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Tailored Networks

Large Employers 101+ employees

Health Net's SmartCare – Expanding Whole-Health Solutions


SmartCare offers easy-to-use benefits, predictable costs and a quality network, delivering an attractive, whole health option for your clients to offer – and for their employees to choose.


What this means for your clients
Enhanced value
Health Net pioneered the creation of tailored networks that deliver affordability without compromise in quality or benefits. SmartCare offers more ways to enhance and protect employee health and trim employer expenses, delivering the value that employers and employees want.


  • Trusted community-based network
    SmartCare is built on a tailored network of trusted, high-quality provider groups and hospitals. Plus, members can access convenient CVS MinuteClinics for walk-in medical services and preventive care.
  • Sustainable affordability
    With simpler plan choices and a mix of copayment and coinsurance designs, SmartCare meets budgets and exceeds expectations. For even more flexibility, employers can offer SmartCare plans alongside other Health Net plans.
  • Well-being as a way of life
    With SmartCare, your clients get benefits that make their employees feel valued, support their well-being, and sustain productivity.

Designed for growth
SmartCare is built to flex and grow over time with planned geographic coverage expansions and participating provider group additions. Our 2016 statewide expansion for employer groups 101+ is a great example! Go to Health Net's ProviderSearch for the most up-to-date listings of where SmartCare is offered and available providers.


Plans that fit employer budgets and employees' lives
Health Net SmartCare is a fit for both small businesses and mid-size/large employer groups. When it comes to benefits, SmartCare takes a 360° view of health. Beyond medical, every plan includes acupuncture, chiropractic and prescription drug coverage. Of course, preventive care is $0 for members. Connect below to learn more about SmartCare plans for our various group sizes.


SmartCare FAQs


Why do SmartCare plans have an HMO design?

Beyond predictable costs and comprehensive benefits, our HMOs leverage the trusted relationship between doctor and patient, which is key to maximizing and improving health. The healthier any group of people is, the lower the costs and the higher the workplace performance.

What wellness resources does SmartCare offer?

Exclusive to Health Net, Decision Power® helps people build healthy habits, make decisions with their doctors, and manage complex health issues with a combination of wellness coaching, online resources and self-guided programs.


Large group adult SmartCare members can earn an annual $50 gift card reward just by investing in their health. All they do is complete the Health Risk Questionnaire (HRQ) at www.healthnet.com, share the results with their primary care physician (PCP) at a scheduled preventive care physical, and note the physician visit in their www.healthnet.com account.

SmartCare gives members instant access to Health Net in the way that works for them,
including:


  • My Health Net: medical records, benefit details and claims information available to registered users on www.healthnet.com.
  • Personal support and first-call resolution by phone.
  • Decision Power Healthy Pregnancy and text4baby.
Can groups offer more than one SmartCare plan to their employees?

Yes, they can offer more than one SmartCare plan. Plus they can offer SmartCare plans alongside other Health Net plans. Different underwriting guidelines apply to different combinations. Your Health Net account executive or broker can provide details.

What can members do at CVS MinuteClinics?

CVS MinuteClinics are walk-in clinics staffed by nurse practitioners and physician assistants who provide treatment for common family illnesses and injuries, administer vaccinations, and offer monitoring for chronic conditions.

Is prescription drug coverage included with SmartCare plans?

Yes, all of our SmartCare plans for small business groups include three-tier prescription drug coverage. Mid-size and large groups have a choice of two pharmacy coverage options to pair with the SmartCare plan they choose.

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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