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Groups 2-50 Forms & Brochures – 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 order for Mail delivery or send by email, select the check box next to the item(s) of your choice and click either the "Mail" or the "Email" button at the bottom of this page.



Plan Brochures / Product Overviews

Plan Brochures

Portfolio Plan Desktopper

English 129kB   10/24/14


Portfolio Guide

English 1.9MB   03/27/15


Product Overview folders

Standard

English 1.5MB   07/17/14

Español (Spanish) 810kB   07/21/14



Presentation Folder, with pocket

English 633kB   02/20/15


Applications and Forms

Enrollment and Change Applications

Employee Enrollment and Change Form

English 605kB   02/20/15

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

English 233kB   11/14/14


Group Service Agreement/Policy Applications

Application for Group Service Agreement/Policy

English 253kB   04/27/15

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 SBG Account Management for processing.


Transition of Care

Medical Transition of Care

English 574kB   07/26/12

Español (Spanish) 329kB   01/28/13

Chinese (Chinese) 1.8MB   11/19/13

Korean 401kB   11/19/13


Pharmacy Transition of Care

English 54kB   11/20/14

Español (Spanish) 41kB   11/20/14

Chinese (Chinese) 738kB   11/20/14

Korean 612kB   11/20/14


Claims

Commercial Claim Form

English 127kB   03/31/15

Español (Spanish) 113kB   03/31/15

Chinese (Chinese) 397kB   03/31/15


Commercial Foreign Claims Questionnaire

English 71kB   03/31/15

Español (Spanish) 456kB   03/31/15


Dental Claim Form

English 2.8MB   04/12/10


Vision Claim Form

English 84kB   04/14/10


Pharmacy Claim Form

English 189kB   04/27/15

Español (Spanish) 199kB   04/27/15

Chinese (Chinese) 454kB   04/27/15

Korean (Korean) 2.1MB   04/27/15


HIPAA Disclosures

Group Health Plan HIPAA Disclosure Forms

Directive and Plan Sponsor Certification 90kB   11/20/14

Disclosure Directive 95kB   04/17/15


Authorization For Disclosure of PHI

English 575kB   04/16/13

Español (Spanish) 586kB   04/16/13

Chinese (Chinese) 487kB   04/16/13


Additional Forms

Group Life Insurance Conversion Form

English 61kB   02/20/15


Evidence of Insurability Life Form

English 142kB   01/21/15


Electronic Check Form (New business only)

