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Groups 51-100 Forms & Brochures – California

On January 1, 2016, the definition of small business group (SBG) changes to 1-100 employees. The redefinition is a provision of the Affordable Care Act. Our 2016 Small Group portfolio is designed to make the transition to ACA-compliant plans easy.
Go to Forms & Brochures for Small Groups | Go to the Broker Hub

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Plan Brochures / Product Overviews


Broker Portfolio Guide

English 2MB   02/09/15


51-100 Choice Flyer

English 280kB   02/14/14


EOA Products Employer Brochure

English 580kB   08/15/14


HMO ExcelCare Network Brochure

English 598kB   08/15/14


Product Overview folders

Standard

English 607kB   06/13/16

En Español (Spanish) 563kB   07/28/16


Presentation Folder

Folder With Pocket

English 529kB   11/25/15


Applications and Forms

Enrollment and Change Applications

Employee Enrollment and Change Form

English 805kB   03/11/16

En Español (Spanish) 1.1MB   03/05/14

Chinese (Chinese) 1.4MB   03/05/14

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


Open Enrollment Medical Plan Change Request Form (2014)

English 0kB   12/31/69


Dual Network Open Enrollment Medical Plan Change Request Form

English 0kB   12/31/69


Group Service Agreement/Policy Application

Application for Group Service Agreement/Policy

English 302kB   05/11/15

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 Account Management for processing.


Transition of Care

Continuity of Care Assistance Request Form

English 104kB   02/04/16

En Español (Spanish) 94kB   02/04/16


Pharmacy Transition of Care

English 43kB   01/26/16

En Español (Spanish) 44kB   01/26/16


Claims

Commercial Medical Claim Form

English 90kB   10/27/16

En Español (Spanish) 74kB   10/27/16


Dental Claim Form

English 2.8MB   04/12/10


Vision Claim Form

English 84kB   04/14/10


Prescription Drug Claim Form

English 59kB   07/20/15

En Español (Spanish) 59kB   07/20/15


HIPAA Disclosures

Group Health Plan HIPAA Disclosure Forms

Disclosure Directive 95kB   06/13/16


Authorization For Disclosure of PHI

English 98kB   02/01/16

En Español (Spanish) 69kB   02/01/16

Chinese (Chinese) 234kB   02/04/16


Additional Forms

Group Life Insurance Conversion Form

English 61kB   02/20/15


Evidence of Insurability Life Form

English 129kB   03/14/16


Electronic Check Form (New business only)

English 83kB   01/21/16


EFT Payment Authorization Form

English 99kB   03/15/13

Commisson deposited directly to a designated account, complete this form and return it to Health Net Broker Commissions Department.


Taxpayer Identification and Worldwide Employee Count Verification Form

English 43kB   07/10/13


Proof of Eligibility Statement For Sole Proprietor, Partner or Corporate Officer

English 51kB   01/06/16


Member Health Questionnaire

English 310kB   04/21/16

En Español (Spanish) 292kB   04/21/16

Chinese (Chinese) 529kB   04/21/16


Underwriting Guidelines


Enhanced Choice

English 105kB   08/13/14


ExcelCare Choice

English 105kB   08/13/14


SmartCare Choice

English 105kB   08/13/14


Dental & Vision

English 90kB   01/21/15


Healh Net Life

English 38kB   02/14/14


Support Tools

Health Care Reform Materials

Large Employer Group Affordable Care Act Mandate

English 480kB   04/07/14


Summary of Benefits Coverage (SBC) Employer Group Instructions Sheet

English 91kB   02/26/14


Summary of Benefits and Coverage (SBC) Search Flyer

English 385kB   03/13/15


Preventive Care Services Overview (ACA Non-Grandfathered Plans)

