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Small Business Group Plans – California

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Plan Overviews / Summary of Benefits (Dec '17 - 2018)

Plan Overviews
EnhancedCare PPO and PPO Silver HDHP plans for new and renewing groups effective 12/1/17. Platinum $30 plan and Gold $35 plan for new and renewing groups effective 7/1/18. All other plans for new and renewing groups effective 1/1/18.

EnhancedCare PPO

Gold Value 515kB   08/22/17

Silver Value 519kB   08/22/17

Silver HDHP 500kB   11/16/17

Bronze HDHP 500kB   11/16/17


PPO

Platinum 90 496kB   11/16/17

Gold 80 496kB   11/16/17

Gold Value 496kB   11/16/17

Silver 70 521kB   02/14/18

Silver Value 500kB   11/16/17

Silver HDHP 499kB   11/16/17

Bronze 60 498kB   11/16/17

Bronze HDHP 499kB   11/16/17


PureCare HSP

Platinum 90 496kB   11/16/17

Gold 80 499kB   11/16/17

Silver 70 499kB   11/16/17

Bronze 60 500kB   11/16/17


HMO

Platinum 10 498kB   11/16/17

Platinum 20 499kB   11/16/17

Platinum 30 509kB   05/02/18

Gold 30 498kB   11/17/17

Gold 35 509kB   05/02/18

Gold 40 498kB   11/16/17

Silver 40 495kB   11/16/17


WholeCare HMO

Platinum 10 497kB   11/16/17

Platinum 20 498kB   11/16/17

Platinum 30 518kB   05/02/18

Gold 30 498kB   11/16/17

Gold 35 537kB   05/02/18

Gold 40 498kB   11/16/17

Silver 40 497kB   11/16/17


SmartCare HMO

Platinum 10 498kB   11/16/17

Platinum 20 498kB   11/16/17

Platinum 30 517kB   05/02/18

Gold 30 499kB   11/16/17

Gold 35 2.3MB   05/02/18

Gold 40 498kB   11/16/17

Silver 40 499kB   11/16/17


Salud HMO y Más

Platinum 10 498kB   11/16/17

Platinum 20 498kB   11/16/17

Platinum 30 2.3MB   05/02/18

Gold 30 498kB   11/16/17

Gold 35 2.3MB   05/02/18

Gold 40 498kB   11/16/17

Silver 40 498kB   11/16/17


CommunityCare HMO

Gold 5 495kB   11/16/17

Silver 20 495kB   11/16/17

Bronze 45 495kB   11/16/17


Summary of Benefits

EnhancedCare PPO

Gold Value 1.6MB   01/25/18

Gold Value w/inf 1.6MB   01/25/18

Silver Value 1.6MB   01/25/18

Silver Value w/inf 1.6MB   01/25/18

Silver HDHP 1.6MB   01/25/18

Silver HDHP w/inf 1.6MB   01/25/18

Bronze HDHP 1.6MB   01/25/18

Bronze HDHP w/inf 1.6MB   01/25/18


PPO

Platinum 90 1.6MB   01/25/18

Platinum 90 w/inf 1.6MB   01/25/18

Gold 80 1.6MB   01/25/18

Gold 80 w/inf 1.6MB   01/25/18

Gold Value 1.6MB   01/25/18

Gold Value w/inf 1.6MB   01/25/18

Silver 70 1.6MB   02/05/18

Silver 70 w/inf 1.6MB   02/05/18

Silver Value 1.6MB   01/25/18

Silver Value w/inf 1.6MB   01/25/18

Silver HDHP 1.6MB   01/25/18

Silver HDHP w/inf 1.6MB   01/25/18

Bronze 60 1.6MB   02/05/18

Bronze 60 w/inf 1.6MB   02/05/18

Bronze HDHP 1.6MB   01/25/18

Bronze HDHP w/inf 1.6MB   01/25/18


PureCare HSP

Platinum 90 1.7MB   02/05/18

Platinum 90 w/inf 1.8MB   02/05/18