English 656kB   07/12/11


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 53kB   01/24/14


Summary of Benefits / Plan Overviews

PPO Plan Overviews

Platinum 90 PPO

English 149kB   12/18/14


Gold 80 PPO

English 149kB   12/18/14


Silver 70 PPO

English 150kB   12/18/14


Bronze 60 PPO

English 148kB   12/18/14


PureCare HSP Plan Overviews

PureCare HSP Silver Standard Coinsurance

English 154kB   12/18/14


PureCare HSP Bronze Standard Coinsurance

English 154kB   12/18/14


HMO Plan Overviews

WholeCare HMO Platinum Standard Copay

English 162kB   12/16/14


WholeCare HMO Gold Standard Copay

English 162kB   12/16/14


EPO Plan Overviews

Gold 80 EPO Alternate

English 183kB   12/18/14


Silver 70 HSA EPO Alternate

English 185kB   12/18/14


PPO Summary of Benefits
Download only

Platinum 90 PPO

English 2.4MB   03/27/15


Platinum 90 PPO with Infertility

English 2.4MB   03/27/15


Gold 80 PPO

English 1.6MB   03/27/15


Gold 80 PPO with Infertility

English 2.4MB   03/27/15


Silver 70 PPO

English 2.4MB   03/27/15


Silver 70 PPO with Infertility

English 2.4MB   03/27/15


Bronze 60 PPO

English 2.5MB   03/27/15


Bronze 60 PPO with Infertility

English 2.5MB   03/27/15


Covered California (SHOP) EPO Plan Overviews

Covered California 80 EPO Alternate

English 182kB   12/18/14


Covered California Silver 70 HSA EPO Alternate

English 184kB   12/18/14



Covered California (SHOP) PPO Plan Overviews

Platinum 90 PPO 150kB   12/18/14

Gold 80 PPO 150kB   03/27/15

Silver 70 PPO 150kB   12/18/14

Bronze 60 PPO 26kB   12/18/14


Covered California (SHOP) PPO Summary of Benefits
Download only

Platinum 90 PPO

English 2MB   03/10/15

Español (Spanish) 2.1MB   03/10/15

Chinese (Chinese) 3MB   03/24/15


Platinum 90 PPO with Infertility

English 2MB   03/10/15

Español (Spanish) 2.1MB   03/10/15

Chinese (Chinese) 3MB   03/24/15


Gold 80 PPO

English 2MB   03/10/15

Español (Spanish) 2.1MB   03/10/15

Chinese (Chinese) 3MB   03/24/15


Gold 80 PPO with Infertility

English 2MB   03/10/15

Español (Spanish) 2.1MB   03/10/15

Chinese (Chinese) 3MB   03/24/15


Silver 70 PPO

English 2MB   03/10/15

Español (Spanish) 2.1MB   03/10/15


Silver 70 PPO with Infertility

English 2MB   03/10/15

Español (Spanish) 2.1MB   03/10/15


Bronze 60 PPO

English 2.1MB   03/10/15

Español (Spanish) 2.1MB   03/10/15

Chinese (Chinese) 3.1MB   03/24/15


Bronze 60 PPO with Infertility

English 2.1MB   03/10/15

Español (Spanish) 2.1MB   03/10/15

Chinese (Chinese) 3.1MB   03/24/15


Covered California (SHOP) EPO Summary of Benefits
Download only

Gold 80 EPO Alternate

English 2.1MB   03/24/15

Español (Spanish) 2.1MB   03/24/15

Chinese (Chinese) 3.1MB   03/24/15


Gold 80 EPO Alternate with Infertility

English 2.1MB   03/24/15

Español (Spanish) 2.1MB   03/24/15

Chinese (Chinese) 2.1MB   03/24/15


Silver 70 HSA EPO Alternate

English 2MB   03/24/15

Español (Spanish) 2MB   03/24/15

Chinese (Chinese) 3MB   03/24/15


Silver 70 HSA EPO Alternate with Infertility

English 2MB   03/24/15

Español (Spanish) 2MB   03/24/15

Chinese (Chinese) 2MB   03/24/15


December 2014 - Plan Overviews

SmartCare HMO Plan Overviews - December 2014

Platinum 10 163kB   09/30/14

Platinum 20 160kB   09/30/14

Platinum 30 160kB   09/30/14

Gold 40 160kB   09/30/14

Gold 50 160kB   09/30/14


WholeCare HMO Plan Overviews - December 2014

Platinum 10 164kB   09/30/14

Platinum 25 162kB   09/30/14

Gold 35 162kB   09/30/14

Gold 45 162kB   09/30/14


Salud HMO y Más Plan Overviews - December 2014

Platinum 10 166kB   09/30/14

Platinum 20 163kB   09/30/14

Platinum 25 163kB   09/30/14

Gold 35 163kB   09/30/14

Gold 45 163kB   09/30/14


December 2014 - Summary of Benefits

SmartCare HMO Summary of Benefits - December 2014

Platinum 10 354kB   10/27/14

Platinum 10 - with infertility 354kB   10/27/14

Platinum 20 354kB   10/27/14

Platinum 20 - with infertility 355kB   10/27/14

Platinum 30 354kB   10/27/14

Platinum 30 - with infertility 354kB   10/27/14

Gold 40 354kB   10/27/14

Gold 40 - with infertility 354kB   10/27/14

Gold 50 355kB   10/27/14

Gold 50 - with infertility 354kB   10/27/14


WholeCare HMO Summary of Benefits - December 2014

Platinum 10 350kB   10/27/14