English 314kB   12/28/15

En Español (Spanish) 297kB   12/28/15

Chinese (Chinese) 1.5MB   12/04/14


SmartCare - Northern California

SmartCare Sales Guide

English 4.9MB   02/14/14


Top Reasons to choose SmartCare

English 322kB   04/12/13


SmartCare - Southern California

SmartCare Sales Guide

English 5.4MB   02/14/14


Top Reasons to choose SmartCare

English 302kB   08/23/12


SmartCare - General

SmartCare Employer Flyer

English 385kB   08/27/15


MinuteClinics Listing

English 188kB   03/08/16


Support Tools

Understanding the Continuity of Care Assistance Policy

English 427kB   02/16/15


Top Reasons to Sell Health Net

English 285kB   10/28/16


Top Reasons for Selling Health Net's Salud Plans

English 253kB   08/15/12


51-100 Renewal Guide

English 3.5MB   06/22/15


Prior-Carrier Deductible Credit Flyer

English 183kB   12/07/15


Commercial Sales Guidelines

English 601kB   02/12/16

Download only


ER vs. Urgent Care (HMO)

English/Spanish 146kB   10/27/16


ER vs. Urgent Care (PPO)

English/Spanish 190kB   03/09/15


Employer Administrative Manual

English 10.9MB   08/27/14


Uniform Glossary of Health Coverage and Medical Terms

English 117kB   07/22/16

En Español (Spanish) 138kB   07/22/16

Chinese (Chinese) 447kB   07/22/16

Navajo 230kB   07/22/16

Korean (Korean) 1.2MB   07/22/16

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.