Gold 80 1.7MB   02/05/18

Gold 80 w/inf 1.8MB   02/05/18

Silver 70 1.7MB   01/25/18

Silver 70 w/inf 1.7MB   01/25/18

Bronze 60 1.8MB   02/05/18

Bronze 60 w/inf 1.7MB   02/05/18


HMO

Platinum 10 1.6MB   01/25/18

Platinum 10 w/inf 1.6MB   01/25/18

Platinum 20 1.6MB   01/25/18

Platinum 20 w/inf 1.6MB   01/25/18

Gold 30 1.6MB   01/25/18

Gold 30 w/inf 1.6MB   01/25/18

Gold 40 1.6MB   01/25/18

Gold 40 w/inf 1.6MB   01/25/18

Silver 40 1.7MB   02/05/18

Silver 40 w/inf 1.7MB   02/05/18


WholeCare HMO

Platinum 10 1.6MB   01/25/18

Platinum 10 w/inf 1.7MB   01/25/18

Platinum 20 1.6MB   01/25/18

Platinum 20 w/inf 1.7MB   01/25/18

Gold 30 1.7MB   01/25/18

Gold 30 w/inf 1.7MB   01/25/18

Gold 40 1.6MB   01/25/18

Gold 40 w/inf 1.7MB   01/25/18

Silver 40 1.7MB   06/13/18

Silver 40 w/inf 1.7MB   06/13/18


SmartCare HMO

Platinum 10 1.6MB   01/25/18

Platinum 10 w/inf 1.6MB   01/25/18

Platinum 20 1.6MB   01/25/18

Platinum 20 w/inf 1.6MB   01/25/18

Gold 30 1.6MB   01/25/18

Gold 30 w/inf 1.6MB   01/25/18

Gold 40 1.6MB   01/25/18

Gold 40 w/inf 1.6MB   01/25/18

Silver 40 1.7MB   06/13/18

Silver 40 w/inf 1.7MB   06/13/18


Salud HMO y Más

Platinum 10 1.7MB   01/25/18

Platinum 10 w/inf 1.7MB   01/25/18

Platinum 20 1.7MB   01/25/18

Platinum 20 w/inf 1.7MB   01/25/18

Gold 30 1.7MB   01/25/18

Gold 30 w/inf 1.7MB   01/25/18

Gold 40 1.7MB   01/25/18

Gold 40 w/inf 1.7MB   01/25/18

Silver 40 1.8MB   06/13/18

Silver 40 w/inf 1.8MB   06/13/18


CommunityCare HMO

Gold 5 1.6MB   01/25/18

Gold 5 w/inf 1.6MB   01/25/18

Silver 20 1.6MB   01/25/18

Silver 20 w/inf 1.6MB   01/25/18

Bronze 45 1.7MB   02/05/18

Bronze 45 w/inf 1.7MB   02/05/18


2017 Plan Overviews / Summary of Benefits

Plan Overviews
For new and renewing groups effective 1/1/2017

PPO

Platinum 90 496kB   12/19/16

Gold 80 496kB   12/19/16

Silver 70 496kB   12/22/16

Bronze 60 499kB   12/22/16

Gold Value 492kB   12/19/16

Silver Value 492kB   12/19/16

Bronze HSA 496kB   12/19/16


PureCare EPO

Gold 80 Alternate 493kB   12/12/16

Silver 70 Alternate 496kB   12/12/16


PureCare HSP

Platinum 90 494kB   12/12/16

Gold 80 494kB   12/12/16

Silver 70 494kB   12/12/16

Bronze 60 496kB   12/12/16


HMO

Platinum 10 496kB   12/12/16

Platinum 20 493kB   12/12/16

Gold 30 493kB   12/12/16

Gold 40 493kB   12/12/16

Gold 50 493kB   12/12/16


WholeCare HMO

Platinum 10 495kB   12/12/16

Platinum 20 495kB   12/12/16

Gold 30 493kB   12/12/16

Gold 40 495kB   12/12/16

Gold 50 495kB   12/12/16


SmartCare HMO

Platinum 10 495kB   12/12/16

Platinum 20 495kB   12/12/16

Gold 30 492kB   12/12/16

Gold 40 495kB   12/12/16

Gold 50 495kB   12/12/16


CommunityCare HMO

Gold 5 492kB   12/12/16

Silver 20 492kB   12/12/16


Salud HMO y Más

Platinum 10 493kB   12/12/16

Platinum 20 493kB   12/12/16

