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Broker Health Care Reform Guide

Attention: The Special Enrollment Quick Reference Chart below is being updated for 2018.

Large Group Plans

Special Enrollment Quick Reference Chart


Life-Changing Qualifying Event (QE) – Mini-Open Enrollment

Any of the following events would allow the subscriber to change plans and/or add themselves or other family members with the effective dates as listed.

Qualifying event Effective date determination Documentation
Newborn Date of event No documentation, but DOB must be on application
Adoption
(must be routed to case coordinator)
Court documentation showing date when court order effective
Marriage First of the month following date application is received
Marriage certificate
Domestic partnership Affidavit of domestic partnership
Legal guardianship
(must be routed to case coordinator)
Date of event Court documentation showing date when court order effective
Court order dependent
(must be routed to case coordinator)

Loss of minimum essential coverage

Includes (but are not limited to) any of the following events which resulted in a loss of minimum essential coverage, NOT INCLUDING voluntary termination, failure to pay premiums or situations allowing rescission.

Qualifying event Effective date determination Documentation
Loss of coverage due to
termination of employment or reduction of hours
Up to 30 days AFTER loss:

  • First of the month following date application is received
One of the following:
  • Front and back of previous carrier ID card
  • Confirmation of work-hour reduction
    including termination from employer (must be
    on employer letterhead and signed by
    employer management)
Loss of coverage due to
death of a covered employee
One of the following:
  • Front and back of previous carrier ID card
Loss of coverage due to
covered employee became entitled to benefits under Medicare
One of the following:
  • Front and back of previous carrier ID card
  • Eligibility document
Loss of coverage due to
divorce or legal separation
One of the following:
  • Front and back of previous carrier ID card
Loss of coverage due to
maximum age dependent
One of the following:
  • Front and back of previous carrier ID card
  • Max age letter from previous carrier

Other

Qualifying event Effective date determination Documentation
The qualified individual or enrollee, or his or her dependent, gains access to a new health plan as a result of a permanent move. Up to 30 days AFTER loss:

  • First of the month following date application is received
Moving IN:
  • Document showing date of entry into the U.S.
  • Document showing date of entry into service area
Moving OUT:
  • Enrollment form with plan change and change of address
Release from incarceration Release paperwork showing date of event
Returning from active duty Active duty discharge documentation
He or she was receiving services under another health benefit plan, from a contracting provider who is no longer participating in that health plan, for any of the following conditions: (a) an acute or serious chronic condition, (b) a terminal illness, (c) a pregnancy, (d) care of a newborn between birth and 36 months, or (e) a surgery or other procedure that has been recommended and documented by the provider to occur within 180 days of the contract's termination date. Letter from provider
He or she demonstrates to Health Net, with respect to health benefit plans offered through the Exchange, that he or she did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because he or she was misinformed that he or she was covered under minimum essential coverage. Letter from applicant supporting the qualifying event
Voluntary cancel due to benefits reduction or employer contribution level change Letter from employer about the contribution level change or benefit reduction.

Management review

These QEs require Health Net Management review and approval.

Qualifying event Effective date determination Documentation
The qualified individual's, or his or her dependent's, enrollment or non-enrollment in a health plan is unintentional, inadvertent or erroneous and is the result of the error, misrepresentation or inaction of an officer, employee or agent of the health plan or its instrumentalities as evaluated and determined by the health plan. Management review and approval
Letter from applicant supporting the qualifying event
The health plan in which the enrollee, or his or her dependent, is enrolled substantially violated a material provision of its contract.
* Abbreviations SEP submission time frame
EOM – End of month
All SEPs except loss of coverage
30 days after event
Loss of coverage only
  • 30 days before date of event
  • 30 days after date of event
  • Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.

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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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