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Forms & Brochures – Small Business Group Plans

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CommunityCare HMO

Health Net CommunityCare HMO

Full Network HMO

Health Net PureCare HMO

Salud HMO y Más

SmartCare HMO

WholeCare HMO

EnhancedCare PPO

PPO

CommunityCare HMO

Health Net CommunityCare HMO

Full Network HMO

Health Net PureCare HMO

Salud HMO y Más

SmartCare HMO

WholeCare HMO

EnhancedCare PPO

PPO

CommunityCare HMO

Full Network HMO

SmartCare HMO

WholeCare HMO

PureCare HSP

Salud HMO y Más

Summary of Benefits

Plans for new and renewing groups effective 1/1/21.

EnhancedCare PPO

Full Network PPO

Ancillary Add-On or Change Form

Ancillary Add-On or Change Form – English (PDF)

Enrollment and Change Applications

Employee Enrollment and Change Form (2022)

Must be completed & submitted at time of enrollment in order to enroll new employees & existing dependents. Also used for employees/dependents waiving coverage.

Renewal Election and Open Enrollment Medical Plan Change Request Form

Must be completed & signed by the Employer Group.

Application for Group Service Agreement/Policy

Must be completed & signed by the Employer Group and Broker at time of enrollment and submitted along with check for first month's premium and enrollment forms. For renewals, this form must be completed and signed by the Employer Group and submitted to SBG Account Management for processing.

Religious Exemption Employer Form

Religious Exemption Employer Form – English (PDF)

Transition of Care

Claims

HIPAA Disclosures

Health Net Life Insurance Forms

Additional Forms

New to Health Net? Contact Health Net Account Management, 1-800-447-8812, option 2, for questions on standard benefit rates. Looking for CalChoice or Covered California Small Business rates? Visit the CalChoice website, or contact Covered California Small Business at 1-877-752-4737.

Standard

Broker Portal Overview – English (PDF)

Health Care Reform Materials

Support Tools

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer, understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.

Online Support Tools

First Health National (Out-of-State) PPO

Travel Guides

Members can download claim forms at Health Net. Claim forms can also be found under the Applications and Forms section on this page.

Members can download claim forms at Health Net. Claim forms can also be found under the Applications and Forms section on this page.

Additional Materials

Download only

Out-of-Pocket Maximum Notification – English (PDF)

Covered California Collateral

Get fact sheets and collateral

Last Updated: 11/19/2021