Enrollment Guidelines

Commercial

Enrollment

Guidelines

Affordable health coverage for you

Effective January 1, 2014

Andre Hamil

We design health plans that are simple to use.

We are your Health Net.

Individual & Family Plans Off-Marketplace

Contents

Introduction

. . . 2

Agent/Broker responsibilities . . . 2

Eligibility Guidelines

. . . 4

Eligibility conditions . . . 4

Annual and Special Enrollment Periods . . . . 5

Addition of new dependents . . . 6

Children attaining age 26 . . . 7

Disabled child . . . 7

Guidelines to Submitting

Your Client’s IFP Applications

. . . 7

Things to remember when submitting applications . . . 7

Payment options . . . 8

Return of applications . . . 8

Most common reasons for delay in processing applications . . . 8

Common Terms/Definitions

. . . 9

Legal Requirements

. . . 11 Applicant/Client responsibility . . . 11 Agent/Broker responsibility . . . 11 Limited/Non-English proficient applicants . . . 11

Member Information

. . . 12 Changing benefits/ Changing plan designs . . . 12

Adding dental and vision option . . . 12

Reinstatement of coverage . . . 12

Nonsufficient fund fee . . . 12

Automatic Bank Draft (ABD) . . . 13

Frequently asked billing questions . . . 13

Certification Requirements for

PPO Insurance Plans

. . . 14

Exceptions . . . 15

Important Broker Information

. . . 16

Application mailing address . . . 16

Introduction

The following Enrollment Guidelines were developed to assist you and your clients with questions that might arise when writing with Health Net of California and/or Health Net Life Insurance Company’s (hereinafter referred to as Health Net) off-Marketplace Individual & Family Plans (IFP).

These guidelines are a brief overview of Health Net’s enrollment guidelines. Only

Health Net’s Membership Department may make a final decision to accept or decline an individual and determine the effective date. An insurance agent/broker cannot guarantee coverage, change terms or waive requirements. The guidelines are

not definitive and are subject to change without notice at Health Net’s sole discretion. Health Net will endeavor to keep brokers informed of changes in a timely manner.

Please advise all applicants to maintain their prior coverage until notified by Health Net of their approval.

The Evidence of Coverage (EOC) issued by Health Net of California, Inc. to HMO members represents the contract for coverage between Health Net of California, Inc. and its HMO members. In the event of any conflicts or inconsistencies between this document and the EOC, the EOC shall govern. A Policy is issued to individuals who elect PPO coverage. The PPO insurance plans are underwritten by Health Net Life Insurance Company (HNL). The Policy issued by HNL to insureds represents the contract for coverage. In the event of any conflicts or inconsistencies between this document and the Policy, the Policy shall govern.

Agent/Broker responsibilities

Health Net agents/brokers are required to comply with all of Health Net’s rules and regulations, including those relating to the completion and submission of

applications for coverage under Health Net’s Group and IFP programs.

Neither the agent/broker, nor any other person may sign the application, except that an applicant’s parent or legal guardian may complete and sign the application if the applicant is under 18 years old. There are no other exceptions.

On each application, Health Net agents/ brokers are required to complete the Agent/ Broker Information Section and its Broker Certification. An application that does not have a completed Agent/Broker Information Section and Broker Certification cannot be processed by Health Net.

As part of the Broker Certification, the Health Net agent/broker is required to indicate whether they assisted the applicant in completing the application or submitting the application to Health Net.

If the Health Net agent/broker did not assist the applicant, in any way, in completing or submitting the application, then the Health Net agent/broker must confirm that the applicant completed all information, with no assistance or advice of any kind from the Health Net agent/broker. The Health Net agent/broker must also confirm they understand that, if any portion of their Broker Certification statement is false, they may be subject to civil penalties, including but not limited to a fine of up to $10,000.