Platinum 10 - with infertility 350kB   10/27/14

Platinum 25 355kB   10/27/14

Platinum 25 - with infertility 350kB   10/27/14

Platinum Standard - with infertility 351kB   10/27/14

Gold 35 351kB   10/27/14

Gold 35 - with infertility 351kB   10/27/14

Gold 45 355kB   10/27/14

Gold 45 - with infertility 350kB   10/27/14

Gold Standard - with infertility 352kB   10/27/14


Salud HMO y Más Summary of Benefits - December 2014

Platinum 10 434kB   10/27/14

Platinum 10 - with infertility 437kB   10/27/14

Platinum 20 435kB   10/27/14

Platinum 20 - with infertility 438kB   10/27/14

Platinum 25 433kB   10/27/14

Platinum 25 - with infertility 437kB   10/27/14

Gold 35 435kB   10/27/14

Gold 35 - with infertility 439kB   10/27/14

Gold 45 355kB   10/27/14

Gold 45 - with infertility 350kB   10/27/14


Rate Guides

Standard

July 2015

English 947kB   04/17/15

Rates effective July 1, 2015 through September 30, 2015.


June 2015

English 1MB   04/01/15

Rates effective June 1, 2015 through June 30, 2015.


April 2015

English 1MB   03/30/15

Rates effective April 1, 2015 through May 31, 2015.


Covered California

July 2015

English 991kB   05/06/15


June 2015

English 996kB   04/14/15

Rates effective June 1, 2015 through June 30, 2015.


April 2015

English 1.1MB   04/10/15

Rates effective April 1, 2015 through May 31, 2015.


Cal-Choice

July 2015

English 557kB   05/06/15


June 2015

English 631kB   04/01/15

Rates effective June 1, 2015 through June 30, 2015.


April 2015

English 636kB   04/01/15

Rates effective April 1, 2015 through May 31, 2015.


Underwriting Guidelines


Enhanced Choice

English 28kB   05/01/15


Dental & Vision

English 31kB   05/01/15


Healh Net Life

English 27kB   05/01/15


Support Tools

Health Care Reform Materials

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

Download only


Questions to Help Determine Grandfathered Plan Status (Employer)

English 54kB   11/22/10


Preventive Care Services Overview (ACA Non-Grandfathered Plans)

English 180kB   12/04/14

Español (Spanish) 161kB   12/04/14

Chinese (Chinese) 1.5MB   12/04/14


Support Tools

Understanding the Continuity of Care Assistance Policy

English 427kB   02/16/15

Download only


Infertility Benefits SBG plans

English 177kB   02/24/15


New Sales Bonus Program

English 213kB   03/27/15


Broker Information Guide

English 978kB   10/30/13


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


SBG Broker/Employer Renewal Guide

English 3.4MB   02/24/15


CVS MinuteClinics Listing

English 334kB   04/06/15


Prior-Carrier Deductible Credit Flyer

English 249kB   03/05/12


Commercial Sales Guidelines

English 5.1MB   02/25/15


Information for Small Business Groups

English 190kB   07/17/12


ER vs. Urgent Care (HMO)

English 193kB   03/09/15


ER vs. Urgent Care (PPO)

English 190kB   03/09/15


SBG Employer Administrative Manual

English 1.8MB   03/20/14


Uniform Glossary of Health Coverage and Medical Terms

English 92kB   09/11/12

Español (Spanish) 357kB   08/28/13

Chinese (Chinese) 231kB   08/28/13

Navajo 409kB   08/28/13

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 562kB   08/12/14


Online Support Tools

Secure Messaging Reference Guide

English 887kB   04/03/15


Online Broker Tools Reference Guide

English 1.6MB   06/17/14


Book of Business Instructional Guide

English 1.6MB   06/17/14


Employer Online Billing and Enrollment Brochure

English 280kB   12/09/14


Health Net Mobile App Instructions

English 360kB   09/05/14


Out of State PPO

Out-of-State PPO Brochure

English 433kB   08/29/14

Español (Spanish) 436kB   08/29/14


First Health Physician Nomination Form

English 87kB   04/28/10


Pharmacy


Pharmacy Benefits Member Guide

English 595kB   04/02/15

Español (Spanish) 732kB   04/02/15


Coverage of Blood Glucose Test Strips - For New Members

English 132kB   10/29/13


Mandatory Mail Order Pharmacy and Maintenance Choice® Program

English 189kB   04/07/15

Español (Spanish) 207kB   03/14/14


Pharmacy Mail Order Caremark Getting Started Kit

English 20kB   05/06/15

Kit includes flyer, form and envelope. This item is for members only and may not be included in Open Enrollment Kits.


