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Forms and Brochures – Medicare Advantage Plans

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2016 Forms


Enrollment Form

English 97kB   10/05/15

Español (Spanish) 169kB   12/01/15

Chinese (Chinese) 4.6MB   12/01/15


Abbreviated Enrollment Form

English 145kB   10/26/15

Español (Spanish) 109kB   12/01/15

Chinese (Chinese) 297kB   12/01/15


Dental Selection Form

English 43kB   10/16/15


Disenrollment Form

English 10kB   09/30/15


Automatic Bank Draft (ABD) Form

English 158kB   03/03/16


Optional Supplemental Benefits Enrollment Form

English 71kB   10/14/15


Jade (HMO SNP) Prequalification Form

English 83kB   03/03/16

Español (Spanish) 58kB   10/20/15


HIPAA Form

English 54kB   09/29/15

Authorization for Disclosure of Protected Health Information


2016 Summary of Benefits

Amber I (HMO SNP)

Kern, Los Angeles, Orange, Riverside & San Bernardino

English 544kB   10/01/15

Español (Spanish) 700kB   11/13/15


Amber II (HMO SNP)

Fresno, Los Angeles, Orange, San Diego & San Francisco

English 545kB   10/01/15

Español (Spanish) 665kB   11/13/15


Kern, Riverside, San Bernardino & Tulare

English 547kB   10/13/15

Español (Spanish) 664kB   11/13/15


Amber II Premier (HMO SNP)

Fresno

English 550kB   10/01/15

Español (Spanish) 672kB   11/13/15


Gold Select (HMO)

Los Angeles, Orange

English 461kB   10/13/15

Español (Spanish) 509kB   11/13/15


Riverside, San Bernardino

English 523kB   10/13/15

Español (Spanish) 583kB   11/13/15


Green (HMO)

Los Angeles, Riverside & San Bernardino

English 478kB   10/01/15

Español (Spanish) 166kB   12/01/15


Alameda, Placer, Sacramento, Sonoma & Stanislaus

English 483kB   10/01/15

Español (Spanish) 508kB   11/13/15


Healthy Heart (HMO)

Alameda & Stanislaus

English 501kB   10/01/15

Español (Spanish) 576kB   11/13/15


Fresno

English 502kB   10/01/15

Español (Spanish) 573kB   11/13/15


Los Angeles, Orange

English 162kB   10/01/15

Español (Spanish) 189kB   11/13/15


Riverside & San Bernardino

English 159kB   10/01/15

Español (Spanish) 593kB   11/13/15


San Diego

English 503kB   10/01/15

Español (Spanish) 573kB   11/13/15


San Francisco

English 529kB   10/01/15

Chinese (Chinese) 354kB   11/19/15


Yolo

English 501kB   10/01/15

Español (Spanish) 572kB   11/13/15


Placer, Sacramento

English 501kB   10/01/15


Jade (HMO SNP)

Kern, Los Angeles & Orange

English 504kB   10/13/15

Español (Spanish) 553kB   11/13/15


Ruby Select (HMO)

Placer, Sacramento

English 159kB   10/01/15


San Francisco

English 559kB   10/13/15

Chinese (Chinese) 642kB   11/19/15


Yolo

English 157kB   10/01/15

Español (Spanish) 509kB   11/13/15


Ruby (HMO)

Kern

English 502kB   10/01/15

Español (Spanish) 575kB   11/13/15


Santa Clara

English 501kB   10/01/15

Español (Spanish) 547kB   11/13/15


Sonoma

English 157kB   10/01/15

Español (Spanish) 548kB   11/13/15


Violet (PPO)

San Francisco

English 509kB   10/01/15

Chinese (Chinese) 396kB   12/01/15


Yolo

English 509kB   10/01/15

Español (Spanish) 199kB   12/01/15


Sapphire (HMO)

Los Angeles, Orange & San Diego

English 498kB   10/13/15

Español (Spanish) 560kB   11/13/15


Kern, Riverside & San Bernardino

English 501kB   10/13/15

Español (Spanish) 560kB   11/13/15


Sapphire Premier (HMO)

Fresno, Los Angeles, Orange, San Diego & San Francisco

English 499kB   10/01/15

Español (Spanish) 538kB   11/13/15


2016 Directories


Provider Directory Update Flyer

English 156kB   12/09/15

Español (Spanish) 159kB   12/09/15

Chinese (Chinese) 155kB   12/09/15


Provider Directories
HMO

HMO Bay Area

English 2MB   10/09/15

Chinese (Chinese) 2.8MB   01/06/16

Alameda, Contra Costa, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma


HMO Central Valley

English 1.5MB   10/21/15

Fresno, Kern, Placer, Sacramento, San Joaquin, Stanislaus, Taulare & Yolo


HMO Inland Empire

English 1.5MB   10/09/15

Riverside & San Bernardino


HMO Santa Barabara

English 425kB   10/09/15

Santa Barabara


HMO Los Angeles

English 4MB   10/09/15

Los Angeles


HMO Orange County

English 2.2MB   10/09/15

Orange


HMO San Diego

English 989kB   10/09/15

San Diego


Healthy Heart (HMO) San Diego

English 611kB   10/09/15

San Diego


Gold Select (HMO) Orange

English 1.6MB   10/09/15

Orange


Gold Select (HMO) Inland Empire

English 949kB   10/09/15

Riverside & San Bernardino


Gold Select (HMO) Los Angeles

English 3MB   10/09/15

Los Angeles


Ruby Select (HMO)

