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Small Business Group Plans – 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 115kB   02/23/16

Portfolio Guide 1.7MB   02/23/16

Renewal Guide 1.8MB   01/21/16

CommunityCare HMO Sell Sheet 741kB   04/04/16



Standard Product Overview Folders

English 646kB   08/13/15

Español (Spanish) 733kB   06/15/15



Presentation Folder, with pocket

English 529kB   11/25/15


Applications and Forms

Enrollment and Change Applications

Top Reasons for Employee Enrollment Delays

English 279kB   08/31/15


Employee Enrollment and Change Form (January 2016)

English 941kB   03/01/16

Español (Spanish) 536kB   02/02/16

Chinese (Chinese) 843kB   02/02/16

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 (December 2015)

English 527kB   12/02/15

Español (Spanish) 544kB   12/04/15

Chinese (Chinese) 831kB   12/04/15

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

January 2016 246kB   11/10/15

December 2015 191kB   11/10/15


Group Service Agreement/Policy Applications

Group Size Attestation Form

English 69kB   01/06/16

Must be completed & signed by the Employer Group.


Application for Group Service Agreement/Policy

January 2016 629kB   03/11/16

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

Continuity of Care Assistance Request Form

English 104kB   02/04/16

Español (Spanish) 94kB   02/04/16


Pharmacy Transition of Care

English 43kB   01/26/16

Español (Spanish) 44kB   01/26/16


Claims

Commercial Foreign Claims Questionnaire

English 71kB   03/31/15

Español (Spanish) 456kB   03/31/15


Medical Claim Form

English 110kB   10/20/15

Español (Spanish) 108kB   10/20/15


Prescription Drug Claim Form

English 59kB   07/20/15

Español (Spanish) 59kB   07/20/15


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

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

Disclosure Directive 95kB   05/27/15


Authorization For Disclosure of PHI

English 98kB   02/01/16

Español (Spanish) 69kB   02/01/16

Chinese (Chinese) 234kB   02/04/16

Korean (Korean) 219kB   02/01/16


Additional Forms

Direct Deposit Authorization Broker Agreement Form

English 83kB   01/21/16

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


Electronic Check Form (For New Business Groups)

English 45kB   01/21/16


Group Life Insurance Conversion Form

English 61kB   02/20/15


Evidence of Insurability Life Form

English 129kB   03/14/16


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


Plan Overviews / Summary of Benefits (Dec '15 - Present)

Plan Overviews
HMO Products – For new and renewing groups effective 12/1/15. PPO/EPO Products – For new and renewing groups effective 1/1/16

PPO

Platinum 90 208kB   10/27/15

Gold 80 206kB   10/27/15

Silver 70 210kB   10/27/15

Bronze 60 39kB   12/10/15

Bronze 60 HSA 211kB   10/27/15


PureCare EPO

Gold 80 Alternate 237kB   10/27/15

Silver 70 Alternate 210kB   10/27/15


PureCare HSP

Platinum 90 197kB   10/27/15

Gold 80 197kB   10/27/15

Silver 70 198kB   10/27/15

Bronze 60 34kB   12/10/15


HMO

Platinum 10 33kB   12/30/15

Platinum 20 33kB   12/30/15

Gold 30 33kB   12/30/15

Gold 40 33kB   12/30/15

Gold 50 32kB   12/30/15


WholeCare HMO

Platinum 10 33kB   12/30/15

Platinum 20 33kB   12/30/15

Gold 30 33kB   12/30/15

Gold 40 33kB   12/30/15

Gold 50 32kB   12/30/15


SmartCare HMO

Platinum 10 33kB   12/30/15

Platinum 20 33kB   12/30/15

Gold 30 33kB   12/30/15

Gold 40 33kB   12/30/15

Gold 50 32kB   12/30/15


CommunityCare HMO

Gold 5 34kB   12/30/15

Silver 20 34kB   12/30/15


Salud HMO y Más

Platinum 10 37kB   12/30/15

Platinum 20 37kB   12/30/15

Gold 30 37kB   12/30/15

Gold 40 37kB   12/30/15

Gold 50 37kB   12/30/15


Covered California for Small Business (PPO)

Platinum 90 190kB   10/27/15

Gold 80 208kB   10/27/15

Silver 70 209kB   10/27/15

Bronze 60 209kB   10/27/15


Covered California for Small Business (PureCare EPO)

Gold 80 Alternate 236kB   10/27/15

Silver 70 Alternate 241kB   10/27/15


Summary of Benefits

PPO

Coming soon!