Supplemental Coverage


Exclusions and Limitations

English 489kB   08/31/12


Chiropractic Care Flyer

English 176kB   11/14/14


Vision

Vision PPO FAQ

English 319kB   06/05/12


Preferred Value Plan 10-2

English 146kB   03/03/14

Español (Spanish) 157kB   03/03/14


Preferred Plan 1025-2

English 185kB   08/14/14


Preferred Plan 1025-3

English 147kB   03/03/14

Español (Spanish) 158kB   03/03/14


Dental

Dental Overview

English 166kB   03/03/14


HMO/HSP Pediatric Dental and Vision Flyer

English 195kB   11/14/14


PPO/EPO Pediatric Dental and Vision Flyer

English 186kB   11/14/14


Dental Provider Search

English/Spanish 276kB   03/03/14


DHMO

Plus (150) Plan Overview

English 162kB   03/03/14

Español (Spanish) 171kB   03/03/14


Plus (150) Schedule of Benefits

English 66kB   05/21/09


Value (150) Schedule of Benefits

English 104kB   05/21/09


Plus (225) Plan Overview

English 236kB   03/06/14


Plus (225) Schedule of Benefits

English 66kB   05/21/09


Value (225) Schedule of Benefits

English 103kB   05/21/09


DPPO

Classic Plus 1 2000

English 244kB   06/05/12

Español (Spanish) 257kB   06/05/12


Classic Plus 2 2000

English 249kB   05/09/12

Español (Spanish) 267kB   06/05/12


Classic 1 1500

English 239kB   06/05/12

Español (Spanish) 180kB   07/12/10


Classic 2 1500

English 242kB   06/05/12

Español (Spanish) 261kB   06/05/12


Classic 3 1500

English 242kB   06/05/12

Español (Spanish) 265kB   06/05/12


Classic 4 1500

English 246kB   06/05/12

Español (Spanish) 262kB   06/05/12


Classic 5 1500

English 536kB   03/11/15

Español (Spanish) 264kB   06/05/12


Classic 6 1500

English 242kB   06/05/12

Español (Spanish) 261kB   06/05/12


Essential 1 1000

English 231kB   10/19/11

Español (Spanish) 261kB   06/05/12


Essential Value 1 1000

English 533kB   02/24/15

Español (Spanish) 265kB   11/17/14


Essential 2 1000

English 246kB   10/19/11

Español (Spanish) 259kB   06/05/12


Essential 3 1000

English 247kB   10/19/11

Español (Spanish) 260kB   06/05/12


Essential 4 1000

English 247kB   10/19/11

Español (Spanish) 258kB   06/05/12


Essential 5 1500

English 246kB   10/19/11

Español (Spanish) 258kB   06/05/12


Essential 6 1500

English 233kB   10/19/11

Español (Spanish) 257kB   06/05/12


Basic 500

English 227kB   10/19/11

Español (Spanish) 241kB   06/05/12


Health Net Life

Product Guide

English 194kB   01/22/13


Basic $10K


Basic $15K

English 289kB   08/29/14


Basic $15K with AD&D

English 154kB   08/29/14


Basic $20K

English 289kB   08/29/14


Basic $20K with AD&D

English 151kB   08/29/14


Basic $25K

English 506kB   08/29/14


Basic $25K with AD&D

English 151kB   08/29/14


Basic $50K

English 277kB   08/29/14


Basic $50K with AD&D

English 151kB   08/29/14


Additional Forms / Brochures

Travel Guides

HMO/POS Travel Guide

English 2.9MB   01/06/15

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 2.7MB   04/16/15

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


Conversion Plan (COBRA)

Summary of Benefits

English 1.4MB   10/30/13


Additional Materials

Understanding your Explanation of Benefits (EOB)