Gold 30 493kB   12/12/16

Gold 40 493kB   12/12/16

Gold 50 493kB   12/12/16


Summary of Benefits

PPO

Platinum 90 2.9MB   03/07/17

Platinum 90 w/inf 2.9MB   03/07/17

Gold 80 3.1MB   03/07/17

Gold 80 w/inf 2.9MB   03/07/17

Silver 70 3.1MB   03/07/17

Silver 70 w/inf 3.1MB   03/07/17

Bronze 60 2.9MB   03/07/17

Bronze 60 w/inf 2.9MB   03/07/17

Gold Value 3.1MB   03/03/17

Gold Value w/inf 3.1MB   03/03/17

Silver Value 3.1MB   03/03/17

Silver Value w/inf 3.1MB   03/03/17

Bronze HSA 3.1MB   03/03/17

Bronze HSA w/inf 3.1MB   03/03/17


PureCare EPO

Gold 80 Alternate 3.1MB   03/03/17

Gold 80 Alternate w/inf 3.1MB   03/03/17

Silver 70 Alternate 3.1MB   03/03/17

Silver 70 Alternate w/inf 3.1MB   03/03/17


PureCare HSP

Platinum 90 2.3MB   01/12/17

Platinum 90 w/inf 2.4MB   01/12/17

Gold 80 3.9MB   01/12/17

Gold 80 w/inf 3.9MB   01/12/17

Silver 70 3.9MB   01/17/17

Silver 70 w/inf 3.9MB   01/17/17

Bronze 60 3.9MB   01/17/17

Bronze 60 w/inf 3.9MB   01/17/17


HMO

Platinum 10 3.3MB   05/15/17

Platinum 10 w/inf 3.3MB   05/15/17

Platinum 20 3.3MB   05/15/17

Platinum 20 w/inf 3.3MB   05/15/17

Gold 30 3.2MB   05/15/17

Gold 30 w/inf 3.2MB   05/15/17

Gold 40 3.2MB   05/15/17

Gold 40 w/inf 3.2MB   05/15/17

Gold 50 3.2MB   05/15/17

Gold 50 w/inf 3.2MB   05/15/17


WholeCare HMO

Platinum 10 3.2MB   05/15/17

Platinum 10 w/inf 3.2MB   05/15/17

Platinum 20 3.2MB   05/15/17

Platinum 20 w/inf 3.2MB   05/15/17

Gold 30 3.2MB   05/15/17

Gold 30 w/inf 3.2MB   05/15/17

Gold 40 3.2MB   05/15/17

Gold 40 w/inf 3.2MB   05/15/17

Gold 50 3.2MB   05/15/17

Gold 50 w/inf 3.2MB   05/15/17


SmartCare HMO

Platinum 10 3.2MB   05/15/17

Platinum 10 w/inf 3.2MB   05/15/17

Platinum 20 3.2MB   05/15/17

Platinum 20 w/inf 3.2MB   05/15/17

Gold 30 3.2MB   05/15/17

Gold 30 w/inf 3.2MB   05/15/17

Gold 40 3.2MB   05/15/17

Gold 40 w/inf 3.2MB   05/15/17

Gold 50 3.2MB   05/15/17

Gold 50 w/inf 3.2MB   05/15/17


CommunityCare HMO

Gold 5 3.2MB   05/15/17

Gold 5 w/inf 3.2MB   05/15/17

Silver 20 3.2MB   05/15/17

Silver 20 w/inf 3.2MB   05/15/17


Salud HMO y Más

Platinum 10 3.7MB   05/15/17

Platinum 10 w/inf 3.8MB   05/15/17

Platinum 20 3.7MB   05/15/17

Platinum 20 w/inf 3.8MB   05/15/17

Gold 30 3.7MB   05/15/17

Gold 30 w/inf 3.8MB   05/15/17

Gold 40 3.7MB   05/15/17

Gold 40 w/inf 3.7MB   05/15/17

Gold 50 3.7MB   05/15/17

Gold 50 w/inf 3.7MB   05/15/17


Plan Brochures / Product Overviews


Portfolio Plan Desktopper

July 2018 188kB   05/24/18

January 2018 78kB   01/10/18


Portfolio Guide

July 2018 1.2MB   05/02/18

January 2018 1.8MB   12/14/17

December 2017 1.3MB   10/05/17

December 2017 Digital Magazine 0kB   12/31/69


Renewal Guide

English 1.7MB   05/02/18


Broker PPO Fast Facts

English 100kB   03/23/18


Heal flyer (PPO and EnhancedCare PPO only)

