HealthNet-Arizona-Health-Insurance-Brochure

Document Sample
HealthNet-Arizona-Health-Insurance-Brochure Powered By Docstoc
					                     if p
                   INDIVIDUAL &
                   FA M I LY p L A N




HEALTH INSURANCE
      AND MORE
FOR THE WAY YOU LIVE
                                          if p
                                        INdIvIduAL &
                                        FA M I Ly p L A N




WELCOME
          TO
         HEALTH NET OF ARIZONA




For over 28 years, we’ve made it our business to
make sure you have the health care coverage and
wellness services you need to help you stay healthy.
That remains our top priority today.

Whatever you’re looking for in a health insurance
plan – affordability, broad benefit coverage, choice
in doctors or wellness programs – you’ll find it with
Health Net of Arizona Individual & Family Plans.

Affordable. Easy. That’s Health Net.
       TABLE OF
                          CONTENTs
       health net plans fit your budget, your life
PART
 1     EAsy TO sEE AdvANTAgEs OF A
       HEALTH NET INdIvIduAL & FAMILy pLAN............................... 3
       HELpFuL dEFINITIONs ................................................................ 4
       ppO pLANs .................................................................................... 5
       • PPO Value Plans.......................................................................................................... 6

       • PPO Advantage Plans ................................................................................................ 6

       HMO pLAN .................................................................................... 7
       HsA-COMpATIBLE ppO pLANs................................................... 8
       dENTAL & vIsION ........................................................................ 9
       INdIvIduAL TERM LIFE INsuRANCE ....................................... 10



PART   no-Cost eXtras
 2     dECIsION pOWERsM ................................................................... 12

       CONsuMER TOOLs ................................................................... 14


PART
       applying for health net Coverage
 3     HOW TO AppLy .......................................................................... 16
       pROTECTINg yOuR HEALTH INFORMATION ........................ 17
       EXCLusIONs ANd LIMITATIONs ............................................. 17
pART 1




         HEALTH NET
          INsuRANCE pLANs
            FIT yOuR BudgET,
                FIT yOuR LIFE




             2
IT’s EAsy TO sEE THE AdvANTAgEs
OF A HEALTH NET INdIvIduAL & FAMILy pLAN


EAsy TO CHOOsE the health plan that fits your budget and your life from our
choice of HMO, PPO and HSA-compatible PPO plan options.

EAsy TO FINd A dOCTOR close to work or home from our large network of
doctors and hospitals.

EAsy TO gET CARE. All Health Net health plans cover essential preventive care,
emergency services and hospitalization.

EAsy TO usE. Online tools plus real people to talk to on the phone add up to a
health plan that’s actually easy to use.

EAsy TO AFFORd. Among the Health Net options that leave some change in your
pocket are our PPO Value Plans. With set copays for many services and manageable
monthly plan premiums, you’re sure to find a plan that fits your life and your budget.

EAsy TO pAy. Use Quick Pay – an automatic deduction from your bank account
– charge to your credit card or send in a check. When it comes to paying your
monthly plan premiums, the choice is yours.

EAsy TO sTAy HEALTHy ANd gET WELL with no-cost extras like Health Coaches,
interactive tools and education that help you work with your doctor and make
informed choices.




