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Medicare Advantage for California

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To view or download a file, click the desired language link. The PDF file will open in a new window or tab of your browser. From there, you can also download or print the file. To send by email, select the check box next to the item(s) of your choice and click the "Email" button at the bottom of this page.

2018 - Employer Group Materials

2018 Pre-Enrollment Kit Components

English 36kB

Pre-Enrollment Folder

English 460kB

Multi-Language Insert* & Nondiscrimination Notice

Multilingual 381kB

*NOTE: This document must be provided in conjunction with Enrollment Forms, Summary of Benefits, ANOC/EOC and Plan Ratings.

2018 HMO Star Ratings

English 87kB

Enrollment related Forms

Seniority Plus Enrollment Form

English 57kB

COB Enrollment Form

English 3.4MB

Medicare Group Disenrollment Form

English 611kB

Claim Forms

Medicare - Medical - MHN Claim Form

English 1MB

Medicare Foreign Claim Questionnaire

Brochures, Flyers and Letters

Seniority Plus Overview Brochure

English 337kB

HMO COB Brochure

English 859kB

PPO COB Brochure

English 3.5MB

Healthy Discounts Brochure

English 391kB

Silver&Fit Flyer

English 281kB

Dental 8R Flyer

English 114kB

County of Kern Transportation Flyer

English 152kB

Vision Overview Flyer - Plan N2

English 134kB

Vision Overview Flyer - Plan 59

English 136kB

Chiropractic Silver&Fit Overview - Plan C01

English 135kB

Chiropractic Care + Silver&Fit – Plan C03

English 135kB

Chiropractic Care + Silver&Fit – Plan C0C

English 144kB

Chiropractic Care + Silver&Fit – C0B

English 145kB

Chiropractic Care Flyer - Plan CY

English 257kB

Chiropractic Care Flyer - Plan CZ

English 258kB

Chiropractic Care Flyer - Plan DG

English 668kB

Chiropractic Care Flyer - Plan DI

English 440kB

Employer Group Formulary

English 2.8MB

Español (Spanish) 2.9MB

Chinese (Chinese) 3.4MB

Directory Notice

English 477kB

Provider & Pharmacy Directory Information

English 165kB

Mail Order Materials
Provided by Caremark

Getting Started with Mail Order Pharmacy Kit

English 147kB

Español (Spanish) 151kB

Information last updated 02-22-2018

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In Addition, Please See Plan Overviews for Medical Benefit Plan Overviews.

2018 Medicare Advantage Plans

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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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