If a Health Net agent/broker assisted the applicant in submitting the application, then the Health Net agent/broker must confirm that: 1. the Health Net agent/broker advised the

applicant that he or she should answer all questions completely and truthfully, and that no information requested on the application should be withheld;

2. the Health Net agent/broker explained to the applicant that withholding information could result in rescission or cancellation of coverage in the future;

3. the applicant indicated to the Health Net agent/broker that he or she understood these instructions and warnings; 4. to the best of the Health Net agent/

broker’s knowledge, the information on the application is complete and accurate; and 5. the Health Net agent/broker understands

that, if any portion of their Broker Certification statement is false, they may be subject to civil penalties, including but not limited to a fine of up to $10,000. The Broker Certification also requires that whether or not the Health Net agent/broker assisted an applicant in completing the application or submitting the application to Health Net, the Health Net agent/broker must also indicate: (a) who completed the application, (b) whether the Health Net agent/ broker personally witnessed the applicant sign the application, and (c) whether the Health Net agent/broker reviewed the application after the applicant signed it.

In addition, Health Net maintains the following expectations of contracted brokers/agents. The agent/broker is expected to:

• Maintain the highest level of ethical conduct in compliance with license requirements.

• Keep informed and obey all insurance laws and regulations.

• Accurately and truthfully represent Health Net products and services. • Provide excellent service to their client. • Place their client’s interest first.

• Identify the client’s needs and recommend products and services that meet those needs. • Stay in touch with their clients and conduct

periodic coverage reviews.

• Protect the confidential information of their clients.

• Follow Health Net’s Enrollment Guidelines and contact Health Net for clarification or questions.

Eligibility

Guidelines

Eligibility conditions

Each applicant applying for Health Net’s IFP insurance plans must meet the following requirements:

• Must be a permanent legal resident of California.

• Must reside continuously in Health Net’s service area.

• May be required to provide a marriage certificate/Domestic Partner Affidavit or legal guardianship document.

• Child-only Policies:

– Applications can be completed on most health plans to insure a child to age 18 without either parent being on the Policy. • Under-age applicants:

– Applicants under the age of 18: The application must be signed by the applicant’s parent or legal guardian. In such event, the parent or legal guardian does hereby agree to be legally responsible for the accuracy of information in the application and for payments of premiums. If such responsible party is not the natural parent of the applicant, copies of the court papers authorizing guardianship, or proof of responsibility for the financial needs of the child including responsibility to provide health care coverage, must be submitted with the application.

• Family coverage:

– Spouse: subscriber’s legally married spouse – Domestic partner: subscriber’s/principal

covered person’s same-sex spouse if the subscriber/principal covered person and spouse are a couple who meet all of the requirements of Section 308(c) of the California Family Code, or the subscriber’s/principal covered person’s registered domestic partner who meets all the requirements of Sections 297 or 299.2 of the California Family Code.

– Dependent child(ren):

» Children of the subscriber or his or her spouse. Includes stepchild, a legally adopted child from the moment of placement in subscriber’s home, and any other child for whom subscriber or subscriber’s spouse is a court-appointed guardian. Each child is eligible to apply for enrollment as a dependent until the age of 26 (the limiting age).

» Children who reach age 26 are eligible to apply for continued enrollment as a dependent (see above for dependent eligibility) for coverage if all of the following conditions apply: (a) the child is incapable of earning his or her own living by reason of mental retardation or physical handicap incurred prior to the limiting age; and (b) the child is chiefly dependent upon the subscriber or subscriber’s spouse for support and was insured under the policy on the date just prior to the day his or her insurance would have ended due to age.

Annual and Special Enrollment

Periods

• Annual Open Enrollment Period – Applicants may apply for coverage during the Annual Open Enrollment Period. For the first year, this period is October 1, 2013–March 31, 2014, for effective dates beginning January 1, 2014, and after. Applications and payments received between October 1, 2013, and December 15, 2013, will be effective January 1, 2014. Applications and payments received after December 15, 2013, will be effective February 1, 2014, and after. For subsequent years, the Annual Open Enrollment Period will be October 1–December 7 for January 1 effective dates.

• Special Enrollment Period – Applicants may apply within 60 days after a qualifying event, if an applicant is without coverage and did not enroll during the initial open enrollment period. Proof of the qualifying event will be required. Special Enrollment Periods are as follows:

1. The qualified individual or his or her dependent loses minimum essential coverage, which could be due to one of the following reasons:

A. The death of the covered employee. B. The termination (other than by

reason of such employee’s gross misconduct), or reduction of hours, of the covered employee’s employment. C. The divorce or legal separation of the

covered employee from the employee’s spouse.