English 359kB   05/19/15


Understanding Your Billing Statement

English 333kB   02/20/14

Download only


How To Read Your Commission Statement

English 555kB   06/06/14

Download only


How To Read Your Commission Statement

English 555kB   06/06/14

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


Smoking and Tobacco Cessation

English 168kB   02/20/15

Español (Spanish) 148kB   02/20/15


Decision Power Employer Brochure

English 179kB   02/20/15


National Observances – for Employers

English 429kB   02/20/15


Wellness Online

English 162kB   02/20/15

Español (Spanish) 178kB   02/20/15


Wellness Webinar flyer – for Employers

English 239kB   01/09/15


Decision Power™ Healthy Discounts Member Flyer

English 454kB   02/20/15

Español (Spanish) 239kB   04/28/15


Decision Power™ Text4Baby Flyer - PDF Only

English 194kB   03/13/15

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 183kB   02/20/15

Español (Spanish) 196kB   02/20/15


Decision Power™ Member Brochure

English 578kB   05/18/15

Español (Spanish) 581kB   05/06/15


Consequences of Obesity

English 300kB   10/04/11

Español (Spanish) 287kB   05/01/12


Consequences of High Blood Pressure

English 206kB   10/04/11

Español (Spanish) 211kB   05/01/12


How Does Your FAT Stack Up?

English 163kB   05/13/15


How Does Your SALT Stack Up?

English 165kB   05/13/15


How Does Your SUGAR Stack Up?

English 327kB   05/13/15


Decision Power Ready to Lose Weight?

English 155kB   04/07/15

Español (Spanish) 278kB   04/07/15


My Blood Pressure Wallet Card

English 95kB   04/24/12

Español (Spanish) 109kB   04/24/12


Preventive Screening Guidelines – Web PDF only

English 288kB   09/18/14

Español (Spanish) 290kB   09/18/14


Tips to Stop Smoking

English 255kB   05/05/15


Exercise Band Workout

English 278kB   02/20/15

Español (Spanish) 273kB   04/28/15


Wellness Seminars Menu

English 379kB   04/21/15


Decision Power™ California

Broker / Employer Materials

Decision Power™ California Employer Classic Toolkit - pdf only

English 2.8MB   04/02/15

Please open the PDF for a listing of all the pieces included in the Decision Power Employer Classic Toolkit. We encourage you to join our efforts to be more environmentally responsible, by reviewing our materials online in pdf format.


Salud con Health Net

Broker/Employer

Salud con Health Net Overview

English 192kB   08/12/14


Salud HMO y Más Service Areas

English 229kB   08/30/12


Member

Salud HMO y Más Brochure

Eng/Span 980kB   09/30/14


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

Provider Search Information

English 386kB   01/09/15

Español (Spanish) 377kB   02/12/15


County Reference Quick Guide

English 61kB   02/05/15



PPO Network

North 6.5MB   12/17/14

South (Region A) 4MB   12/17/14

South (Region B) 5.1MB   12/17/14

Download only



WholeCare HMO Network

North 17.5MB   12/17/14

South (Region A) 6.6MB   12/17/14

South (Region B) 5.5MB   12/17/14



ExcelCare Network

North 1.7MB   10/24/14

Central Valley 1.7MB   10/24/14

South (Region A) 11.5MB   10/24/14

South (Region B) 8.7MB   10/24/14

Download only



Salud

Salud HMO y Más 3.2MB   12/17/14

SIMNSA 451kB   10/11/13


Ancillary

Acupuncturists (Statewide)

English 1.2MB   11/18/14


Chiropractors (Statewide)

English 1.6MB   11/18/14


Health Net Vision (Statewide)

English 803kB   11/18/14


Health Net Dental

DHMO (North)

English 781kB   11/18/14


DHMO (South)

English 1.2MB   11/18/14


DPPO (North)

English 1.6MB   11/18/14


DPPO (South) Region A

English 1.5MB   11/18/14


DPPO (South) Region B

English 2MB   11/18/14



Tailored Networks Comparison Lists

Northern California 168kB   04/20/15

Central California 162kB   04/20/15

Los Angeles County 180kB   04/20/15

Orange County 167kB   04/20/15

Riverside County 161kB   04/20/15

San Bernardino County 163kB   04/20/15

San Diego 163kB   04/20/15

Download only



Information last updated 01-14-2015

Select documents in the language you desire, then click mail or email.

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Looking for Covered California Materials?

Fact sheets and collateral for IFP and SHOP.
Go to www.coveredca.com\collateral

Looking for HealthEquity Materials?

Learn more about HealthEquity HSA/HRA Plans on the HealthEquity website.
Go to HealthEquity sales resource site

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

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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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