Coverage and Services

Members may access sensitive services in a timely manner and without barriers. Prior authorization is not required for access to certain services. Members may access most sensitive services from any qualified provider, in- or out-of-network, except obstetrical care for pregnancy and services related to substance abuse and mental health. The primary care physician (PCP) should encourage members to access in-network providers for services whenever possible. This process improves coordination of care and has a positive impact on health outcomes. Out-of-network providers must demonstrate reasonable efforts to coordinate services with a member's PCP or obtain the member's written refusal to do so. Health Net only covers out-of-network provider services that are within the definition of sensitive services.

Members should receive medical care according to the nature of the medical problem. The member or PCP should make the determination of timely access. Members can receive family planning services, including pregnancy testing, sexually transmitted infection (STI) diagnosis and treatment and HIV counseling and testing from participating or non-participating providers. Refer to the Family Planning and HIV Testing and Counseling discussions under the Benefits topic and the Sexually Transmitted Infections discussion under the Public Programs topic for additional information.

Although pregnancy testing is considered to be a family planning service and may be obtained from any qualified provider, in- or out-of-network, obstetrical care for pregnancy must be arranged through in-network providers. Refer to the Maternity discussion under the Benefits topic for additional information.

Refer to the Alcohol and Drug Treatment Services and Mental Health under Public Programs topic for additional information.