D. The covered employee becoming entitled to benefits under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].

E. A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan. F. A proceeding in a case under title 11,

commencing on or after July 1, 1986, with respect to the employer from whose employment the covered employee retired at any time. In this case, a loss of coverage includes a substantial elimination of coverage with respect to a qualified beneficiary described in section 1167 (3)(C) of this title within one year before or after the date of commencement of the proceeding. 2. The qualified individual gains a dependent

or becomes a dependent through marriage, birth, adoption or placement for adoption; 3. The qualified individual’s or his or her

dependent’s, enrollment or non-enrollment in a health plan is unintentional,

inadvertent or erroneous and is the result of the error, misrepresentation or inaction of an officer, employee or agent of the Exchange or HHS or its instrumentalities as evaluated and determined by the Exchange.

4. The enrollee or his or her dependent adequately demonstrates to Health Net that the health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;

5. The qualified individual or enrollee, or his or her dependent, gains access to new health plan as a result of a permanent move;

6. The qualified individual or his or her dependent is enrolled in an eligible employer-sponsored plan that is not qualifying coverage in an eligible employer-sponsored plan and is allowed to terminate existing coverage. Health Net must permit such an individual to access this Special Enrollment Period 60 days prior to the end of his or her coverage through such eligible employer-sponsored plan.

7. With respect to individuals enrolled in non-calendar year individual health insurance policies, a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014.

8. He or she is mandated to be covered as a dependent pursuant to a valid state or federal court order.

9. He or she has been released from incarceration.

10. He or she was receiving services under another health benefit plan, from a contracting provider who is no longer participating in that health plan, for any of the following conditions: (a) an acute or serious chronic condition; (b) a terminal illness; (c) a pregnancy; (d) care of a newborn between birth and 36 months; or (e) a surgery or other procedure authorized as part of a documented course of treatment to occur within 180 days of the contract’s termination date or the effective date of coverage for a newly covered member.

11. He or she demonstrates to Health Net, with respect to health benefit plans offered through the Exchange, that he or she did not enroll in a health benefit plan during the immediately preceding enrollment period available to the individual because

he or she was misinformed that he or she was covered under minimum essential coverage.

12. He or she is a member of the reserve forces of the United States military

returning from active duty or a member of the California National Guard returning from active duty service under Title 32 of the United States Code.

13. The qualified individual, who was not previously a citizen, national, or lawfully present individual gains such status.

Addition of new dependents

• Coverage of a newborn – Medical

expenses related to a newborn with service dates within 30 days from the date of birth can be covered under the terms and conditions of either the mother’s or father’s medical coverage. Coverage for a newborn’s medical expenses under this provision will discontinue for service dates after 30 days from the date of birth.

• Adding a newborn or adopted child to an

existing family policy – A newborn can

be added to an existing family policy by using the Addition of Newborn or Adopted Child Enrollment Application if completed within 31 days of a newborn’s birth or within 31 days of an adopted child’s date of adoption or placement of the child. The child can be added to a family Policy only (not a subscriber-only plan). Coverage will be effective retroactive to the date of birth for a newborn child. For an adopted child, coverage will be effective on the date of adoption or the date of placement for adoption, as requested by the adoptive parent. The monthly premium will retroactively reflect the addition of the child. You must enroll the child within 31 days of birth or adoption/placement

for coverage to continue by submitting a Newborn Addition Form to Health Net and paying any applicable subscription charges. If you do not enroll the child within 31 days after birth/adoption/placement, your child will be eligible to enroll as a late enrollee.

Children attaining age 26

Coverage for a dependent child terminates under the member’s EOC or Policy at the end of the month in which the child attains age 26 (see below regarding a disabled child).

Such child may apply for his or her own contract or Policy. A new enrollment

application must be submitted and approved by Membership.

Disabled child

Children who reach age 26 are eligible to apply for continued enrollment as a dependent for coverage if all of the following conditions apply: (a) The child is incapable of earning his or her own living by reason of mental retardation or physical handicap incurred prior to the limiting age; and (b) The child is chiefly dependent upon the subscriber or subscriber’s spouse for support and who was insured under the policy on the date just prior to the day his or her insurance would have ended due to age.

