Who Is Eligible
To be eligible for Salud HMO y más or Salud PPO, you must: be under the age of 65, not be eligible for Medicare, reside continuously in our Salud service area (see the Salud Service Area description earlier in this guide), and meet our application and underwriting requirements for coverage. In addition, your spouse or domestic partner, if under age 65, and all your unmarried dependent children under 19 years of age also are eligible (subject to underwriting requirements). Unmarried dependent children enrolled in an accredited school as full-time students and under 24 years of age are also eligible, if proof of full-time student status is provided.
Domestic Partner is defined as two adults who have chosen to share one another’s lives in an intimate and committed relationship of mutual caring. A domestic partner is a person eligible for coverage provided that the partnership with the Subscriber meets all domestic partnership requirements under California law. The Domestic Partner and Subscriber must:
• Both persons have a common residence • Neither person is married to someone else or is a member of another domestic partnership that has not been terminated, dissolved, or judged a nullity
• The two persons are not related by blood in a way that would prevent them from being married in California
• Both persons are at least 18 years old
• Both persons are members of the same sex, or opposite sex couples if one or both persons is over age 62 and is eligible for Social Security benefits
• Both persons are capable of consenting to the domestic partnership
• Both file a Declaration of Domestic Partnership with the Secretary of State, or both are persons of the same sex who have validly formed a legal union other than marriage in a jurisdiction outside of California which is substantially equivalent to a Domestic Partnership as defined under California law
AM I ELIGIBLE FOR GUARANTEED ISSUE COVERAGE, WITHOUT THE NEED FOR MEDICAL UNDERWRITING?
The federal Health Insurance Portability and Accountability Act (HIPAA) makes it easier for people covered under existing group health plans to maintain coverage regardless of pre-existing conditions when they change jobs or are unemployed for brief periods of time. California law provides similar and additional protections. Applicants who meet the following requirements are eligible to enroll in a guaranteed issue individual health plan from any health plan that offers individual coverage, including Health Net’s Guaranteed HMO and PPO insurance plans, without medical underwriting. A health plan cannot reject your application for guaranteed issue individual health coverage if you meet the following requirements, agree to pay the required premiums and live or work in the plan’s service area.
To qualify for a HIPAA plan, you must:
• Have completed a total of 18 months of coverage without a significant break (excluding any employer imposed waiting period) under a group health plan
• The most recent coverage must have been under a group health plan (COBRA and Cal-COBRA coverage are considered group coverage)
• The applicant must not be eligible for coverage under any group health plan, Medicare or Medicaid, and must not have other health insurance coverage
• The individual’s most recent coverage could not have been terminated due to fraud or nonpayment of premiums
• If COBRA or Cal-COBRA coverage was available, it must have been elected and such coverage must have been exhausted
If you want to find out if you qualify, contact us so that we can determine your eligibility and tell you about the available HIPAA plans. If you believe your rights under HIPAA have been violated, please contact the Department of Managed Health Care at 1-888-HMO-2219 or visit the Department’s website at www.hmohelp.ca.gov
HOW DOES THE MONTHLY BILLING WORK?
Your premium must be received by Health Net by the first day of the coverage month. If there are premium increases after the enrollment effective date, you will be notified at least 30 days in advance. If you choose Health Net’s Simple Pay option you will be exempt from any administrative billing fees. If you do not choose Health Net’s Simple Pay option, a $5 per month administrative fee will be charged each month to cover the expense of issuing a monthly bill. If there are changes to the Health Net Salud HMO y más Plan Contract and EOC or Salud PPO Policy, including changes in benefits, you will be notified at least 30 days in advance.
CAN BENEFITS BE TERMINATED?
You may cancel your coverage at any time by giving Health Net written notice. In such event, termination will be effective on the first day of the month following our receipt of your written notice to cancel. Health Net has the right to terminate your coverage for any of the following reasons:
• You do not pay your premium on time
• You and/or your family member(s) cease being eligible
• You knowingly submit to Health Net materially incorrect or incomplete information which is reasonably relied upon by Health Net in issuing or renewing individual and family plan coverage
• You and/or your family member(s) repeatedly or materially disrupt the operations of the Physician Group, SIMNSA or Health Net to the extent that your behavior substantially impairs Health Net’s ability to furnish or arrange services for you or other Health Net members, or the physician’s office or Contracting Physician Group’s ability to provide services to other patients
• You and/or your family member(s) threaten the safety of the health care provider, his or her office staff, the contracting Physician Group, SIMNSA or Health Net personnel if such behavior does not arise from a diagnosed illness or condition.
