HEALTH NET CHARTER POS MEDICAL PLAN
The Health Net Charter POS plan provides comprehensive coverage for a wide range of benefits and services such as physician and hospital charges, laboratory tests and treatment for mental health conditions and substance abuse.
The Health Net Charter POS plan is an "open access" plan that offers you the opportunity to use either Health Net participating or non participating providers each time you seek medical care for most services. "Open access” means that you do not need a primary care physician's referral in order to see specialists such as dermatologists or cardiologists. You and your covered dependents can self-refer to any provider in the Health Net directory for in network care. This plan also gives you the choice of receiving your care for covered services from providers who are not part of the Health Net network, at the time you need care. The decision is yours.
Prescription drugs
Prescription drugs, when purchased at participating pharmacies or through the mail order program, are covered after a low co-pay. For prescription drugs purchased at a participating retail pharmacy, the plan pays 100% of the charge after you pay a $10 co-pay for generic or brand name prescription drugs specified by your doctor. For mail order prescription drugs (i.e., 90 day supply), there is a $10 co-pay for generic and a $15 co-pay for brand name prescriptions specified by your doctor.
In-Network
If you see a Health Net participating provider, your benefits will be greater than if you see a non participating provider. The in-network plan offers preventive health services such as well-baby care, routine physical examinations for adults, vision and hearing exams and immunizations. In addition, there are no claim forms to complete and no deductibles to pay. For an updated list of participating providers, please review their website at www.health.net .
You do not need to select a primary care physician in order to enroll in the Charter POS plan. However, we encourage you to establish a relationship with a network provider, who can assist you in coordinating your care. When you use a network provider, that provider is responsible for working with Health Net to review the appropriateness and effectiveness of any treatment you may need, including hospital charges.
Out-of-Network
If you choose to see a doctor who does not participate in the Health Net network, you will need to pay a deductible (i.e., $300 individual, $900 family) for all expenses and the plan will pay 70% of the usual, reasonable and customary (UCR) charges. You will need to complete claim forms in order to receive reimbursement.
You need to contact Health Net in order to initiate a review process for any treatment you may need, including inpatient care (i.e., hospital) or outpatient diagnostic or surgical procedures. If you do not obtain this authorization, a $200 penalty will apply.
If you are an employee or retiree living out of the Health Net Charter POS network area and do not choose an HMO, you will be covered by the Health Net Out of Area plan. This plan covers the same services and supplies as the out of network Charter POS plan but the plan will pay at 80% of the UCR. The Health Net Out-of-Area Plan covers dependent children that are not in college and who live out of the Health Net Charter POS network. Please contact Human Resources/Benefits directly if this situation applies.
Out-of-Pocket Maximum
Whatever choice you make, the plan will pay 100% of any additional covered charges you have during the year, once you have reached the annual out-of-pocket maximum. The out of pocket maximum does not include charges in excess of the allowed amount or benefits not covered by the plan.
Benefit Summary
A summary of the highlighted benefits offered through Health Net Charter Point of Service can be found at the end of this publication. You may also obtain it at our website, www.pace.edu/hr. Please refer to the plan document for more specific details about the benefits provided.
HEALTH MAINTENANCE ORGANIZATION (HMO)
Health Maintenance Organizations (HMOs) are alternatives to traditional insured
medical plans.
Pace University offers five HMOs:
| Aetna | www.aetna.com |
| Empire Blue Cross Blue Shield Prestige | www.empirehealthcare.com |
| Health Net | www.health.net |
| HIP of New York | www.hipusa.com |
| Oxford | www.oxfordhealth.com |
If you choose an HMO, you and your dependents are not eligible for benefit payments under Health Net’s Charter POS Plan. The HMO will provide your medical and prescription drug coverage. In addition, you will get medical care (including preventive care) from doctors who work for or are participating in your HMO. Typically, there are no forms to complete or charges made for services you receive. However, co payments will be required for some services, including office visits.
You must select a primary care physician and receive referrals from this physician in order to see specialists or obtain medical care. For an updated list of participating providers, please refer to the websites noted above. Be sure to indicate a primary care physician for each family member you enroll in an HMO. If you wish to change your primary care physician , you may do so at any time by contacting your HMO customer service.
A summary of the highlighted benefits offered through each HMO can be found, at the end of this publication. You may also obtain it at our website, www.pace.edu/hr. Please refer to the plan document for more specific details about the benefits provided.