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Introduction to Health Net Please see the "Schedule of Benefits and Copayments"section for covered services.A Terminal Illness (for the durationof the Terminal Illness); or A surgery or other procedure thathas been authorized by theMember’s prior health plan as partof a documented course oftreatment.For definitions of Acute Condition, Serious ChronicCondition and Terminal Illness see the "Definitions"section.Health Net and SIMNSA will distribute ProviderDirectories at the time of enrollment. Please callHealth Net’s Customer Contact Center or SIMNSAif you need a Provider Directory or if you havequestions involving reasonable access to care.SIMNSA Members may contact SIMNSA at (01152-664) 683-29-02 or 683-30-05 or 1-619-407-4082.Some Hospitals and other providers do not provideone or more of the following services that may becovered under your Evidence of Coverage and thatyou or your family member might need: familyplanning; contraceptive services, including emergencycontraception; sterilization, including tubal ligation atthe time of labor and delivery; Infertility treatments;or abortion. You should obtain more informationbefore you enroll. Call your prospective doctor,medical group, independent practice association, orclinic, or call Health Net’s Customer Contact Centerat 1-888-926-4921 to ensure that you can obtain theHealth Care Services that you need.Health Net may provide coverage for completion ofservices from such a provider, subject to applicableCopayments and any exclusions and limitations ofthis Plan. You must request the coverage within 60days of your Group’s effective date unless you canshow that it was not reasonably possible to make therequest within 60 days of your Group’s effective date,and you make the request as soon as reasonablypossible. The non-participating provider must bewilling to accept the same contract terms applicable toproviders currently contracted with Health Net, whoare not capitated and who practice in the same orsimilar geographic region. If the provider does notaccept such terms, Health Net is not obligated toprovide 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).If you would like more information on how to requestcontinued care, or request a copy of our continuity ofcare policy, please contact the Customer ContactCenter at the telephone number on your Health NetID Card.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 Salud ConHealth Net Plan is available.Selecting a Primary Care PhysicianHealth Net requires the designation of a Primary CarePhysician. A Primary Care Physician provides andcoordinates your medical care. You have the right todesignate any Primary Care Physician who participates in our network and who is available to acceptyou or your Family Members, subject to the requirements set out below under “Selecting a ContractingPhysician Group.”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 enrollmentwith Health Net, you were receiving care from such aprovider for any of the following conditions: An Acute Condition;A Serious Chronic Condition notto exceed twelve months from theyour Effective Date of coverageunder this Plan;A pregnancy including the durationof the pregnancy and immediatepostpartum care;A newborn up to 36 months of agenot to exceed twelve months fromyour Effective Date of coverageunder this Plan;Pending DMHC ApprovalFor children, a pediatrician may be designated as thePrimary Care Physician. Until you make this PrimaryCare Physician designation, Health Net designatesone for you. Information on how to select a PrimaryCare Physician and for a list of the participatingPrimary Care Physicians in the Health Net ServiceArea are available on the Health Net website atwww.healthnet.com. You can also call the CustomerContact Center at the number shown on your HealthNet I.D. Card to request provider information.10

Introduction to Health Netin order to be covered. No prior authorization isrequired for Outpatient office visits, but a voluntaryregistration with the Behavioral Health Administratoris encouraged. Please refer to the “Mental Disordersand Chemical Dependency” provision in the “Covered Services and Supplies,” section for a completedescription of Mental Disorders and ChemicalDependency services and supplies, including thosethat require prior authorization by the BehavioralHealth Administrator.Selecting a Contracting Physician GroupAt the time of enrollment, Subscribers and FamilyMembers who live in California must select a SaludNetwork Physician Group close enough to theirresidence or place of work to allow reasonable accessto medical care. Family Members may select differentParticipating Physician Groups.A Subscriber who resides outside the Health NetSalud Service Area may enroll based on the Subscriber’s work address that is within the Health Net SaludService Area. Family Members who reside outside theHealth Net Salud Service Area may also enroll basedon the Subscriber’s work address that is within theHealth Net Salud Service Area. If you choose aPhysician Group based on its proximity to theSubscriber’s work address, you will need to travel tothat Physician Group for any non-emergency or nonurgent care that you receive. Additionally, somePhysician Groups may decline to accept assignment ofa Member whose home or work address is not closeenough to the Physician Group to allow reasonableaccess to care. Subscribers and Family Members wholive in California may also obtain covered servicesfrom SIMNSA Providers in Mexico.Specialists and Referral CareSometimes, you may need care that your Physiciancannot provide. At such times, in order to see aSpecialist or other Health Care Provider for that care,you will need to have a referral. Refer to the “Selectinga Participating Mental Health Professional” sectionabove for information about receiving care for MentalDisorders and Chemical Dependency.If you are a California Member and you need medicalcare that your Salud Network Physician Groupcannot provide, your Physician Group may refer youto a Specialist or other Health Care Provider for thatcare. Your Salud Network Physician Group mustauthorize all treatments recommended by suchprovider.When enrollment is allowed by the Employer group,family Members living in Mexico, may go to anycontracting Physician Group in the SIMNSANetwork and are not required to select a particularSIMNSA Physician Group for covered services. SuchFamily Members may not obtain any services inCalifornia, except in the case of Emergency Care orUrgently Needed Care.Members Mexico may self-refer to any provider in theSIMNSA Network in Mexico without prior authorization. You must receive authorization from SIMNSAto receive care from providers outside the SIMNSANetwork, except in case of Emergency or UrgentlyNeeded Care.THE CONTINUED PARTICIPATION OF ANYONE PHYSICIAN, HOSPITAL OR OTHERPROVIDER CANNOT BE GUARANTEED.Selecting a Participating Mental HealthProfessionalMental Disorders and Chemical Dependency benefitsare administered by MHN Services, an affiliatebehavioral health administrative services company(the Behavioral Health Administrator), whichcontracts with Health Net to administer thesebenefits. When you need to see a Participating MentalHealth Professional, contact the Behavioral HealthAdministrator by calling the Health Net CustomerContact Center at the phone number on your HealthNet I.D. card. The Behavioral Health Administratorwill help you identify a Participating Mental HealthProfessional, a participating independent Physician ora sub-contracted provider association (IPA) within thenetwork, close to where you live or work, with whomyou can make an appointment.THE FACT THAT A PHYSICIAN OR OTHERPROVIDER MAY PERFORM, PRESCRIBE,ORDER, RECOMMEND OR APPROVE ASERVICE, SUPPLY OR HOSPITALIZATIONDOES NOT, IN ITSELF, MAKE IT MEDICALLYNECESSARY OR MAKE IT A COVEREDSERVICE.Standing Referral to Specialty Care for Medical andSurgical ServicesA standing referral is a referral to a participatingSpecialist for more than one visit without yourPrimary Care Physician having to provide a specificreferral for each visit. You may receive a standingreferral to a Specialist if your continuing care andrecommended treatment plan is determined MedicallyNecessary by your Primary Care Physician, inconsultation with the Specialist, Health Net’s MedicalDirector and you. The treatment plan may limit theCertain services and supplies for Mental Disordersand Chemical Dependency may require priorauthorization by the Behavioral Health AdministratorPending DMHC Approval11

