay for the same coveredservices received from a contracted networkprovider. You are also financially responsible forcare that this Plan does not cover.QuestionsCall Health Net's Customer Contact Center orSIMNSA with questions about this Plan at thenumbers shown on your Health Net ID Card.If you see a Specialist before you get a referral,you may have to pay for the cost of the treatment.If Health Net denies the request for a referral,Health Net will send you a letter explaining thereason. The letter will also tell you what to do ifyou don’t agree with this decision. This noticedoes not give you all the information you needabout Health Net’s Specialist referral policy. Toget a copy of our policy, please contact us at thenumber shown on your Health Net ID Card.Timely Access to CareThe California Department of Managed HealthCare (DMHC) has issued regulations (CaliforniaCode of Regulations, Title 28, Section1300.67.2.2) with requirements for timely accessto non-emergency Health Care Services.112020 Salud HMO y Más Basic Plan

Introduction to Health Net Please contact Health Net at the number shownon your Health Net ID Card, 7 days per week, 24hours per day to access triage or screeningservices. Health Net provides access to coveredHealth Care Services in a timely manner. Please see "Customer Contact Center InterpreterServices" in the "General Provisions" section, andthe "Notice of Language Services" section, forinformation regarding the availability of no costinterpreter services. PCP appointments: within 10business days of request for anappointment.Urgent care appointment with PCP:within 48 hours of request for anappointment.Routine Check-up/Physical Exam:within 30 business days of request foran appointment.Your Primary Care Physician may decide that it isokay to wait longer for an appointment as long asit does not harm your h

Introduction to Health Net 7 2020 Salud HMO y Más Basic Plan INTRODUCTION TO HEALTH NET. This Salud Con Health Net Plan is specifically designed for Groups located in the Health Net Salud Service Area. Please refer to the "Health Net Salud Service Area" section at the end of the EOC for more information on the approved areas