English 0kB   12/31/69


Consumer Open Enrollment PPO Brochure

English 1.6MB   08/15/17



Standard Product Overview Folders

English 1.1MB   10/05/17

En Español (Spanish) 819kB   10/05/17



Presentation Folder, with pocket

English 529kB   11/25/15


Applications and Forms

Enrollment and Change Applications

Top Reasons for Employee Enrollment Delays

English 656kB   05/24/18


Employee Enrollment and Change Form (July 2018)

English 2.4MB   06/14/18

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


Employee Enrollment and Change Form (January 2018)

English 1.2MB   01/23/18

En Español (Spanish) 767kB   03/23/18

Chinese (Chinese) 1.1MB   05/24/18

Korean (Korean) 905kB   06/13/18

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

July 2018 1.3MB   05/02/18

January 2018 298kB   10/20/17


Open Enrollment Meeting Request Form

English 107kB   08/25/16


Group Service Agreement/Policy Applications

Small Group 10+ Participation Attestation Form

English 52kB   05/11/18


Group Size Attestation Form

English 473kB   05/11/18

Must be completed & signed by the Employer Group.


Application for Group Service Agreement/Policy

July 2018 769kB   06/13/18

January 2018 700kB   11/30/17

December 2017 1.2MB   10/20/17

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.


Renewal Date Change Request Form

English 68kB   11/02/17


Religious Exemption Employer Form

English 892kB   12/12/17


Transition of Care

Continuity of Care Assistance Request Form

English 524kB   01/17/18

En Español (Spanish) 572kB   01/17/18


Prescription Transition form

English 464kB   05/15/18

En Español (Spanish) 463kB   05/15/18


Claims

Commercial Medical Claim Form

English 542kB   12/19/17

En Español (Spanish) 502kB   12/19/17


Prescription Drug Claim Form

English 3.2MB   09/29/17

En Español (Spanish) 3.2MB   09/29/17


Dental Claim Form

English 2.8MB   04/12/10


Vision Claim Form

English 84kB   04/14/10


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

Korean (Korean) 219kB   02/01/16


Health Net Life Insurance Forms

Employee Enrollment and Change Form

English 938kB   07/25/17

En Español (Spanish) 549kB   07/25/17


Group Life Insurance Conversion Form

English 61kB   02/20/15


Evidence of Insurability Life Form

English 618kB   02/22/18


Additional Forms

Employer Group Size Verification Form

English 64kB   08/01/17


Electronic Check Form

English 69kB   06/07/17


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

English 51kB   01/06/16


Rate Guides

Standard

July 2018

English 1.6MB   05/24/18

Rates effective July 1, 2018, through September 15, 2018


April 2018

English 1.3MB   04/03/18

Rates effective April 1, 2018, through June 15, 2018


January 2018

English 1.3MB   10/20/17

Rates effective January 1, 2018, through March 15, 2018


Covered California

July 2018

English 1.5MB   04/18/18

Rates effective July 1, 2018, through September 15, 2018


April 2018

English 1.8MB   02/05/18

Rates effective April 1, 2018, through June 15, 2018


January 2018

English 1.7MB   11/02/17

Rates effective January 1, 2018, through March 15, 2018


Cal-Choice

July 2018

English 928kB   04/18/18

Rates effective July 1, 2018, through September 15, 2018


April 2018

English 854kB   04/03/18

Rates effective April 1, 2018, through June 15, 2018


January 2018

English 1MB   10/20/17

Rates effective January 1, 2018, through March 15, 2018


Underwriting Guidelines


Underwriting Promotions

English 48kB   11/08/17


July 2018

Enhanced Choice

English 283kB   05/14/18


EnhancedCare PPO Choice

English 287kB   05/14/18


Dental & Vision

English 290kB   05/14/18


Health Net Life

English 285kB   05/14/18


April 2018

Enhanced Choice

English 283kB   04/16/18


EnhancedCare PPO Choice

English 287kB   04/16/18


Dental & Vision

English 290kB   04/16/18


Health Net Life

English 285kB   04/16/18


Support Tools


Broker Portal Overview

English 3.8MB   07/15/16

Broker Portal Overview (Flip Book)


Health Care Reform Materials

Summary of Benefits Coverage (SBC) Employer Group Instructions Sheet

English 52kB   08/22/17


Summary of Benefits and Coverage (SBC) Search Flyer

English 385kB   03/13/15

Download only


Ensure Your Employees Understand Their Health Care

English 58kB   05/24/18


Preventive Care Services Overview (ACA Non-Grandfathered Plans)