                                            3
                                      HELpFuL
                                            dEFINITIONs
Here are some commonly used           Copayment is the fixed dollar          and provide referrals as needed.
health insurance terms that are       amount you pay for certain             Members must use providers
referenced in this guide. We’ve       covered services at the time you       within the contracted network for
defined them here to help make        receive care.                          services to be covered, except for
everything fast to read and easy to                                          emergency care.
                                      Deductible is the amount you pay
understand.
                                      for covered services each calendar     PPO (Preferred Provider
                                      year before an insurance plan          Organization) is a health
                                      begins to pay benefits for certain     insurance plan designed to provide
                                      covered services.                      benefits for covered medical
                                                                             services from doctors, hospitals
                                      Coinsurance is a percentage of
                                                                             and other providers both in- and
                                      medical costs you pay for most
                                                                             out-of-network. Members using
                                      covered services after you have
                                                                             in-network providers (providers
                                      received care and your claim has
                                                                             contracted with the insurance
                                      been processed.
                                                                             company at a discounted rate)
                                      Out-of-Pocket Maximum is               generally pay lower out-of-pocket
                                      the limit to the total amount of       costs than members who use
                                      copayments, coinsurance and/or         out-of-network providers (non-
                                      deductibles you pay each calendar      contracted providers).
                                      year. Certain expenses may not apply
                                                                             Preferred or Contracted
                                      to the “out-of-pocket maximum;”
                                                                             Providers (also referred to as
                                      individual maximums can be
                                                                             in-network providers) are the
                                      different from family maximums.
                                                                             doctors, hospitals and other
                                      Lifetime Maximum is the dollar         health care providers that have
                                      amount of covered services and         an agreement with Health Net
                                      supplies your health insurance         to provide health care services for
                                      policy will pay for the duration of    our members at a contracted rate.
                                      your lifetime.                         This generally means lower out-
                                      HMO (Health Maintenance                of-pocket costs for our members.
                                      Organization) is a health plan         If you receive care from a non-
                                      that provides access to health care    contracted or out-of-network
                                      services through doctors, hospitals    provider, you may pay higher out-
                                      and other providers who have a         of-pocket costs for your services.
                                      contract with the HMO. The
                                      HMO requires members to select
                                      a primary care physician (PCP)
                                      who directs their medical needs




                                                       4
                                     ppO: FLEXIBILITy
                                          ANd CHOICE

                                     If freedom of choice is what you want, our PPO plans are just right
                                     for you. You can go to any doctor or hospital in our Health Net PPO
                                     network1 – there are more than 3,300 primary care physicians, 3,250
                                     specialists and 50 hospitals to choose from. You can also see providers
                                     outside of the Health Net PPO network.
                                     When you choose a preferred (or in-network) provider, you pay:
                                     •	 A	calendar	year	deductible,	if	applicable.
                                     •	 A	fixed	copayment	or	coinsurance	after	you’ve	met	your	calendar	year	
                                        deductible (up to the calendar year out-of-pocket maximum).
                                     When your doctor submits a bill for services he/she provided to you,
                                     we pay our portion and send you a statement called an Explanation of
                                     Benefits that lists the amount you owe. Your doctor will then bill you for
                                     the amount on the statement.
                                     When you see a non-preferred (or out-of-network) provider, you generally pay:

Is A HEALTH NET ppO pLAN             •	 A	calendar	year	deductible.
RIgHT FOR yOu?
                                     •	 A	coinsurance	after	you’ve	met	your	calendar	year	deductible	(up	to	the	
Yes, if you want:
                                        calendar year out-of-pocket maximum). The copayment/coinsurance is
•	 Freedom	of	choice,	no	               higher when you go out-of-network, which means you’ll pay more.
   referrals required.
                                     •	 Charges	that	exceed	allowances	for	covered	services.
•	 Access	to	in-	and	out-of-
   network providers – your costs    Some services may be covered only when you receive them from in-network
   are usually lower when you        physicians and facilities. And all hospital care (including outpatient
   use our in-network providers.     procedures) requires precertification. Of course, in an emergency go to the
                                     closest emergency facility. Emergency care is available worldwide.
•	 Broad	network	access	
   throughout Arizona. Plus,
   when traveling you’ll have
   access to more than 8,000
   hospitals and 525,000 providers
   available nationwide through an
   arrangement with First Health®,
   a national PPO network.
•	 Time	saving	convenience	–	
   no claim forms to file when
   you use network services.          1Those living in Apache, Navajo, Yavapai and Yuma counties must always use the First
                                      Health network to receive in-network benefits in these areas. When accessing care in all
                                      other counties in Arizona, PPO members must use the Health Net provider network to
                                      receive in-network benefits.


