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Consumer Health Care Reform Guide

Health Care Reform Timeline

Legend Plans for Indivduals and Families Plans for Indivduals and Families Small Group Plans Small Group Plans Large Group Plans Large Group Plans

2010

  • Choice of any participating primary care provider and access to ob-gyns Plans for Indivduals and Families Small Group Plans Large Group Plans
  • No lifetime limits on the dollar value of coverage; restrictions on annual limits Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Over-age dependent coverage for adult children to age 26 Plans for Indivduals and Families Small Group Plans Large Group Plans
  • 100% coverage for preventive care (all nongrandfathered plans) Plans for Indivduals and Families Small Group Plans Large Group Plans
  • No pre-existing conditions exclusions for children who are under 19 years of age Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Emergency services for all nongrandfathered plans are covered for: Plans for Indivduals and Families Small Group Plans Large Group Plans
    • With no prior authorization.
    • For any provider, whether in- or out-of-network.
    • At the same copayment or other cost-sharing, whether in- or out-of-network.
    • Without difference in coverage, whether in- or out-of-network.
  • Rescinding of coverage now limited to cases of consumer fraudPlans for Indivduals and Families Small Group Plans Large Group Plans
  • Nondiscrimination rules Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Early retiree reinsurance program Small Group Plans Large Group Plans
  • Tax credit up to 35% for eligible employers Small Group Plans

2011

  • Medical Loss Ratio (MLR) Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Over-the-counter drug reimbursements Small Group Plans Large Group Plans

2012

  • Summary of Benefits and Coverage (SBCs) Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Women's preventive services Plans for Indivduals and Families Small Group Plans Large Group Plans
  • PCORI fee Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Report value of employer-sponsored coverage on W-2s if filing 250+ W-2s Large Group Plans

2013

  • Health insurance marketplaces open in October for enrollment effective 1/1/14 Plans for Indivduals and Families Small Group Plans
  • FSA contribution limits Small Group Plans Large Group Plans
  • Notify employees about the new marketplace by October 1, 2013, per Department of Labor Small Group Plans Large Group Plans

2014

  • Individuals and small business can buy health coverage via the health insurance marketplaces. Plans for Indivduals and Families Small Group Plans
  • Individual mandate to have health insurance coverage. Applies to most Americans. People currently insured through an employer or a plan they bought on their own likely meet the requirements already. So do those enrolled in a Medicare plan, TRICARE, Medicaid, and a few other programs.
  • Essential health benefits (EHB):
    • Coverage required for nongrandfathered individual and small group commercial plans Plans for Indivduals and Families Small Group Plans
    • Plans subject to EHB requirements — or that choose to cover these services — must cover them with
      no annual dollar limits Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Guaranteed availability of insurance; no pre-existing condition exclusions Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Premium rating rules Plans for Indivduals and Families Small Group Plans
  • Annual cost-sharing limits Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Health insurance tax Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Reinsurance contribution fee Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Clinical trials Plans for Indivduals and Families Small Group Plans Large Group Plans
  • Wellness program rewards Small Group Plans Large Group Plans
  • Tax credit up to 50% for eligible employers Small Group Plans

2015

  • Employer shared responsibility for large employers with 100 or more full-time employees Large Group Plans

2016

  • Employer shared responsibility for employers with 51-99 full-time employees Large Group Plans
  • SHOP expands to businesses with up to 100 employees Small Group Plans

2017

  • States have the option to expand SHOP to businesses with 100+ employees Large Group Plans

2018

  • Excise tax on high-cost insurance plans Small Group Plans Large Group Plans

 

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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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Dental: 1-800-213-6991

Where You Can Buy Plans

You can buy health coverage directly from Health Net. We are also a part of Covered California® so you can buy a Health Net plan through the marketplace.


You have to buy health coverage through Covered California to get financial help from the government. You can click our link below to see if you qualify. Then Health Net can help you sign-up.

About Plan Levels

Health plans for individuals and families come in four metal levels: platinum, gold, silver and bronze. The difference between the levels is how much you pay versus how much the health insurance company pays.

There is also a minimum coverage option for people under 30. It’s also for people having financial hardship.

Health Net offers plans in all metal levels. So we have an option for you no matter what level of coverage you want.

About Plan Types

We offer several types of plans. There are HMO and HSP plans offered by Health Net of California, Inc. PPO and EPO insurance plans are offered by Health Net Life Insurance Company.

With an HMO, you have one main doctor called a primary care physician who coordinates all your care. You see your PCP for checkups, advice and care when sick or hurt. Your doctor refers you to other services when you need them. You get all services from the HMO network. There is no coverage if you see doctors who are not in the network, except in an emergency.

EPO insurance plans also come with a network of doctors and hospitals. You do not need a referral to use covered services but you do have to use the EPO network. There is no coverage if you see doctors who are not in the network, except in an emergency.

An HSP (Health care service plan) has one network to use for all covered services. There is no coverage for services received outside of the network, except in an emergency or for urgent care. With an HSP, you are required to pick a primary care physician (PCP)– a main doctor to see for checkups, advice and care when sick or hurt. Members can go directly to any doctor or specialist in the network without the need for a referral.

PPO plans give you the choice to go directly to any doctor. You can see a doctor in the PPO provider network. Or you can visit a doctor outside our network. You generally pay less out-of-pocket when you go to a doctor that is in the PPO network.

You have a PCP PCP referral needed before you get services Have one network for all services OK to get services outside of the network
HMO Yes Yes Yes, CommunityCare No, except as noted above.
EPO No No Yes, PureCare One No, except as noted above.
HSP Yes No Yes, PureCare No, except as noted above.
PPO No No No. Using the PPO network is your choice. When you do, you generally pay less out-of-pocket! Yes

About Financial Help

You can buy health coverage directly from Health Net. We are also a part of Covered California® so you can buy a Health Net plan through the marketplace.

You have to buy health coverage through Covered California to get financial help from the government. You can click our link below to see if you qualify. Then Health Net can help you sign-up.

Special Needs Plan Disclaimer

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