PureCare EPO

Coming soon!


PureCare HSP

Platinum 90 569kB   02/05/16

Platinum 90 w/inf 570kB   02/05/16

Gold 80 566kB   02/05/16

Gold 80 w/inf 569kB   02/05/16

Silver 70 573kB   02/05/16

Silver 70 w/inf 576kB   02/05/16

Bronze 60 574kB   02/05/16

Bronze 60 w/inf 577kB   02/05/16


HMO

Platinum 10 516kB   02/05/16

Platinum 10 w/inf 518kB   02/05/16

Platinum 20 517kB   02/05/16

Platinum 20 w/inf 519kB   02/05/16

Gold 30 511kB   02/05/16

Gold 30 w/inf 520kB   02/05/16

Gold 40 515kB   02/05/16

Gold 40 w/inf 515kB   02/05/16

Gold 50 517kB   02/05/16

Gold 50 w/inf 520kB   02/05/16


WholeCare HMO

Platinum 10 377kB   02/05/16

Platinum 10 w/inf 380kB   02/05/16

Platinum 20 377kB   02/05/16

Platinum 20 w/inf 380kB   02/05/16

Gold 30 393kB   02/05/16

Gold 30 w/inf 395kB   02/05/16

Gold 40 393kB   02/05/16

Gold 40 w/inf 393kB   02/05/16

Gold 50 393kB   02/05/16

Gold 50 w/inf 385kB   02/05/16


SmartCare HMO

Platinum 10 330kB   02/05/16

Platinum 10 w/inf 332kB   02/05/16

Platinum 20 330kB   02/05/16

Platinum 20 w/inf 332kB   02/05/16

Gold 30 342kB   02/05/16

Gold 30 w/inf 333kB   02/05/16

Gold 40 331kB   02/05/16

Gold 40 w/inf 332kB   02/05/16

Gold 50 330kB   02/05/16

Gold 50 w/inf 338kB   02/05/16


CommunityCare HMO

Gold 5 332kB   02/05/16

Gold 5 w/inf 400kB   02/05/16

Silver 20 380kB   02/05/16

Silver 20 w/inf 372kB   02/05/16


Salud HMO y Más

Platinum 10 511kB   02/05/16

Platinum 10 w/inf 507kB   02/05/16

Platinum 20 518kB   02/05/16

Platinum 20 w/inf 521kB   02/05/16

Gold 30 448kB   02/05/16

Gold 30 w/inf 519kB   02/05/16

Gold 40 518kB   02/05/16

Gold 40 w/inf 517kB   02/05/16

Gold 50 512kB   02/05/16

Gold 50 w/inf 508kB   02/05/16


Plan Overviews / Summary of Benefits (Jan '15 - Nov '15)

Plan Overviews
HMO Products – For groups that renewed between 1/1/15 –11/1/15. PPO/EPO Products – For groups that renewed between 1/1/15 – 12/1/15