Guidelines to

Submitting

Your Client’s IFP Insurance

Plan

Applications

Things to remember when submitting

applications

• Applications must be completed and signed by the applicant in blue or black ink.

• Applications signed by a broker will not

be accepted.

• Health Net relies on the applicant to provide truthful, complete and accurate information in the application process. • Only the 1st of the month effective date is

available.

• The effective date is determined based on when the application and premium payment are received by Health Net, either delivered or postmarked, whichever occurs

(a) Within the first 15 days of the month, coverage under the plan becomes effective no later than the first of the following month; or (b) After the 15th day of the month, coverage shall become effective no later than the first day of the second month. • If the application is being faxed, the

application must be completed in black ink. If the applicant authorizes Health Net and/ or Heath Net Life Insurance Company to debit his or her account based on the facsimile copy of his or her premium check, they can do so by completing and signing the Simple Pay Option form. This form can be faxed with the application for processing. Corporate checks, third-party checks,

Lisa Pasillas-Le, Health Net

We support

sustainability with green business practices.

orders, traveler’s checks, official checks, and government checks cannot be accepted. Once the premium check is faxed, DO NOT

MAIL the original application or check. A

photocopy or facsimile of this application and authorization is considered as valid as the original. Health Net recommends that brokers keep the application or a copy on file as well as the copy of the Simple Pay Option form for no less than seven (7) years. • All applicants, except newborns, require a

Social Security number/Matricular Consula ID (Mexican Consulate ID). Matricular Consula ID can be accepted in place of Social Security numbers.

• A check must accompany the application when submitted to Health Net. The check will not be processed unless the application is approved by Health Net’s Membership Department. The original check, submitted by the applicant, will be returned if the application is declined. If a member of a contract (subscriber and spouse/domestic partner, subscriber and child, subscriber and children, family) is declined, Health Net will deposit the check at the request of the primary applicant. • If the premium check is insufficient or

not included with the application, the application will not be processed. All applications must include the first month’s premium. The application must be filled out accurately and completely.

• For additional information or explanations to be submitted with the application, attach extra sheets of paper if necessary. All attachments must be signed and dated by the applicant.

• Please see the section titled “Rescission or cancellation of coverage for fraud or intentional misrepresentation of material fact” on page 9 for important information on rescission of membership.

Payment options

• Preferred Payment Option: Automatic

Bank Draft (ABD) – One month’s premium

must be remitted with the application along with the Simple Pay Option form. The premiums withdrawn from the account will be for future billing periods plus any past due balances. The first month’s withdrawal may be for multiple billing periods if the applicant did not submit a binder check or due to the timing of the ABD setup. The premium will be withdrawn from the applicant’s bank account approximately 10 days in advance of the due date.

• Monthly billing – One month’s premium must be remitted with the application.

Credit/debit cards are accepted for the first month’s premium payment only.

Return of applications

Applications will be returned for the following reasons:

• A missing signature of the applicant, spouse, domestic partner, guardian, and dependent(s) age 18 or older.

• Undated applications.

• Applications completed in pencil. • Incomplete applications.

Most common reasons for delay in

processing applications

• First month’s premium not remitted with the application.

• Plan type is not selected.

• Social Security numbers are omitted. • Incomplete address information. • Broker ID is missing. Health Net relies on the applicant to provide truthful, complete and accurate information in the application process.

Common Terms/

Definitions

Confidentiality of medical information

In compliance with state and federal regulations that protect the confidentiality of medical information, Health Net staff will not disclose or discuss an applicant’s medical history to anyone other than the applicant without the applicant’s written authorization. Any such authorization must specify the medical information that may be discussed or disclosed and the specific person(s) with whom it may be discussed or disclosed.

Coordination of benefits

There are no coordination of benefits provisions for the IFP plans.

Creditable coverage

Any individual or group policy, contract or program that is written or administered by a disability insurance company, health care service plan, fraternal benefits society, self-insured employer plan, or any other entity, in this state or elsewhere, and that arranges or provides medical, hospital and surgical coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage but does not include accident-only, credit, coverage for onsite medical clinics, disability income, Medicare supplement, long-term care insurance, dental, vision, coverage issued as a supplement to liability insurance, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

Minimum Essential Coverage

Minimum essential coverage is defined as: • coverage under certain

government-sponsored plans;

• employer-sponsored plans, with respect to any employee;

• plans in the individual market; • grandfathered health plans; and

• any other health benefits coverage, such as a state health benefits risk pool, as recognized by the HHS Secretary.

