- Participating Physician Groups (PPG)
The Health Net (Flex-Net) Indemnity (out-of-network) benefit level plan affords members the freedom to seek treatment from any out-of-network licensed health care provider. Certain prior authorization requirements may apply; refer to the Prior Authorization topic for more information. The member is responsible for the deductible, coinsurance amount and any amount billed by the provider above the maximum allowable amount covered by the plan.
The PPO product offers two benefit levels, in-network and out-of-network, depending on which type of provider a member uses and how the member obtains care. Members receiving covered services and care from PPO in-network providers have lower out-of-pocket costs than when receiving care from out-of-network providers. The member may choose either benefit level when seeking care.
In-Network Benefit Level
PPO in-network plans afford comprehensive care at lower out-of-pocket costs to members who use the preferred provider network. Members are free to obtain treatment from any provider in the network without a referral from a primary care physician. However, prior authorization requirements may apply as stated in the member's Certificate of Insurance (COI). A member's failure to obtain a required prior authorization may result in penalty that reduces benefits otherwise payable. Out-of-pocket expenses for members are limited to the copayment or coinsurance amounts designated for particular benefits, and deductibles and penalties for failure to obtain required prior authorizations that apply. Refer to the Prior Authorization section for more information.
Behavioral health and substance abuse services are administered by MHN.
Out-of-Network Benefit Level
PPO out-of-network plans afford members the freedom to seek covered services and treatment from any out-of-network licensed health care provider, but at a higher out-of-pocket cost than at the in-network level. Prior authorization requirements may apply as stated in a member's COI. A member is responsible for the deductible, coinsurance amount, and any amount billed by the provider above the maximum allowable amount (less any applicable financial penalties for failure to obtain a required prior authorization) covered by the plan.
PPO providers must provide advance notice to the member when proposing or considering the use of out-of-network providers for non-emergent services as part of their plan of care for a member.