Health Net Beginnings

Health Net Beginnings

English 137kB   10/01/15

En Español (Spanish) 136kB   10/01/15


Online Support Tools

Secure Messaging Reference Guide

English 887kB   04/03/15


Online Broker Tools Reference Guide

English 1.6MB   12/01/16


Book of Business Instructional Guide

English 0kB   12/31/69


Employer Online Billing and Enrollment Brochure

English 294kB   06/19/15


Health Net Mobile App Instructions

English 360kB   09/05/14


Out of State PPO

Out-of-State PPO Brochure

English 555kB   08/31/16

En Español (Spanish) 443kB   07/09/15


First Health Physician Nomination Form

English 87kB   04/28/10


Pharmacy


Pharmacy Benefits Member Guide

English 3.6MB   05/09/16

En Español (Spanish) 740kB   05/09/16


Mail Order Pharmacy and Maintenance Choice® Program

English 116kB   12/15/16

En Español (Spanish) 184kB   03/30/16


Coverage of Blood Glucose Test Strips - For New Members

English 109kB   11/02/15


Getting Started With Mail Order Pharmacy Kit

English 912kB   11/08/16

En Español (Spanish) 661kB   11/08/16


Supplemental Coverage

Acu / Chiro Information

Acupuncture Benefit Flyer

English 252kB   02/21/14


Chiropractic Benefit Flyer

English 261kB   02/21/14


Combined Acu & ChiroBenefit Flyer

English 270kB   02/21/14


DHMO

Plus (150) Plan Overview

English 237kB   02/21/14

En Español (Spanish) 246kB   02/21/14


Plus (225) Plan Overview

English 236kB   02/21/14



Broker/Employer DHMO/DPPO Plan Overview

English 183kB   07/07/14


DPPO

Classic Plus 1 2000

English 244kB   06/05/12

En Español (Spanish) 257kB   06/05/12


Classic Plus 2 2000

English 249kB   05/09/12

En Español (Spanish) 254kB   02/21/14


Classic 1 1500

English 239kB   06/05/12

En Español (Spanish) 180kB   07/12/10


Classic 2 1500

English 242kB   06/05/12

En Español (Spanish) 261kB   06/05/12


Classic 3 1500

English 242kB   06/05/12

En Español (Spanish) 265kB   06/05/12


Classic 4 1500

English 241kB   02/21/14

En Español (Spanish) 262kB   06/05/12


Classic 5 1500

English 536kB   03/11/15

En Español (Spanish) 264kB   06/05/12


Classic 6 1500

English 242kB   06/05/12

En Español (Spanish) 261kB   06/05/12


Essential Value 1 1000

English 533kB   02/24/15

En Español (Spanish) 265kB   02/21/14


Essential 2 1000

English 246kB   10/19/11

En Español (Spanish) 259kB   06/05/12


Essential 3 1000

English 247kB   10/19/11

En Español (Spanish) 260kB   06/05/12


Essential 4 1000

English 247kB   10/19/11

En Español (Spanish) 258kB   06/05/12


Essential 5 1500

English 246kB   10/19/11

En Español (Spanish) 249kB   02/21/14


Essential 6 1500

English 248kB   02/21/14

En Español (Spanish) 246kB   02/21/14


Basic 500

English 227kB   10/19/11

En Español (Spanish) 241kB   06/05/12


Vision Materials

PPO Vision FAQ

English 302kB   10/01/15


Broker/Employer PPO Vision Flyer

English 233kB   06/05/12


Member HMO Vision Flyer

English 158kB   10/01/15

En Español (Spanish) 158kB   10/01/15


Vision PPO - Preferred

10-2

English 227kB   11/17/14


1025_2

English 225kB   11/17/14


1025-3

English 222kB   11/17/14


Dental

Your Dental Website (member)

English 263kB   07/29/15


Health Net Life

Product Guide

English 194kB   01/22/13


Basic $15K with AD&D

English 154kB   08/29/14

En Español (Spanish) 167kB   08/29/14


Basic $25K with AD&D

English 151kB   08/29/14

En Español (Spanish) 165kB   08/29/14


Basic $50K with AD&D

English 151kB   08/29/14

En Español (Spanish) 162kB   08/29/14


Additional Forms / Brochures

Travel Guides

HMO/POS Travel Guide

English 3.5MB   06/27/16

** Limited quantity: NOT to be placed in KITS ** Members can download claim forms at www.healthnet.com. Claim forms can also be found under the Applications and Forms section on this page.


PPO Travel Guide

English 2.9MB   12/14/16

** Limited quantity: NOT to be placed in KITS ** Members can download claim forms at www.healthnet.com. Claim forms can also be found under the Applications and Forms section on this page.


MHN

Employee Assistance Program & Behavioral Health Services Brochure

English 403kB   03/22/10


Health Wellness Productivity Solutions Brochure

English 266kB   03/22/10


Additional Materials

Understanding your Explanation of Benefits (EOB)

English 359kB   05/19/15


Understanding Your Billing Statement

English 0kB   12/31/69


How To Read Your Commission Statement

English 555kB   06/06/14

Download only


EZAccess HSA Program


HSA Employer Brochure

English 2MB   09/15/16


HSA Member Brochure

English 1.7MB   08/21/15


Bank of America Rollover Instructions and Form

English 50kB   08/10/09


Bank of America HSA Enrollment Packet

English 346kB   01/11/13


Decision Power™ / Wellness


Smoking and Tobacco Cessation

English 112kB   12/14/16

En Español (Spanish) 113kB   12/14/16


Decision Power Employer Flyer

English 154kB   12/14/16


National Observances Calendar for Employers

English 566kB   12/29/15


Wellness Online

English 287kB   11/24/15

En Español (Spanish) 165kB   11/24/15


Wellness Webinar flyer – for Employers

English 397kB   11/30/15


Decision Power™ Healthy Discounts Member Flyer

English 454kB   02/20/15

En Español (Spanish) 239kB   04/28/15


Decision Power™ Text4Baby Flyer - PDF Only

English 112kB   04/29/16

En Español (Spanish) 118kB   06/22/16

Promotional flyer and press releases for Health Net's new "Text4Baby" program. This new service provides the expectant mother with 3 free text messages a week, providing helpful information throughout her pregnancy and for baby's first year.


Decision Power™ Wellness Menu for Members

English 186kB   12/16/16

En Español (Spanish) 319kB   11/24/15


Decision Power™ Member Brochure

English 900kB   12/14/16

En Español (Spanish) 582kB   11/24/15


Decision Power Ready to Lose Weight?

English 155kB   04/07/15

En Español (Spanish) 278kB   04/07/15


Preventive Screening Guidelines – Web PDF only

English 161kB   08/12/16

En Español (Spanish) 235kB   10/05/16


Tips to Stop Smoking

English 224kB   01/26/16


Wellness Seminars Menu

English 380kB   05/26/15


Health Coaching Program Flyer

English 143kB   08/26/15


myStrength Program Flyer

English 244kB   10/05/16


Decision Power™ California

Broker / Employer Materials

Decision Power™ California Employer Classic Toolkit

English 38kB   04/12/16

This document is currently unavailable online. Please contact your Wellness account manager or Wellness representative for an employer tool kit.