PPO

Platinum 90 149kB   12/18/14

Gold 80 149kB   12/18/14

Silver 70 150kB   12/18/14

Bronze 60 148kB   12/18/14


EPO

Gold 80 Alternate 183kB   12/18/14

Silver 70 HSA Alternate 185kB   12/18/14


PureCare HSP

Silver Standard Coinsurance 154kB   12/18/14

Bronze Standard Coinsurance 154kB   01/04/16


WholeCare HMO

Platinum 10 164kB   01/05/16

Platinum 25 162kB   01/05/16

Gold 35 162kB   01/05/16

Gold 45 162kB   01/05/16

Platinum Standard Copay 162kB   12/16/14

Gold Standard Copay 162kB   12/16/14


SmartCare HMO

Platinum 10 163kB   01/05/16

Platinum 20 160kB   01/05/16

Platinum 30 160kB   01/05/16

Gold 40 160kB   01/05/16

Gold 50 160kB   01/05/16


Salud HMO

Platinum 10 166kB   01/05/16

Platinum 20 163kB   01/05/16

Platinum 25 163kB   01/05/16

Gold 35 163kB   01/05/16

Gold 45 163kB   01/05/16


Summary of Benefits

PPO

Platinum 90 2.4MB   03/27/15

Platinum 90 w/ inf 2.4MB   03/27/15

Gold 80 1.6MB   03/27/15

Gold 80 w/ inf 2.4MB   03/27/15

Silver 70 2.4MB   03/27/15

Silver 70 w/ inf 2.4MB   03/27/15

Bronze 60 2.5MB   03/27/15

Bronze 60 w/ inf 2.5MB   03/27/15


Covered California (SHOP) Plan Overviews

EPO

Gold 80 Alternate 182kB   12/18/14

Silver 70 HSA Alternate 184kB   12/18/14


PPO

Platinum 90 150kB   12/18/14

Gold 80 150kB   03/27/15

Silver 70 150kB   12/18/14

Bronze 60 26kB   12/18/14


Covered California (SHOP) PPO Summary of Benefits

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

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


Rate Guides

Standard

April 2016

English 1MB   02/15/16

Rates effective April 1, 2016, through June 30, 2016


January 2016

English 947kB   12/03/15

Rates effective January 1, 2016, through March 31, 2016


December 2015

English 1.1MB   11/25/15

Rates effective December 1, 2015, through December 31, 2015


Covered California

April 2016

English 1MB   02/15/16

Rates effective April 1, 2016, through June 30, 2016


January 2016

English 1MB   12/03/15

Rates effective January 1, 2016, through March 31, 2016


Cal-Choice

April 2016

English 389kB   02/12/16

Rates effective April 1, 2016, through June 30, 2016


January 2016

English 392kB   01/04/16

Rates effective January 1, 2016, through March 31, 2016


Underwriting Guidelines

April 2016

Enhanced Choice A

English 28kB   04/11/16


Enhanced Choice B

English 28kB   04/11/16


Dental & Vision

English 31kB   04/11/16


Health Net Life

English 27kB   04/11/16


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 1kB   04/04/16


Ensure Your Employees Understand Their Health Care

English 56kB   12/18/15


Preventive Care Services Overview (ACA Non-Grandfathered Plans)