                                                         5
ppO pLAN CHOICEs

vALuE pLANs
Our Value Plans are just the right fit for those who don’t require a lot of
medical attention. These high deductible plans give you coverage when you
need it most with a lower monthly plan premium that’s affordable for you.
With our Value Plan benefits, you get in-network hospital, lab and X-ray
services at no charge after you’ve met your deductible. Your office visits are
a fixed copay – $30 for a primary care doctor visit and preventive care, $60
for a specialist visit.
AdvANTAgE pLANs
If you’re looking for a plan with lower deductibles, look to our Advantage
Plans. Choose from a wide range of deductible plans that suit your needs
and your budget.
Our Advantage Plan benefits include in-network hospital services at
only a 20 percent coinsurance after you’ve met your deductible. Lab and
X-ray services are no charge in the doctor’s office or freestanding facility
(non-hospital affiliated). And you pay a fixed copay for primary care and
specialist office visits and preventive care.
IN-sTORE HEALTH CARE CLINICs (CONvENIENT CARE CLINICs)
All of our plans give you access to the In-Store Health Care Clinics
(Convenience care clinics) located throughout the Phoenix and Tucson
areas – for just an office visit copay.
These clinics provide care for minor illnesses, such as flu and allergies.
Plus, you can access wellness services including immunizations and blood
pressure checks.
In-Store Health Care Clinic services are available through Take Care Health
Systems in Walgreen’s Pharmacies, MinuteClinics in select CVS Pharmacies
and The Little Clinic in five select Fry’s Food Stores in the Phoenix area.




                                                            6
HMO:
  CONFIdENCE
          ANd
   pREdICTABILITy
It’s easy to see why those looking for predictability go with our HMO plan.
It’s designed for people who want to know what they’ll pay for their health
care services at the time they receive them. Plus, they feel confident that
their doctor coordinates most of their medical needs.
With our HMO plan, you’ll choose a primary care physician (PCP) from
our Health Net network of contracted providers. We have one of the
largest provider networks in the state, with more than 3,300 primary care
physicians, 3,200 specialists and 50 hospitals to choose from. We’ve also
been voted Arizona’s #1 HMO since 2005, based on the state’s largest
opinion poll, “Ranking Arizona,” conducted by Arizona Business Magazine.        Is A HEALTH NET HMO pLAN
That speaks volumes.                                                            RIgHT FOR yOu?
OuR HMO pLAN                                                                    Yes, if you want:
With decades of HMO experience behind us, you get the security of               •	 Fixed	copayments	for	most	
comprehensive health care coverage along with a comfortable monthly                services.
plan premium.                                                                   •	 A	wide	range	of	covered	
Our HMO plan includes a $1,000 deductible for individual applicants and            services.
$2,000 for families. You pay a fixed copay of $25 for primary care office       •	 Lower	costs	by	using	
visits and preventive care, and $50 for specialist visits. Plus, a 30 percent      in-network providers.
coinsurance for hospital services after your deductible is met. Just as with
                                                                                •	 Your	doctor	to	coordinate	
our PPO plans, you have access to the In-Store Health Care Clinics.
                                                                                   most of your health care needs.
                                                                                •	 No	claim	form	filing.
                                                                                •	 Worldwide	emergency	
                                                                                   coverage.