English 611kB   03/07/18

En Español (Spanish) 613kB   03/07/18


Support Tools

Broker Bonus Program

English 228kB   05/03/18


Understanding the Continuity of Care Assistance Policy

English 427kB   02/16/15

Download only


How To Read Your Commission Statement

English 477kB   02/11/16

Download only


Top Reasons to Sell Health Net

English 200kB   02/26/15


Top Reasons for Selling Health Net's Salud Plans

English 253kB   08/15/12


Protect Your Wallet. Always Use the PureCare HSP Network flyer

English 249kB   01/21/16


Cadillac Tax Fact Sheet

English 141kB   01/19/16


Health Net Beginnings

English 193kB   02/22/18

En Español (Spanish) 171kB   02/22/18


MinuteClinics Brochure

English 701kB   06/15/18


Prior-Carrier Deductible Credit Flyer

English 635kB   04/18/18


Commercial Sales Guidelines

English 738kB   05/24/18


Information for Small Business Groups

English 151kB   01/04/16


ER vs. Urgent Care

English/Spanish 150kB   08/14/17


Flu Shot Flyer

English 5.1MB   01/17/18

En Español (Spanish) 5.1MB   01/17/18


SBG Employer Administrative Manual


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.


HSA Employer Brochure

English 737kB   03/15/18


HSA Member Brochure

English 1.7MB   04/19/18


Bank of America HSA Enrollment Packet

English 124kB   05/26/17


Online Support Tools

Secure Messaging Reference Guide

English 887kB   04/03/15


Group Administrator Registration Guide

English 239kB   10/05/17


EFT Set Up Instructions

English 2.3MB   03/10/17


Broker Book of Business Tool Update

English 559kB   12/18/15


Book of Business Instructional Guide

English 1.6MB   12/01/16


Employer Online Billing and Enrollment Brochure

English 227kB   05/02/18


Health Net Mobile App How-To Guide

English 267kB   03/13/17


Out of State PPO

Out-of-state employee PPO flyer

English 295kB   03/29/17


First Health Physician Nomination Form

English 636kB   03/09/17


Pharmacy


Coverage of Blood Glucose Test Strips - For New Members

English 514kB   02/08/18


Generic vs Brand-Name Drugs Information

English 297kB   05/16/16


Getting Started With Mail Order Pharmacy Kit

English 147kB   11/29/17

En Español (Spanish) 151kB   11/29/17


Supplemental Coverage


Pediatric Dental and Vision

Pediatric Dental/Vision (HMO/HSP) 3.5MB   11/02/17

Pediatric Dental/Vision (PPO) 3.5MB   11/02/17

Pediatric Dental/Vision (EPO/EC-PPO) 3.5MB   04/21/18


Exclusions and Limitations

English 489kB   08/31/12


Infertility Benefits

English 177kB   02/24/15


Vision

Vision PPO FAQ

English 302kB   10/01/15


Member HMO Vision Flyer

English 158kB   10/01/15

En Español (Spanish) 158kB   10/01/15


Vision Website (member)

English 5.1MB   02/22/18


Preferred Value Plan 10-2

English 146kB   03/03/14

En Español (Spanish) 157kB   03/03/14


Preferred Plan 1025-2

English 583kB   12/20/17

En Español (Spanish) 583kB   12/20/17


Preferred Plan 1025-3

English 147kB   03/03/14

En Español (Spanish) 158kB   03/03/14


Dental

Dental Overview

English 166kB   03/03/14


Dental Provider Search

English 554kB   04/18/18

En Español (Spanish) 584kB   04/18/18


Your Dental Website (member)

English 5.1MB   02/22/18


DHMO

Plus (150) Plan Overview

English 1.1MB   02/14/18

En Español (Spanish) 3.4MB   02/14/18


Plus (150) Schedule of Benefits

English 313kB   01/23/17


Plus (225) Plan Overview

English 1.1MB   02/14/18

En Español (Spanish) 3.5MB   02/14/18


Plus (225) Schedule of Benefits

English 275kB   01/23/17


DPPO

Classic 4 1500

English 1.1MB   02/14/18

En Español (Spanish) 3.5MB   02/14/18


Classic 5 1500

English 1.1MB   02/14/18

En Español (Spanish) 3.4MB   02/14/18


Essential 2 1000

English 1.1MB   02/14/18

En Español (Spanish) 3.4MB   02/14/18


Essential 5 1500

English 1.1MB   02/14/18

En Español (Spanish) 3.4MB   02/14/18


Essential 6 1500

English 646kB   02/14/18

En Español (Spanish) 3.5MB   02/14/18


Health Net Life

Product Guide

English 194kB   01/22/13


Basic Life Insurance with AD&D

English 565kB   01/17/18

En Español (Spanish) 565kB   01/17/18

These forms are customizable to allow for the addition of benefit level ($15,000, $25,000 or $50,000).