English 314kB   12/28/15

Español (Spanish) 297kB   12/28/15


Support Tools

Broker Bonus Program

English 171kB   03/04/16


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


Protect Your Wallet. Always Use the PureCare One EPO Network flyer

English 273kB   01/21/16


Cadillac Tax Fact Sheet

English 141kB   01/19/16


Health Net Beginnings

English 137kB   10/01/15

Español (Spanish) 136kB   10/01/15


MinuteClinics Listing

English 188kB   03/08/16


Prior-Carrier Deductible Credit Flyer

English 183kB   12/07/15


Commercial Sales Guidelines

English 601kB   02/12/16


Information for Small Business Groups

English 151kB   01/04/16


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 4.8MB   02/23/16


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 490kB   08/21/15


Online Support Tools

Secure Messaging Reference Guide

English 887kB   04/03/15


Group Administrator Registration Guide

English 794kB   03/09/16


Online Broker Tools Reference Guide

English 1.6MB   06/17/14


Broker Book of Business Tool Update

English 559kB   12/18/15


Book of Business Instructional Guide

English 1.6MB   06/17/14


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 438kB   07/09/15

Español (Spanish) 443kB   07/09/15


First Health Physician Nomination Form

English 87kB   04/28/10


Pharmacy


Coverage of Blood Glucose Test Strips - For New Members

English 109kB   11/02/15


Getting Started With Mail Order Pharmacy Kit

English 385kB   02/16/16

Español (Spanish) 401kB   02/16/16


Supplemental Coverage


Pediatric Dental and Vision

Vision 786kB   01/22/16

HMO/HSP 195kB   02/01/16

PPO/EPO 186kB   02/01/16


Exclusions and Limitations

English 489kB   08/31/12


Infertility Benefits

English 177kB   02/24/15


Chiropractic Care Flyer

English 173kB   01/15/16


Vision

Vision PPO FAQ

English 302kB   10/01/15


Member HMO Vision Flyer

English 158kB   10/01/15

Español (Spanish) 158kB   10/01/15


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


Dental Provider Search

English/Spanish 276kB   03/03/14


Your Dental Website (member)

English 263kB   07/29/15


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 Life Insurance with AD&D

English 173kB   01/08/16

Español (Spanish) 173kB   01/08/16

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

English 2.9MB   06/19/15

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 0kB   12/31/69

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 141kB   11/06/15

Español (Spanish) 142kB   11/06/15


Decision Power Employer Flyer

English 184kB   11/24/15


National Observances Calendar for Employers

English 566kB   12/29/15


Wellness Online

English 287kB   11/24/15

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

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 318kB   11/24/15

Español (Spanish) 319kB   11/24/15


Decision Power™ Member Brochure

English 578kB   05/18/15

Español (Spanish) 582kB   11/24/15


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


Preventive Screening Guidelines – Web PDF only

English 288kB   09/18/14

Español (Spanish) 290kB   09/18/14


Tips to Stop Smoking

English 224kB   01/26/16


Exercise Band Workout

English 278kB   02/20/15

Español (Spanish) 273kB   04/28/15


Wellness Seminars Menu

English 380kB   05/26/15


Health Coaching Program Flyer

English 143kB   08/26/15


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


Member

Salud HMO y Más Brochure

Eng/Span 930kB   12/03/15


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 180kB   04/08/16

Central California 162kB   03/29/16

Los Angeles County 459kB   03/29/16

Orange County 360kB   03/29/16

Riverside County 327kB   03/29/16

San Bernardino County 331kB   03/29/16

San Diego County 338kB   03/29/16



Provider Search Information

English 1.2MB   04/26/16

Español (Spanish) 256kB   11/06/15


County Reference Quick Guide

English 61kB   02/05/15



HMO Network

North 9.6MB   10/20/15

South (Region A) 10.5MB   10/20/15

South (Region B) 9.7MB   10/20/15


PPO Network

North 11.8MB   03/11/16

South (Region A) 12.6MB   03/11/16

South (Region B) 15.5MB   03/11/16



WholeCare HMO Network

North 8.5MB   10/20/15

South (Region A) 9.2MB   10/20/15

South (Region B) 10.1MB   10/20/15



SmartCare HMO Network

North 7.5MB   10/20/15

South (Region A) 9MB   10/20/15

South (Region B) 7.8MB   10/20/15



ExcelCare Network

North 11.5MB   10/20/15

Central Valley 12.2MB   10/20/15

South (Region A) 14.8MB   10/20/15

South (Region B) 14MB   10/20/15



Salud

Salud HMO y Más 1.9MB   10/20/15

SIMNSA 441kB   05/28/15


Ancillary

Acupuncturists (Statewide)

English 1.4MB   03/08/16


Chiropractors (Statewide)

English 1.6MB   03/08/16


Health Net Vision (Statewide)

English 1.1MB   03/08/16


Health Net Dental

DHMO (North)

English 1.2MB   03/08/16


DHMO (South)

English 1.7MB   03/08/16


DPPO (North)

English 2.6MB   03/08/16


DPPO (South) Region A

English 2.3MB   03/08/16


DPPO (South) Region B

English 2.9MB   03/08/16



Information last updated 04-26-2016

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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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