Below you will find information about the plans that Health Net of Oregon will be offering to Oregonians.
When you need health care, this plan lets you receive services from Providers in our CommunityCare network or outside of our CommunityCare network. Who performs the services determines which benefit level applies to covered services and how much you will pay out-of-pocket.
To receive CommunityCare benefits, you must select a Primary Care Provider (PCP) from our CommunityCare network. Your PCP coordinates all your care. When your PCP refers you to providers in our CommunityCare network, you will receive CommunityCare level benefits. When you receive covered services from Providers in our CommunityCare network, your expenses may include a Calendar Year Deductible, fixed dollar amounts for certain services and a fixed percentage that is applied to our contracted rates with providers in your CommunityCare network. If your PCP refers you to Providers outside of our CommunityCare network, you will receive Level 2 benefits.
PPO Benefits: When you receive covered services from Providers in our PPO network, your expenses may include a Calendar Year Deductible, fixed dollar amounts for certain services or a fixed percentage that is applied to our contracted rates with PPO Providers.
Out-of-Network Benefits: When services are performed by a Provider who is not in our PPO network, your expenses include a Calendar Year Deductible and a fixed percentage of Maximum Allowable Amount (MAA) rates. We pay Out-of-Network Providers based on MAA rates, not on billed amounts. MAA rates may often be less than the amount a Provider bills for a service. Out-of-Network Providers may therefore hold you responsible for amounts they charge that exceed the MAA rates we pay. Amounts that exceed our MAA rates are not covered and do not apply to your annual out-of-pocket maximum.
10 Essential Benefits
Healthcare reform says all health plans must include ten essential benefits. The basic benefits include:
- Outpatient Care - the kind you get without being admitted to a hospital
- Emergency Services - for issues that could lead to death or disable you if you do not treat them.
- Inpatient Care - covers room and board, tests, drugs, and care from doctors and nurses while admitted, which may include organ and tissue transplants, and hospice and respite care.
- Maternity and Newborn Care - care before and after your baby is born
- Mental Health and Substance Use Disorder Services - this includes behavioral health treatment, counseling, and psychotherapy.
- Prescription Drugs - covers retail, mail order, and specialty drugs.
- Rehabilitative and Habilitative Services - services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
- Laboratory Services - covers lab tests, X-ray services, and pathology, and imaging and diagnostics such as MRI, CT scan, and PET scan.
- Preventive and Wellness Services - including mammograms, colonoscopies, vaccines. Covered in full if you use in-network providers for care such as routine physicals, screening, and immunizations. Disease management coordinates care for diabetes, asthma, and other conditions.
- Pediatric Services - including dental care (preventive, basic, major) and vision care (eye exam, lenses, and eyewear).