Salud con Health Net

Broker/Employer

Salud con Health Net Overview

English 200kB   11/19/15


Salud HMO y Más Service Areas

English 140kB   12/02/15


Salud Mexico Flyer

Eng/Span 223kB   11/10/16


Member

Salud HMO y Más Brochure

Eng/Span 923kB   05/17/16


Summary of Benefits / Plan Overviews (ACA-compliant)

Plan Overviews

SmartCare HMO

Standard HMO 10 21kB   11/17/14

Standard HMO 20 21kB   11/17/14

Standard HMO 30 21kB   11/17/14

Standard HMO 40 21kB   11/17/14

Standard HMO 50 21kB   11/17/14

Value HMO 50 21kB   11/17/14


Standard HMO

Standard HMO 10 150kB   11/17/14

Standard HMO 15 151kB   11/17/14

Standard HMO 20 20kB   05/07/15

Standard HMO 20 (Dual Network) 153kB   11/17/14

Standard HMO 25 20kB   11/17/14

Standard HMO 30 20kB   05/07/15

Standard HMO 30 (Dual Network) 153kB   11/17/14

Standard HMO 35 20kB   11/17/14

Standard HMO 40 20kB   05/07/15

Standard HMO 50 20kB   11/17/14


Value HMO

Value HMO 10 20kB   11/17/14

Value HMO 20 20kB   11/17/14

Value HMO 30 20kB   11/17/14

Value HMO 30 (Dual Network) 20kB   11/17/14

Value HMO 40 20kB   11/17/14

Value HMO 40 (Dual Network) 20kB   11/17/14

Value HMO 50 150kB   12/17/14


Advantage HMO

Advantage HMO 25 20kB   11/17/14

Advantage HMO 35 20kB   11/17/14

Advantage HMO 45 20kB   11/17/14


Standard EOA

Standard EOA 10 153kB   01/22/15

Standard EOA 15 153kB   01/22/15

Standard EOA 20 154kB   01/22/15

Standard EOA 25 154kB   01/22/15

Standard EOA 30 154kB   01/22/15

Standard EOA 35 154kB   01/22/15

Standard EOA 40 154kB   01/22/15

Standard EOA 50 154kB   01/22/15


Value EOA

Value EOA 10 153kB   01/22/15

Value EOA 20 153kB   01/22/15

Value EOA 30 154kB   01/22/15

Value EOA 40 154kB   01/22/15

Value EOA 50 154kB   01/22/15


Advantage EOA

Advantage EOA 25 155kB   01/22/15

Advantage EOA 35 156kB   01/22/15

Advantage EOA 45 155kB   01/22/15


POS

POS 10 161kB   02/04/15

POS 20 511kB   10/29/15


Standard PPO

Standard PPO 10 21kB   11/17/14

Standard PPO 15 22kB   11/17/14

Standard PPO 20 22kB   11/17/14

Standard PPO 25 22kB   11/17/14

Standard PPO 30 22kB   06/05/15

Standard PPO 35 22kB   11/17/14

Standard PPO 40 22kB   11/17/14

Standard PPO 45 22kB   11/17/14


Value PPO

Value PPO 10 21kB   11/17/14

Value PPO 15 22kB   11/17/14

Value PPO 20 22kB   11/17/14

Value PPO 25 22kB   11/17/14

Value PPO 30 22kB   11/17/14

Value PPO 35 22kB   11/17/14

Value PPO 40 22kB   11/17/14

Value PPO 45 22kB   11/17/14


Advantage PPO

Advantage PPO 45 22kB   11/17/14


HSA-Compatible

Value HSA 4500 157kB   02/25/15

Can be offered with integrated HealthEquity account options.


HRA-Compatible

HRA 3000 21kB   11/17/14

HRA 5000 21kB   11/17/14

Can be offered with integrated HealthEquity account options.