Introduction to Health NetTimely Access to Non-Emergency Health CareServicesnumber of visits to the Specialist, the period of timethat the visits are authorized or require that theSpecialist provide your Primary Care Physician withregular reports on the health care provided. Extendedaccess to a participating Specialist is available toMembers who have a life threatening, degenerative ordisabling condition (for example, Members withHIV/AIDS). To request a standing referral ask yourPrimary Care Physician or Specialist.The California Department of Managed Health Care(DMHC) has issued regulations (Title 28, Section1300.67.2.2) with requirements for timely access tonon-emergency Health Care Services.Please contact Health Net at the number shown onyour Health Net I.D. Card, 7 days per week, 24 hoursper day to access triage or screening services. HealthNet provides access to covered Health Care Services ina timely manner.If you see a Specialist before you get a referral, youmay have to pay for the cost of the treatment. IfHealth Net denies the request for a referral, HealthNet will send you a letter explaining the reason. Theletter will also tell you what to do if you don’t agreewith this decision. This notice does not give you allthe information you need about Health Net’sSpecialist referral policy. To get a copy of our policy,please contact us at the number shown on yourHealth Net I.D. Card.Definitions Related to Timely Access to NonEmergency Health Care ServicesTriage or Screening is the evaluation of a Member’s health concerns and symptoms by talking to adoctor, nurse, or other qualified health care professional to determine the Member's urgent need forcare.Changing Contracting Physician Groups FacilitiesTriage or Screening Waiting Time is the time ittakes to speak by telephone with a doctor, nurse, orother qualified health care professional who is trainedto screen or triage a Member who may need care.Subscribers and Dependents residing in Californiamay, depending on the circumstances, transfer toanother contracting Physician Group in the SaludNetwork. These transfers must be according to theconditions explained in the "Transferring to AnotherContracting Physician Group" portion of the "Eligibility, Enrollment and Termination" section.Business Day is every official working day of theweek. Typically, a business day is Monday throughFriday, and does not include weekends or holidays.Scheduling Appointments with Your Primary CarePhysicianIf enrollment is allowed Members residing in Mexicowill not be required to select a contracting PhysicianGroup; they may obtain care from any Physicianprovided he or she contracts to participate in theSIMNSA network.When you need to see your Primary Care Physician(PCP), call his or her office for an appointment at thephone number on your Health Net I.D. card. Pleasecall ahead as soon as possible. When you make anappointment, identify yourself as a Health NetMember, and tell the receptionist when you wouldlike to see your doctor. The receptionist will makeevery effort to schedule an appointment at a timeconvenient for you. If you need to cancel an appointment, notify your Physician as soon as possible.Your Financial ResponsibilityYour Salud Network or SIMNSA Provider willauthorize and coordinate all your care, providing youwith medical services or supplies. You are financiallyresponsible only for any required Copayment described in the "Schedule of Benefits and Copayments"section.This is a general idea of how many business days, asdefined above, that you may need to wait to see yourPrimary Care Physician. Wait times depend on yourcondition and the type of care you need. You shouldget an appointment to see your PCP:However, you are completely financially responsiblefor medical care that is not provided or authorized byyour Salud Network or SIMNSA Provider except forMedically Necessary care provided in a legitimateemergency. You are

clinic, or call Health Net’s Customer Contact Center at 1-888-926-4921 to ensure that you can obtain the Health Care Services that you need. Health Net Salud Service Area The Health Net Salud Service Area encompasses certain regions in Southern California and Mexico (Baja Californ