Health Net can terminate your coverage, together with all like policies, by giving 90 day’s written notice. If your coverage is terminated because Health Net ceases to offer all like policies, you may be entitled to Conversion coverage. Should such a termination occur, information on Conversion coverage will be provided in the written termination notice. Members are responsible for payment of any services received after termination of coverage at the provider’s prevailing non-Member rates. This is also applicable to Members who are hospitalized or undergoing treatment for an ongoing condition on the termination date of coverage. If you terminate coverage for yourself or any of your family members, you may apply for re-enrollment, but Health Net may decline enrollment at its discretion.
ARE THERE ANY RENEWAL PROVISIONS?
Subject to the termination provisions discussed, coverage will remain in effect for each month prepayment fees are received and accepted by Health Net. You will be notified 30 days in advance of any changes in fees, benefits or contract provisions.
DOES HEALTH NET COORDINATE BENEFITS?
There are no Coordination of Benefit provisions for individual plans in the state of California.
WHAT IS UTILIZATION REVIEW?
Health Net makes medical care covered under our Salud HMO y más or Salud PPO insurance plans subject to policies and procedures that lead to efficient and prudent use of resources and, ultimately, to continuous improvement of quality of care. Health Net bases the approval or denial of services on the following main procedures:
• Evaluation of medical services to assess medical necessity and appropriate level of care
• Implementation of case management for long-term or chronic conditions
• Review and authorization of inpatient admission and referrals to noncontracting providers
• Review of scope of benefits to determine coverage If you would like additional information regarding Health Net’s Utilization Review System, please call the Member Services department at 1-800-839-2172. Members in Mexico, please call SIMNSA at (011-52-664) 683-29-02 or (011-52-664) 683-30-05 or 619-407-4082 for additional information.
DOES HEALTH NET COVER THE COST OF PARTICIPATION IN CLINICAL TRIALS?
Routine patient care costs for patients diagnosed with cancer who are accepted into phase I, II, III, or IV clinical trials are covered when Medically Necessary, recommended by the Member’s treating Physician and authorized by Health Net. The Physician must determine that participation has a meaningful potential to benefit the Member and the trial has therapeutic intent. For further information, please refer to the Salud HMO y más Plan Contract and Evidence of Coverage or Salud PPO Policy. Clinical trials are not available in Mexico.
WHAT IF I HAVE A DISAGREEMENT WITH HEALTH NET?
Members dissatisfied with the quality of care received, or who believe they were denied service or a claim in error, may file a grievance or appeal. In addition, plan Members can request an independent medical review of disputed health care services from the Department of Managed Health Care if they believe that health care services eligible for coverage and payment under their Health Net plan was improperly denied, modified or delayed by Health Net or one of its contracting providers.
Also, if Health Net denies a Member’s appeal of a denial for lack of medical necessity, or denies or delays coverage for requested treatment involving experimental or investigational drugs, devices, procedures or therapies, Members can request an independent medical review of Health Net’s decision from the Department of Managed Health Care if they meet eligibility criteria set out in the Plan Contract and Evidence of Coverage. Members not satisfied with the results of the appeals process may submit the problem to binding arbitration. Health Net uses binding arbitration to settle disputes, including medical malpractice. As a condition of enrollment, Members give up their right to a jury or trial before a judge for the resolution of such disputes.
Members who obtain care through SIMNSA in Mexico have certain grievance rights, but do not have access to the same legal rights and remedies regarding grievance processing as those members who obtain care through the Salud Network in California. See the Salud HMO y más Plan Contract and EOC or Salud PPO Policy for details.
The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against Health Net, you should first telephone Health Net at 1-800-839-2172 and use our grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an Emergency, a grievance that has not been satisfactorily resolved by Health Net, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the Medical Necessity of a proposed service or treatment, coverage decisions for treatments that are Experimental or Investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department’s Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.
HEALTH NET LIFE IMPORTANT NOTICE TO CALIFORNIA POLICYHOLDERS
In the event that a member needs to contact someone about his or her insurance coverage for any reason, please contact:
Health Net Life Insurance Company
Individual & Family Plans
Post Office Box 1150
Rancho Cordova, California 95741-1150
If a member has been unable to resolve a problem concerning his or her insurance coverage, after discussions with Health Net Life Insurance Company, or its agent or other representative, her or she may contact:
California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
If you need help with a grievance involving an Emergency, a grievance that has not been satisfactorily resolved by Health Net or a grievance that has remained unresolved for more than 30 days, you may call the Department of Insurance for assistance.
You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the Medical necessity of a proposed service or treatment, coverage decisions for treatments that are Experimental or Investigational in nature and payment disputes for emergency or urgent medical services.
WHAT IF I NEED A SECOND OPINION?