Salud

Salud HMO y Más 15 159kB   12/09/14

Salud HMO y Más 25 160kB   12/09/14

Salud HMO y Más 35 161kB   12/09/14

Salud Mexico 27kB   11/17/14


Summary of Benefits

Summary of Benefits Amendment

English 149kB   11/04/14

This accompanies all Summaries of Benefits listed below.


SmartCare HMO (Northern California)

Standard HMO 10 297kB   11/04/14

Standard HMO 20 295kB   11/04/14

Standard HMO 30 295kB   11/04/14

Standard HMO 40 295kB   11/04/14

Standard HMO 50 295kB   11/04/14

Value HMO 50 295kB   11/04/14


SmartCare HMO (Southern California)

Standard HMO 10 295kB   11/04/14

Standard HMO 20 294kB   11/04/14

Standard HMO 30 294kB   11/04/14

Standard HMO 40 294kB   11/04/14

Standard HMO 50 298kB   11/04/14

Value HMO 50 297kB   11/04/14


Standard HMO

Standard HMO 10 282kB   11/04/14

Standard HMO 15 282kB   11/04/14

Standard HMO 20 282kB   11/04/14

Standard HMO 20 (Dual Network) 282kB   11/04/14

Standard HMO 25 282kB   11/04/14

Standard HMO 30 282kB   11/04/14

Standard HMO 30 (Dual Network) 282kB   11/04/14

Standard HMO 35 285kB   11/04/14

Standard HMO 40 285kB   11/04/14

Standard HMO 50 285kB   11/04/14

Standard HMO 10 EC 287kB   11/04/14

Standard HMO 15 EC 288kB   11/04/14

Standard HMO 20 EC 291kB   11/04/14

Standard HMO 25 EC 287kB   11/04/14

Standard HMO 30 EC 287kB   11/04/14

Standard HMO 35 EC 291kB   11/04/14

Standard HMO 40 EC 290kB   11/04/14

Standard HMO 50 EC 291kB   11/04/14


Value HMO

Value HMO 10 286kB   11/04/14

Value HMO 20 286kB   11/04/14

Value HMO 30 286kB   11/04/14

Value HMO 30 (Dual Network) 286kB   11/04/14

Value HMO 40 286kB   11/04/14

Value HMO 40 (Dual Network) 286kB   11/04/14

Value HMO 50 286kB   11/04/14

Value HMO 10 EC 291kB   11/04/14

Value HMO 20 EC 292kB   11/04/14

Value HMO 30 EC 291kB   11/04/14

Value HMO 40 EC 292kB   11/04/14

Value HMO 50 EC 292kB   11/04/14


Advantage HMO

Advantage HMO 25 286kB   11/04/14

Advantage HMO 35 286kB   11/04/14

Advantage HMO 45 287kB   11/04/14

Advantage HMO 25 EC 291kB   11/04/14

Advantage HMO 35 EC 291kB   11/04/14

Advantage HMO 45 EC 291kB   11/04/14


Standard EOA

Standard EOA 10 369kB   11/04/14

Standard EOA 15 369kB   11/04/14

Standard EOA 20 369kB   11/04/14

Standard EOA 25 369kB   11/04/14

Standard EOA 30 369kB   11/04/14

Standard EOA 35 369kB   11/04/14

Standard EOA 40 369kB   11/04/14

Standard EOA 50 369kB   11/04/14

Standard EOA 10 EC 375kB   11/04/14

Standard EOA 20 EC 375kB   11/04/14

Standard EOA 25 EC 375kB   11/04/14

Standard EOA 30 EC 375kB   11/04/14

Standard EOA 35 EC 371kB   11/04/14

Standard EOA 40 EC 371kB   11/04/14

Standard EOA 50 EC 371kB   11/04/14


Value EOA

Value EOA 10 373kB   11/04/14

Value EOA 20 372kB   11/04/14

Value EOA 30 372kB   11/04/14

Value EOA 40 371kB   11/04/14

Value EOA 50 372kB   11/04/14

Value EOA 10 EC 373kB   11/04/14

Value EOA 20 EC 379kB   11/04/14

Value EOA 30 EC 379kB   11/04/14

Value EOA 40 EC 379kB   11/04/14

Value EOA 50 EC 379kB   11/04/14


Advantage EOA

Advantage EOA 25 372kB   11/04/14

Advantage EOA 35 373kB   11/04/14