Minimum essential coverage does not include health insurance coverage consisting of excepted benefits, such as dental-only coverage.

Policy dating

The effective date is determined based on when the application and payment are received by Health Net. When the application and payment are delivered or postmarked, whichever occurs earlier: (a) Within the first 15 days of the month, coverage under the plan becomes effective no later than the first of the following month; or (b) After the 15th day of the month, coverage shall become effective no later than the first day of the second month.

Rescission or cancellation of coverage for fraud or intentional misrepresentation of material fact

Under certain circumstances as described below, Health Net may rescind or cancel coverage after issuing a Plan Contract or Policy.

Recission of a Plan Contract or Insurance Policy

Any act or practice which constitutes fraud, or any intentional misrepresentation of material fact in written information submitted by the applicant or on the applicant’s behalf on or with the applicant’s application materials may be cause for disenrollment and rescission of the Plan Contract or Insurance Policy. Such rescission is limited to the first 24 months of coverage. Health Net may recoup from the applicant any amounts paid under the Plan Contract or Insurance Policy obtained as a result of such act, practice, or intentional misrepresentation of material fact. In addition, if there is any act or practice which constitutes fraud, or if there is any intentional misrepresentation of material fact in written information submitted on or with the application, Health Net shall have no liability for the provision of coverage under the Plan

Contract or Insurance Policy. The application will become part of the contract between Health Net and the applicant.

By signing the application, the applicant agrees to abide by the terms of the contract. Before the contract is rescinded, Health Net will provide the applicant written notice

and an opportunity to provide information. Should the contract be rescinded, Health Net will provide a written notice that will explain the basis of the decision and the applicant’s appeals rights. Health Net will refund all amounts paid by the applicant, less any medical expenses that Health Net paid.

Cancellation of a Plan Contract or Insurance Policy

Health Net may cancel a Plan Contract or Insurance Policy for any act or practice which constitutes fraud, or for any intentional misrepresentation of material fact under the terms of the Plan Contract or Insurance Policy. If this Plan Contract or Insurance Policy is cancelled, you will be sent a notice of cancellation, and cancellation will be effective upon the date the notice of cancellation is mailed.

Broker commission is adversely affected by any retroactive cancellations. Any commissions paid on a policy that is

rescinded will be charged back and collected from the broker.

Legal

Requirements

Applicant/Client responsibility

Health Net requires all applicants age 18 and over to read, complete and assume accountability for the “Conditions of

enrollment” section by signing and dating the application. The applicant and the applicant’s spouse must complete the application, and it must be signed with blue or black ink. For applicants under the age of 18 years old, the parent or legal guardian is legally responsible for the accuracy of information in the application and for payments of premiums. If such responsible party is not the natural parent of the applicant, copies of the court papers authorizing guardianship, or proof of responsibility for the financial needs of the child, including responsibility to provide health care coverage, must be submitted with the application.

Agent/Broker responsibility

It is important that you protect yourself during the enrollment process. You want to be sure you are not at fault for any errors or omissions in information on behalf of your clients. You need to advise your client that they must provide complete and accurate information, even if the information does not seem important to you or your client. ALL APPLICATIONS, ONLINE AND PAPER, MUST BE SIGNED BY THE APPLICANT.

In order to become a Health Net contracted broker, you or your brokerage firm must: (a) have an active California Life Agent license; (b) sign and complete the Health Net Agent/Broker Agreement; (c) sell a group with Health Net or sell an IFP insurance plan;

and (d) have E&O insurance. You or your brokerage firm must become a contracted Health Net broker in order to receive commissions.

Limited/Non-english

proficient applicants

An individual who is limited English proficient is a person who does not speak English as their primary language and who has a limited ability to speak, read, write, or understand English.

In 2003, the California Legislature passed Senate Bill 853 mandating that all California health plans and insurers provide language assistance services to their enrollees with limited English proficiency in order to alleviate language and cultural barriers. The legislation stipulates that all vital documents must be translated into threshold languages and interpretation services be made available to enrollees at all points of contact.

