Health Net Medical Benefit Health Net HMO Plan

This page provides basic information about the Health Net HMO medical plan available through the UNITE HERE Local 11 Health Benefit Fund. For eligibility rules and full plan details, see the Summary Plan Description.

  • Getting started
  • What’s covered
  • What you pay
  • Choose a primary care doctor
  • Find network providers
  • 24-hour nurse advice line
  • Specialty care
  • Emergency care
  • Submit a claim

Getting started

The Health Net of California, Salud y Mas Plan is an HMO medical plan provided by Health Net, Inc., which has contracted with the Fund to provide you and your dependents with comprehensive healthcare coverage, including medical, hospital, mental/behavioral health, and substance use disorder benefits.

Get started in two easy steps:

  • Check the mail for your Health Net insurance card. Your card will include your Subscriber ID (member ID), which you will need to create your online account. If you do not receive your insurance card within two weeks, or if you need care before receiving your card, call Health Net at (800) 522-0088. En Espanol 800-331-1777.

  • Make an appointment for a first time visit with a primary care doctor by calling your assigned primary care doctor’s number located on the right side of your Health Net card—or you can visit the Health Net website at www.healthnet.com or call (800) 522-0088 to make an appointment. Once you have a primary care doctor, they can refer you to specialty and other care. You can change your primary care doctor to another Health Net HMO Salud y Mas doctor at any time by going to the website or calling Health Net.

Health Net service area

The Health Net service area encompasses certain regions in Southern California and Mexico (Baja California within fifty miles of the California-Mexico border). Coverage is generally not provided to enrollees outside of the Health Net service area, except in cases of emergency or urgently needed care.

What’s covered

This is a simple summary. For detailed information about the Health Net Plan, including information on covered services, cost sharing, exclusions and limitations, and the procedures for filling claims and appeals, please refer to Health Net’s Evidence of Coverage (the “EOC”), in the Find Forms & Documents section, which has been prepared by Health Net specifically for the Fund.

Benefits 11

Primary Care $5

Benefits 11

Preventive Care Screenings $0

Benefits 11

Immunizations $0

Benefits 11

Diagnostic Tests

(x-ray, bloodwork) $0

Benefits 11

Medications

(generic, brand name, and specialty) provided by Express Scripts

Benefits 11

Urgent Care $10 and ER Visits $150

Benefits 11

Pregnancy and Pediatrics

Benefits 11

Mental Health and Substance Use Disorders

Benefits 11

Ambulance $50

Benefits 11

Home Health Care and Rehabilitation

Benefits 11

Medical Equipment $0

Benefits 11

Surgeries and Hospital Stays $0

Do not go out of network, or you will pay for all charges! Medications are covered under the Prescription benefit and not covered by Health Net.

Note: If there is a conflict between any description of Health Net benefits on this website and the Health Net’s EOC or the Fund’s contract or policy with Health Net, the EOC or the contract or policy with Health Net will control.

For other benefits, visit the following pages:

What you pay

See the Summary of Benefits and Coverage (SBC) for what the Plan covers and what you pay for covered services. You can find the SBC, EOC, and Summary Plan Description in the Forms & Documents section of this website.

Choose a primary care doctor

You and your Dependents who live in California must each designate a Primary Care Physician (“PCP”) and a Salud Network Physician Group (also called a “Participating Physician Group”) within the Salud Network.

Your Primary Care Physician will work within your Participating Physician Group and provide and/or coordinate your medical care. Until you make this designation, Health Net designates one for you. When selecting a Primary Care Physician, consider the following:

  • Your Participating Physician Group must be close enough to your home or workplace to allow for reasonable access to medical care. Note that some Participating Physician Groups may decline to accept assignment of an enrollee whose home or work address is not close enough to allow reasonable access to care.

  • You and your Dependents may have different Primary Care Physicians and different Participating Physician Groups.

  • For children, a pediatrician may be designated as the Primary Care Physician.

  • You may change your Primary Care Physician up to once per month by calling Health Net.

For more information on how to select a Primary Care Physician, and for a list of the participating primary care providers, call Health Net at (800) 522-0088 or visit the Health Net website at www.healthnet.com. Fund staff can also help you find a Primary Care Physician.

Find network providers

You must use network providers or there is no coverage, except for the following: (1) Emergency or Urgently Needed Care; (2) referrals to non-network providers (e.g., specialists) when issued by your in-network doctor; and (3) covered services provided by a non-network provider when authorized by the Salud Network or the SIMNSA Network.

The Health Net Plan offers the following two provider networks:

  • The Salud HMO y Mas network in Southern California (referred to as the “Salud Network”); and

  • The SIMNSA network in Mexico (the “SIMNSA Network”).

Be aware, your network provider might use an out-of-network provider for some services (such as lab work). You should always check to make sure your provider is in either the Salud Network or the SIMNSA Network before you get services.

24-hour nurse advice line

If you are sick and cannot reach your doctor, like on the weekend or when the office is closed, you can call Health Net’s Customer Contact Center at the number shown on your Health Net I.D. Card (800-893-5597) and select the triage and/or screening option. You will be connected to a health care professional (such as a doctor, nurse, or other provider, depending on your needs) who will be able to help you and answer your questions 24 hours a day, 7 days a week.

Specialty care

If you need medical care that your Primary Care Physician or Participating Physician Group cannot provide, you will need a referral to a specialist or other health care provider from your Primary Care Physician or Participating Physician Group. Once you get approval to receive specialist services, you can call the specialist’s office to schedule an appointment.

Emergency care

For emergency care, you can go to the nearest hospital, regardless of whether the hospital is in network or not, but it is critical that you contact your Salud Network Primary Care Physician or Physician Group in California, or your SIMNSA Provider in Mexico as soon as you can after receiving emergency services from others outside your Physician Group. Your Salud Network Primary Care Physician or SIMNSA Physician Group will evaluate your circumstances and make all necessary arrangements to assume responsibility for your continuing care.

Submit a claim

All claims and appeals for benefits under the Health Net of California, Inc. Plan must be submitted to Health Net and will be processed according to Health Net’s claims and appeals procedures.

How to file a claim

Download and print a claim form:

  • Log in to your member account with your username and password.

  • From My Plan Activity, under the Claims section, select Claim Forms.

  • Select the appropriate claim form.

You will be asked to provide the bill and proof of payment. For full instructions, see the claim form.