Health Net Members have the right to request a second opinion when:
• The Member’s Primary Care Physician or a referral Physician gives a diagnosis or recommends a treatment plan with which the Member is not satisfied
• The Member is not satisfied with the result of treatment received
• The Member is diagnosed with, or a treatment plan is recommended for, a condition that threatens loss of life, limb, or bodily function, or a substantial impairment, including but not limited to a serious chronic condition, or
• The Member’s Primary Care Physician or a referral Physician is unable to diagnose the Member’s condition, or test results are conflicting
To obtain a copy of Health Net’s second opinion policy, contact the Health Net Member Services Department at 1-800-839-2172. Members in Mexico, please call SIMNSA at (011-52-664) 683-29-02 or (011-52-664) 683-30-05 for additional information.
WHAT ARE HEALTH NET’S PREMIUM RATIOS?
Health Net’s 2004 ratio of premium costs to health services paid for Individual & Family HMO plans was 75%. Health Net Life’s 2004 ratio for the Individual & Family PPO insurance plans was 67%.
WHAT IS THE RELATIONSHIP OF THE INVOLVED PARTIES?
Physician groups, contracting physicians, SIMNSA, hospitals and other health care providers are not agents or employees of Health Net or Health Net Life. Health Net or Health Net Life and each of their employees are not the agents or employees of any physician group in the Salud Network, SIMNSA, contract physician, hospital or other health care provider. All of the parties are independent contractors and contract with each other to provide you the covered services or supplies of your coverage option. Members are not liable for any acts or omissions of Health Net or Health Net Life, their agents or employees or of the Salud Network, or SIMNSA provider, or of physician groups, any physician or hospital, or any other person or organization with which Health Net or Health Net Life has arranged or will arrange to provide the covered services and supplies of your plan.
WHAT ABOUT CONTINUITY OF CARE UPON TERMINATION OF A PROVIDER CONTRACT?
If Health Net’s contract with a physician group or other provider is terminated, Health Net will transfer any affected Members to another contracting physician group or provider and make every effort to ensure continuity of care. At least 60-days prior to termination of a contract with a Physician Group or acute care hospital to which members are assigned for services, Health Net will provide a written notice to affected Members. For all other hospitals that terminate their contract with Health Net, a written notice will be provided to affected members within five days after the effective date of the contract termination. In addition, the Member may request continued care from a provider whose contract is terminated if at the time of termination the Member was receiving care from such a provider for:
• An acute condition
• A serious chronic condition not to exceed twelve months from the contract termination date
• A pregnancy (including the duration of the pregnancy and immediate postpartum care)
• A newborn up to 36 months of age, not to exceed twelve months from the contract termination date
• A terminal illness (for the duration of the terminal illness)
• A surgery or other procedure that has been authorized by Health Net as part of a documented course of treatment
Health Net may provide coverage for completion of services from a provider whose contract has been terminated, subject to applicable Copayments and any other exclusions and limitations of this Plan and if such provider is willing to accept the same contract terms applicable to the provider prior to the provider’s contract termination. You must request continued care within 30 days of the provider’s date of termination, unless you can show that it was not reasonably possible to make the request within 30 days of the provider’s date of termination and you make the request as soon as reasonably possible.
If you would like more information on how to request continued care, or request a copy of Health Net’s continuity of care policy, please contact the Member Services department at 1-800-839-2172. Members in Mexico, please call SIMNSA at (011-52-664) 683-29-02 or (011-52-664) 683-30-05 or 619-407-4082 for additional information.
WHAT ARE SEVERE MENTAL ILLNESS AND SERIOUS EMOTIONAL DISTURBANCES OF A CHILD?
Severe Mental Illness includes schizophrenia, schizoaffective disorder, bipolar disorder (manicdepressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorders, pervasive developmental disorder (including Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder and Pervasive Developmental Disorder not otherwise specified to include Atypical Autism, in accordance with the most recent edition of the Diagnostic and Statistical Manual for Mental Disorders), autism, anorexia nervosa, and bulimia nervosa.
Serious emotional disturbances of a child is when a child under the age of 18 has one or more mental disorders identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance abuse disorder or a developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms.
In addition, the child must meet one or more of the following: (a) as a result of the mental disorder the child has substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community; and either (i) the child is at risk of removal from home or has already been removed from the home or (ii) the mental disorder and impairments have been present for more than six months or are likely to continue for more than one years; (b) the child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder; and/or (c) the child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570) of Division 7 of Title 1 of the Government Code.
DO PROVIDERS LIMIT SERVICES FOR REPRODUCTIVE CARE?
Some hospitals and other providers do not provide one or more of the following services that may be covered under your Plan Contract and Evidence of Coverage or Policy and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call Health Net’s Member Services Department at 1-800-839-2172 or SIMNSA at (011-52-664) 683-29-02 or 683-30-05 or 1-619-407-4082 to ensure that you can obtain the health care services that you need.