Health Net requires that only the applicant can sign the enrollment application. A limited English proficient applicant would need to use the services of a qualified interpreter to complete the application. Interpreter services are available through Health Net at no charge by calling 1-800-909-3447, option 2.

For a person other than someone from Health Net’s contracted interpreter service to be considered a qualified interpreter, they should meet the following qualifications.

All applications, online and paper, must be signed by the applicant.

A qualified bilingual speaker would:

• Have the vocabulary equivalent of a native speaker who has received an advanced education (college or university equivalent) in the non-English language.

• Be able to demonstrate cultural sensitivity in their communication, taking into consideration that every language encompasses a wide range of variation.

• Have native speaker language skills. Native speaker language skills are developed by growing up or functioning in a language community.

• Have corresponding reading and writing skills in the non-English language. The reading and writing skills would be demonstrated by advanced education in the native language.

Member

Information

Changing benefits/Changing

plan designs

There are no health plan changes allowed outside of the Annual Enrollment Period. Only those members that experience a Qualifying Event may change their health plan coverage.

Adding dental and vision option

There is no waiting period to add

the dental and vision option to the client’s HMO or PPO insurance plan; however, if they remove the dental and vision option from their plan, there is a 12-month waiting period to add the dental and vision option back to the client’s existing plan.

Reinstatement of coverage

• A reinstatement request must be received at Health Net within 30 days of the cancellation notice.

• The reinstatement request must be accompanied by a check that includes all past-due premiums plus current month and prepaid premiums (if billing has been generated). For example, if a member terminated November 1 and requests reinstatement on December 1, he or she must remit November, December and any billed January premiums to be reinstated. • To ensure payment is received, a credit card

(Visa/MasterCard) will be accepted. • A reinstatement fee of $5 will be charged. There will be no more than one reinstatement in a given 12-month period, and upon the reinstatement the member must pay by Automatic Bank Draft.

Nonsufficient fund fee

A nonsufficient fund (NSF) fee of $25 will be charged to a member’s account if there is a check/credit card returned for NSF.

Automatic Bank Draft (ABD)

If there are two nonsufficient fund

transactions related to ABD, the member will be set up on the standard billing option for one year.

Frequently asked billing questions

When does Health Net send out billing statements?

Bills are mailed out on approximately the 9th of the month for HMO plans and the 10th for PPO insurance plans.

When are payments due?

Payments are due on the first of every month.

Where would a billing payment be mailed?

Health Net PO Box 894702

Los Angeles, CA 90189-4702

If a member is late paying their bill, how long do they have to pay before their plan is cancelled?

Premiums are due on the first of the month of coverage, and if payment is not received by the end of the 30-day grace period, coverage will be terminated. Members will be duly notified prior to termination due to nonpayment of premium. Such termination will be effective at the conclusion of the required 30-day grace period, and the member will be responsible for payment of any unpaid premiums for this coverage period.

Are late notices sent out?

Late notices are sent on approximately the 15th of the month.

What is the draft date if the billing option selected is by Automatic Bank Draft (ABD)?

Premiums are deducted on the 20th of every month, unless that day falls on a Sunday, then it will be on the following Monday.

How much notice needs to be provided to Health Net if the member needs to stop having premiums taken out of their bank account?

It takes approximately 30 days to stop premiums from being deducted from a bank account.

If I send in a check, how long will it take for my check to post?

It takes approximately four to seven business days for a check to post.

Certification Requirements

for PPO Insurance Plans

1. Inpatient admissions :

Any type of facility, including but not limited to:

• acute rehabilitation center • chemical dependency facility • hospice

• hospital

• mental health facility • skilled nursing facility

2. Ambulance: non-emergency, air or ground ambulance services.

3. Bariatric-related services: non-surgical bariatric-related consultations and services.

4. Clinical trials. 5. Custom orthotics.

6. Durable medical equipment:

• Bone growth stimulator

• Continuous positive airway pressure (CPAP) • Custom-made items • Hospital beds • Power wheelchairs • Scooters 7. Experimental/Investigational services and new technologies.

8. Home health care services including home uterine monitoring, hospice, nursing, occupational therapy, physical therapy, speech therapy, and tocolytic services.

