Page 5 - JONS EE Guide 08-17 - final English 1

BENEFITS

Medical Insurance

Health Net | Salud HMO Plan

The Health Net Salud Health Maintenance Organization (HMO) plan allows California members to visit a select network of
providers and physician groups in their local service area, while accessing doctors in Tijuana, Mexicali, Rosarito or Tecate without a
referral using the SIMNSA network. Many services in California, such as office visits, require only a simple copay. When receiving
care from participating SIMNSA providers in Mexico, your copays will be even lower. Above all, many of the Salud HMO network
doctors and office staff in California speak both English and Spanish, and have a history of service in the Latino community. Under
this plan, you must choose a Primary Care Physician (PCP) or Medical Group for all of your care utilized in California, and all of your
care must be directed through your PCP or Medical Group. Any specialty care you need in California will be coordinated through
your PCP (except emergency care) and will generally require a referral or authorization. When using the SIMNSA network in
Mexico, there is no need to select a Primary Care Physician and you may visit any SIMNSA provider with no referrals required.

Health Net | ExcelCare EOA Medical Plan

Health Net’s ExcelCare Elect Open Access (EOA) network combines all of the best benefits from their HMO and PPO plans with a
select network of affordable providers. Except for emergency care, benefits for physician and hospital services are only available
when you live or work in the ExcelCare network service area and use an ExcelCare network provider. If you choose to see a
provider who is not part of the ExcelCare HMO or PPO network, you will be required to pay the full cost for your care.

Health Net | PPO Medical Plan
The Health Net Preferred Provider Organization (PPO) plan allows you to direct your own care. If you receive care from a physician
who is a member of the PPO network, a greater percentage of the entire cost will be paid by the insurance plan, however, you are
not limited to the physicians within the network and you may self-refer to specialists. If you obtain services using a non‐network
provider, please note that you will be responsible for the difference between the covered amount and the actual charges, and you
may be responsible for filing claims.

Finding a Medical Provider
Go to www.healthnet.com or call (800) 522-0088 for Salud HMO/ExelCare EOA or (800) 676-6976 for PPO.
 Salud HMO: Refer to the “SIMNSA” (Mexico) or the “Salud HMO y Mas” (California) networks when
prompted.
 ExcelCare EOA: Refer to the “Elect Open Access-ExcelCare” network when prompted.
 PPO: Refer to the “PPO” network when prompted.

Summary of Benefits and Coverage (SBC)
Health insurance issuers and group health plans are required to provide you with an easy-to-understand summary about your
health plan’s benefits and coverage, referred to as a Summary of Benefits and Coverage (SBC). This guide is designed to help you
understand the medical plan options offered to you by JONS Marketplace. Please refer to the SBC and carrier contracts provided by
Health Net for additional plan details.

Educational Video
Benefits terminology can get confusing. Click here to watch a quick video to learn the basics of how our
medical plans work.

Deductibles, Copays, Coinsurance, and Out-of-Pocket Maximums
http://video.burnhambenefits.com/terms/

5