English 563kB   10/09/15

Chinese (Chinese) 1.3MB   01/06/16

San Francisco


Ruby Select (HMO)

English 539kB   10/09/15

Placer & Sacramento


Ruby Select (HMO)

English 563kB   10/09/15

Yolo


Sapphire (HMO)

English 4.1MB   10/09/15

Los Angeles


Sapphire (HMO)

English 3.5MB   10/09/15

Kern, Orange, Riverside, San Bernardino & San Diego


Provider Directories
HMO SNP

Amber I / Amber II (HMO SNP)

English 4.1MB   10/09/15

Los Angeles


Amber I (HMO SNP)

English 3MB   10/22/15

Kern, Orange, Riverside & San Bernardino


Amber II (HMO SNP)

English 1.2MB   10/21/15

Fresno, Kern, San Francisco & Tulare


Amber II (HMO SNP)

English 3.1MB   10/22/15

Orange, Riverside, San Bernardino & San Diego


Jade (HMO SNP)

English 1.2MB   10/09/15

Kern & Orange


Jade (HMO SNP)

English 2.5MB   10/09/15

Los Angeles


Sapphire Premier (HMO)

English 718kB   10/19/15

Fresno & San Francisco


Sapphire Premier (HMO)

English 2.2MB   10/19/15

Orange & San Diego


Sapphire Premier (HMO)

English 3.3MB   10/19/15

Los Angeles


Amber II Premier (HMO SNP)

English 315kB   10/19/15

Fresno


Provider Directories
PPO

Violet (PPO)

English 431kB   10/09/15

Chinese (Chinese) 1.1MB   01/06/16

San Francisco & Yolo


Dental Directories

Dental (HMO)

English 2.7MB   03/07/16


Dental (PPO)

English 1.7MB   10/16/15

Los Angeles


Dental (PPO)

English 1.3MB   10/16/15

Northern California


Dental (PPO)

English 1.7MB   10/16/15

Southern California


Other Directories

Chiropractic / Acupunture

English 1.1MB   10/16/15


Mental Health Network (MHN)

English 994kB   10/16/15


Vision

English 815kB   10/16/15


Silver Sneakers

English 632kB   10/16/15


Pharmacy Network Changes

English 130kB   05/23/16


Pharmacy

English 745kB   10/15/15

Español (Spanish) 1.3MB   11/09/15

Chinese (Chinese) 1.5MB   11/09/15

Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Sapphire (HMO), Health Net Seniority Plus Sapphire Premier (HMO), and Health Net Seniority Plus Employer (HMO)


Pharmacy

English 770kB   08/25/15

Español (Spanish) 792kB   11/09/15

Chinese (Chinese) 1MB   11/09/15

Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), and Health Net Violet (PPO)


2016 Flyers, Brochures and Inserts


Quick Reference Flyer

English 150kB   05/10/16


Medicare Newsletter

English 10.6MB   06/07/16


Multi-Language Insert

Multilingual 341kB   10/05/15


Pharmacy

Mail Order Pharmacy

Getting Started With Mail Order Pharmacy Kit

English 385kB   02/16/16

Español (Spanish) 401kB   02/16/16


Medication Therapy Management

Personal Medication List

English 25kB   05/02/16


Prescription Claims

Prescription Drug Claim Form (Medicare Members)

English 145kB   11/23/15


Prescription Drug Claim Form (Commercial Members)

English 59kB   07/20/15

Español (Spanish) 59kB   07/20/15


Prescription Transition Form

Prescription Transition Form (Commercial Members)

English 43kB   01/26/16

Español (Spanish) 44kB   01/26/16


Star Ratings

HMO Star Ratings

Part C and Part D

English 119kB   10/26/15

Español (Spanish) 27kB   10/26/15

Chinese (Chinese) 187kB   10/26/15


HMO SNP Star Ratings

Part C and Part D

English 113kB   10/26/15


PPO Star Ratings

Part C and Part D

English 111kB   10/26/15

Español (Spanish) 64kB   10/26/15

Chinese (Chinese) 180kB   10/26/15



Information last updated 09-01-2016

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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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For more information, please review carefully the disclosure form for your plan. It includes additional terms and information on certain exclusions and limitations.

The Evidence of Coverage (EOC) for your plan contains the complete terms and conditions of your Health Net coverage. It is important for you to thoroughly review the disclosure form and EOC for your plan, especially those sections that apply to those with special health care needs. You may view your Evidence of Coverage by: closing the current window and clicking on MY MEDICAL BENEFITS.

You may request copies of the forms referenced above for your health plan by: closing this window and clicking on Contact Us at the top of any web page.
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