9. Hospice care.

10. Intensity modulated radiation therapy (IMRT).

11. Neuro or spinal cord stimulator. 12. Occupational and speech therapy. 13. Organ, tissue and stem cell transplant

services, including pre-evaluation and pre-treatment services and the transplant procedure.

14. Outpatient diagnostic imaging:

• CT (computerized tomography) • MRA (magnetic resonance

angiography)

• MRI (magnetic resonance imaging) • PET (positron emission tomography) • Nuclear cardiology procedures,

including SPECT (single photon emission computed tomography)

15. Outpatient pharmaceuticals:

• Self-injectables

• Hemophilia factors and intravenous immunoglobulin (IVIG)

• Certain physician-administered drugs, whether administered in a physician office, free-standing infusion center, ambulatory surgery center, outpatient dialysis center, or outpatient hospital. Refer to www.healthnet.com for a list of physician-administered drugs that require certification.

16. Outpatient physical, cardiac and pulmonary rehabilitation therapy and acupuncture (exceeding 12 visits), subject to any benefit maximums stated in the “Schedule of Benefits” section of the Certificate of Insurance.

17. Outpatient surgical procedures including:

• Abdominal, ventral, umbilical, incisional hernia repair • Bariatric procedures • Blepharoplasty

• Breast reductions and augmentations • Mastectomy for gynecomastia

• Orthognathic procedures (includes TMJ treatment)

• Rhinoplasty

• Treatment of varicose veins

• Uvulopalatopharyngoplasty (UPPP) and laser assisted UPPP

• Medically Necessary dental or

orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures. Cleft palate includes cleft palate, cleft lip or other craniofacial anomalies associated with cleft palate.

18. Prosthesis over $2,500 in billed charges. 19. Stereotactic radiosurgery and

stereotactic body radiotherapy (SBRT). 20. Tocolytic services (intravenous drugs

used to decrease or stop uterine contractions in premature labor).

Exceptions

Certification is not needed for the first 48 hours of inpatient hospital services following a vaginal delivery nor the first 96 hours following a cesarean section. However, HNL should be notified within 24 hours following birth. Certification must be obtained for a scheduled cesarean section or if the physician determines that a longer hospital stay is medically necessary either prior to or following the birth.

Certification is not required for the length of a hospital stay for reconstructive surgery incident to a mastectomy (including lumpectomy).

Certification is not needed for renal dialysis. However, HNL should be notified if renal dialysis services are received within 24 hours of the service.

Prior certification is not required for behavioral health treatment for pervasive developmental disorder or autism; however, prior notification is required. Notification must include documentation that a licensed physician or licensed psychologist has established the diagnosis of pervasive developmental disorder or autism. In addition, the Qualified Autism Service Provider must submit the initial treatment plan to HNL.

Karen Boyd, Health Net We work to make a difference, one member at a time.

Important

Broker

Information

Application mailing address

Individual & Family Enrollment

Health Net PO Box 1150

Rancho Cordova, CA 95741-1150 Fax: 1-800-977-4161

Forms and brochures

All materials to enroll your client are available on our broker site. You have the ability to order, email or download the forms you need. Log in to www.healthnet.com > Quick Links >

Forms and Brochures > Individual and Family Plans.

Forms and brochures available

• Sales brochures • Rate guides • Plan overviews

• Applications and other forms • Support tools

You can create your own personalized

provider directory. Go to www.healthnet.com and click on ProviderSearch.

6029256 CA103347 (1/14)

Health Net Individual & Family HMO health plans are offered by Health Net of California, Inc. Health Net Individual & Family PPO insurance plans, Policy Form #P30601 are underwritten by Health Net Life Insurance Company. Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.

For more information please contact

Health Net

PO Box 1150

Rancho Cordova, CA 95741-1150 Fax: 1-800-977-4161

Individual & Family Plans

1-800-909-3447

Assistance for the hearing and speech impaired

1-800-995-0852

Other options

Coverage for family members over 65 years of age 1-800-944-7287

Coverage for children in a low-income household 1-800-327-0502

Coverage for businesses with 50 and fewer employees 1-800-447-8812

Coverage for businesses with 50+ employees 1-800-448-4411, option 4