Additional Forms / Brochures

Travel Guides

HMO/POS Travel Guide - Web PDF only

English 2MB   09/07/17

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 - Web PDF only

English 1.9MB   09/07/17

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 336kB   08/26/16

Download only


Premium Only Plans (POP)


FlexSystem Highlights Overview

English 789kB   09/27/11


FlexSystem Premium Only Plan (POP) Information Sheet

English 1.4MB   09/27/11


FlexSystem Premium Only Plan Application

English 215kB   09/27/11


Decision Power/Wellness - Member


Smoking and Tobacco Cessation

English 112kB   12/14/16

En Español (Spanish) 113kB   12/14/16


Wellness Online

English 679kB   03/28/18

En Español (Spanish) 610kB   05/15/18


Healthy Discounts Member Flyer

English 3MB   02/23/18

En Español (Spanish) 3MB   02/23/18


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.


Wellness Menu for Members

English 564kB   02/08/18

En Español (Spanish) 569kB   03/28/18


Decision Power™ Member Brochure

English 876kB   02/08/18

En Español (Spanish) 1MB   02/16/17


Decision Power Ready to Lose Weight?

English 3.4MB   09/29/17

En Español (Spanish) 3.4MB   10/12/17


Preventive Screening Guidelines – Web PDF only

English 161kB   09/07/17

En Español (Spanish) 160kB   09/07/17


Tips to Stop Smoking

English 224kB   01/26/16


Health Coaching Program Flyer

English 143kB   08/26/15


myStrength Program Flyer

English 4.8MB   05/10/17

En Español (Spanish) 4.8MB   05/10/17


Decision Power/Wellness - Employer/Broker

Broker / Employer Materials

Decision Power Employer/Broker Toolkit

English 575kB   05/15/18


Wellness Incentive Broker Flyer

English 1.4MB   06/15/17


Wellness Incentive Employer FAQ

English 20kB   06/15/17


Decision Power Employer Flyer

English 154kB   12/14/16


National Observances Calendar for Employers

English 229kB   01/12/18


Wellness Webinar flyer – for Employers

English 157kB   01/12/18


Wellness Seminars Menu

English 380kB   05/26/15


Salud con Health Net


Salud Hmo y Más service area

English 141kB   03/16/18


Broker/Employer

Salud con Health Net Overview

English 200kB   11/19/15


Member

Salud HMO y Más Brochure

Eng/Span 923kB   05/17/16


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 289kB   03/13/18

Central California 274kB   03/13/18

Los Angeles County 300kB   03/13/18

Orange County 279kB   03/13/18

Riverside County 268kB   03/13/18

San Bernardino County 270kB   03/13/18

San Diego County 270kB   03/13/18



How Soon Can I See the Doctor

English 776kB   05/04/18

En Español (Spanish) 40kB   04/18/18



Provider Search Information

English 477kB   07/26/17

En Español (Spanish) 414kB   09/07/17


County Reference Quick Guide

English 61kB   02/05/15


Provider Directories
If you are looking for a participating provider, please use ProviderSearch.


Pharmacy

Standard Pharmacy Network

English 3.3MB   03/16/18


Advanced Choice Pharmacy Network

English 4.5MB   03/16/18


Ancillary

Acupuncturists (Statewide)

English 9.3MB   06/06/18


Chiropractors (Statewide)

English 9.8MB   06/06/18


Health Net Vision (Statewide)

English 16.1MB   06/06/18


Health Net Dental

DHMO (North)

English 4MB   06/06/18


DHMO (South)

English 2.4MB   06/06/18


DPPO (North)

English 5.4MB   06/06/18


DPPO (South) Region A

English 4.8MB   06/06/18


DPPO (South) Region B

English 5.9MB   06/06/18



Information last updated 06-15-2018

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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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