Advantage EOA 45 373kB   11/04/14

Advantage EOA 25 EC 380kB   11/04/14

Advantage EOA 35 EC 379kB   11/04/14

Advantage EOA 45 EC 379kB   11/04/14


POS

POS 10 390kB   11/04/14

POS 20 390kB   11/04/14


Standard PPO

Standard PPO 10 288kB   11/04/14

Standard PPO 15 288kB   11/04/14

Standard PPO 20 287kB   11/04/14

Standard PPO 25 289kB   11/04/14

Standard PPO 30 288kB   11/04/14

Standard PPO 35 287kB   11/04/14

Standard PPO 40 286kB   11/04/14

Standard PPO 45 289kB   11/04/14


Value PPO

Value PPO 10 289kB   11/04/14

Value PPO 15 289kB   11/04/14

Value PPO 20 288kB   11/04/14

Value PPO 25 289kB   11/04/14

Value PPO 30 289kB   11/04/14

Value PPO 35 289kB   11/04/14

Value PPO 40 289kB   11/04/14

Value PPO 45 289kB   11/04/14


Advantage PPO

Advantage PPO 45 288kB   11/04/14


HSA-Compatible

Value HSA 4500 288kB   11/04/14

Can be offered with integrated HealthEquity account options.


HRA-Compatible

HRA 3000 289kB   04/15/15

HRA 5000 288kB   04/15/15

Can be offered with integrated HealthEquity account options.


Salud

Salud HMO y Más 15 325kB   04/27/15

Salud HMO y Más 25 382kB   11/04/14

Salud HMO y Más 35 362kB   11/04/14

Salud EPO 352kB   11/04/14

Salud Mexico 320kB   11/04/14


Provider Directories / Tailored Network Comparison Lists
Refer to County Reference Quick Guide to determine service areas in each directory.

Tailored Networks Comparison Lists

Northern California 193kB   06/10/16

Central California 175kB   06/10/16

Los Angeles County 200kB   06/10/16

Orange County 176kB   06/10/16

Riverside County 169kB   06/10/16

San Bernardino County 168kB   06/10/16

San Diego County 170kB   06/10/16



Provider Search Information

English 481kB   05/16/16

En Español (Spanish) 405kB   12/14/16


County Reference Quick Guide

English 61kB   02/05/15



HMO Network

North 25.7MB   10/27/16

South (Region A) 28MB   11/01/16

South (Region B) 23.2MB   10/27/16



ExcelCare Network

North 17.4MB   10/27/16

Central Valley 17.3MB   10/27/16

South (Region A) 23.8MB   11/01/16

South (Region B) 20.8MB   10/27/16



SmartCare Network

South (Region A) 18.6MB   11/01/16

South (Region B) 20.3MB   10/27/16



Salud Network

Salud HMO y Más 24.3MB   10/27/16

SIMNSA 8.3MB   10/28/16



PPO/EPO Network

North 19.4MB   10/28/16

South (Region A) 18.2MB   10/28/16

South (Region B) 19.1MB   10/28/16

EPO (Statewide) 6.3MB   10/28/16


Pharmacy

Commercial Pharmacy

English 2.6MB   09/30/16


Ancillary

Acupuncturists (Statewide)

English 1.4MB   07/01/16


Chiropractors (Statewide)

English 1.6MB   07/01/16


Health Net Vision (Statewide)

English 1.2MB   07/01/16


Health Net Dental

DHMO (North)

English 1.3MB   07/01/16


DHMO (South)

English 1.7MB   07/01/16


DPPO (North)

English 2.6MB   07/01/16


DPPO (South) Region A

English 2.4MB   07/01/16


DPPO (South) Region B

English 2.9MB   07/01/16



Information last updated 10-08-2018

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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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