                                                          7
HsA-COMpATIBLE pLANs:
   HIgH dEduCTIBLE ppO pLANs
WITH TAX sAvINg OppORTuNITIEs

                                     Health Net’s HSA-compatible plans work just like our PPO plans – you
                                     choose whether to see a provider in our network or go to an out-of-network
                                     licensed physician or health care professional. When you go out-of-network,
                                     you usually pay more for the services you receive. Either way, you don’t
                                     need a referral from your doctor to see a specialist or go to the hospital.
                                     HSA-compatible PPO plans are different in that the deductible is higher
                                     but you spend less on monthly premiums. Here are some key facts to know
                                     about our plans.
                                     •	 HSA-compatible	plans	have	combined	medical	and	pharmacy	deductibles.	
                                        This means that you pay the full cost of prescriptions and medical care (at
Is A HEALTH NET HsA-                    our negotiated rate) until your annual deductible has been met.
COMpATIBLE pLAN RIgHT
FOR yOu?                             •	 The	deductible	for	preventive	care	benefits	is	waived	for	the	first	$500	
Yes, if you want:                       (in-network only).
•	 Freedom	of	choice,	no	            Plus, you can open a health savings account (HSA) and use tax-free
   referrals required.               dollars to pay for qualified medical expenses.2 Other HSA advantages
•	 Access	to	in-	and	out-of-         include the following:
   network providers – your costs    •	 You	have	complete	control	over	your	health	care	dollars.
   are usually lower when you
   use our in-network providers.     •	 Contributions	(up	to	the	IRS	maximum)	and	withdrawals	are	tax-free	
                                        when used for qualified medical and pharmacy expenses.
•	 Broad	network	access	
   throughout Arizona. Plus,         •	 HSA	funds	can	be	invested	and	investment	earnings	are	non-taxable	
   when traveling, you’ll have          when used for qualified medical expenses.
   access to more than 8,000         •	 It	offers	long-term	savings,	rollover	features	(no	time	limit	for	using	the	funds)	
   hospitals and 525,000 providers      and catch-up contributions for insureds between the ages of 55 and 65.
   available nationwide through an
   arrangement with First Health®,   HsA-COMpATIBLE ppO pLAN CHOICEs
   a national PPO network.           These plans work well for people who want protection against the
                                     unexpected and more control over their own health care dollar.
•	 Time	saving	convenience	–	no	
   claim forms to file when you      With our HSA-compatible PPO Plans you have three deductibles to choose
   use in-network services.          from starting at $2,000 for individual applicants up to $5,000 for a family.
                                     After you meet your calendar year deductible, in-network benefits are paid
•	 Tax-savings	advantages	of	a	
                                     at 100 percent. Plus, you have immediate coverage for preventive care
   health savings account – a
                                     services. You also have access to the In-Store Health Care Clinics.
   smart way to save, spend
   and invest your health care       2A full list of qualified medical expenses can be found at www.irs.gov. This brochure
   dollars.2                          provides general information only. For more information about the tax implications of
                                      an HSA or HSA program, contact a professional tax advisor.


                                                         8
dENTAL
   & vIsION
  If you’re looking for dental and vision coverage, we’ve got it here. Health Net’s
  Optional Voluntary Dental & Vision Plan is available to members enrolled in a
  Health Net Individual & Family medical plan. For just $19.53 per person per
  month, it’s a great way to round out your health coverage.
  dENTAL COvERAgE BENEFITs:
  •	 Choose	your	own	licensed	dental	provider	–	no	need	to	stay	within	
     a network
  •	 Flexibility	–	no	referrals	to	see	specialists
  •	 Added	savings	–	your	$50	deductible	is	waived	for	diagnostic	services
  vIsION COvERAgE BENEFITs:
  •	 Low	copayments	for	vision	exams	and	lenses	and	allowances	for	
     other services
  •	 $120	retail	plan	allowance	on	frames
  •	 Freedom	to	choose	licensed	vision	care	providers	both	in-	and	
     out-of-network
  •	 Large	network	of	independent	providers,	including	optical	retailers	
     LensCrafters®, Pearle Vision, SearsSM Optical, Target Optical® and
     JCPenney® Optical
  Ask your broker for more information and for a copy of our Health Net
  Individual & Family Plan Dental & Vision Coverage brochure. Go online
  to www.healthnet.com to find dental and vision providers in your area.



                     9
         Life insurance is one way we protect the people we care about the most.
         For that added peace of mind, you can purchase Individual Term Life
         Insurance from Health Net Life Insurance Company. You must be
         enrolled in a Health Net Individual & Family medical plan to purchase
         individual term life insurance.
         You have a choice of four coverage amounts for policies that cover you
         and your spouse. The monthly premium is based on the age of the person
         covered by the life insurance policy.
         See the chart below for monthly rates.

         LIFE INsuRANCE
         Monthly terM life insurance rates
              Primary                                            Cost for         Cost for
                           Cost for $1,000   Cost for $15,000
           Insured’s Age                                         $30,000          $50,000
              19-29             $0.19             $2.85           $5.70            $9.50
              30-39             $0.22             $3.30           $6.60            $11.00
              40-49             $0.50             $7.50          $15.00            $25.00
              50-59             $1.37            $20.55           $41.10           $68.50
              60-64             $2.00            $30.00          $60.00           $100.00




 INdIvIduAL
        TERM LIFE
INsuRANCE pLANs
         Here are a few things you should know:
         •	 If	you	wish	to	purchase	life	insurance,	you	must	purchase	a	minimum	
            of $15,000. The maximum life insurance benefit is $50,000.
         •	 Coverage	can	be	purchased	for	both	you	and	your	spouse.
         •	 Term	life	insurance	coverage	is	only	available	to	individuals	19	years	of	
            age or older.
         •	 If	you	purchase	life	insurance	coverage,	be	sure	to	fill	out	the	
            beneficiary information found on the enrollment application.
         •	 Your	coverage	will	become	effective	once	you’ve	been	approved	by	
            Health Net Life Insurance Company.




         Individual term life insurance is underwritten by Health Net Life Insurance Company.


                           10
pART 2




         NO-COsT
           EXTRAs




             11
dECIsION pOWER                                                           sM


                          HEALTH IN BALANCE

INFORMATION, REsOuRCEs ANd suppORT
FOR EvERy pERsON, EvERy sTAgE OF HEALTH
When you choose Health Net, you
get more than health care coverage.
You get Decision Power.
Decision Power brings together
under one roof the information,
resources and personal support
that fit you, your health and your
life. Whether you’re focused on
staying fit, dealing with back
pain or facing a serious diagnosis,
we’re here to help you work with
your doctor and make informed
decisions. Here’s how it works:


            sTAyINg HEALTHy Is                       yOuR HEALTH,             Log on to www.healthnet.com:
            jusT As IMpORTANT                        yOuR TIME,               Take the Health Risk
            As gETTINg WELL.                         yOuR CHOICE.             Questionnaire (HRQ) – with
Making the most of your health is
                                      Whether you…                            its instant results and interactive
what Decision Power is all about.
                                      •	 have	a	question                      features, the HRQ is your gateway
We’re focused on your whole
                                                                              to recommendations and resources
health, not just one concern or       •	 want	to	help	with	a	specific	
                                                                              based on your unique health profile.
disease. So we work with you             health goal
to identify potential health risks    •	 need	treatment	but	want	to	          Try a step-by-step plan for
and help prevent minor concerns          understand all your options          losing weight, stopping smoking
from becoming big problems. And                                               or boosting nutrition. You can
                                      •	 are	living	with	illness
we’re here should you face serious                                            start with our online coaching and
medical concerns.                     …you choose how and when                self-help tools. Phone coaching
                                      to use the information, resources       support is included so making
                                      and support available. You can          lasting, healthy changes is easier.
                                      use Decision Power online or
                                                                              Set up a Personal Health Record
                                      by calling a Health Coach. Try
                                                                              (PHR) to track your health
                                      multiple resources at once, or one
                                                                              progress and have a complete
                                      at a time. 24 hours a day, seven
                                                                              medical snapshot whenever you
                                      days a week, Decision Power is
                                                                              need it.
                                      here for you.


                                                        12
                                                                              Decision Power –
                                                                              use it whenever and
                                                                              as often as you like.
                                                                              Because when it
                                                                              comes to your health,
                                                                              there’s more than
                                                                              one right answer.




Find support for any kind of          Steps to avoid cardiometabolic                        dOCTOR-pATIENT
mental health concern such as         risk – the combination of three or                    CONNECTION.
depression, excessive alcohol use     more of the six risk factors (e.g.,     Doctors know medicine. You
and eating disorders.                 waist size, blood pressure, HDL         know your body. With Decision
                                      cholesterol level) that predict         Power, it’s easy to learn what
Be informed – access information
                                      diabetes, heart disease and colon,      questions to ask, how to explain
resources, such as Healthwise®
                                      uterine and prostate cancers.           your preferences and to get the
Knowledgebase, an online
                                                                              support you need from your
health encyclopedia; HEAR®            24-hour answers to health
                                                                              doctor. The more you know, the
Audio Library, which contains         questions or concerns. Always
                                                                              easier it is to navigate complicated
information on 355 health topics;     call 9-1-1 or go straight to
                                                                              health choices and make the ones
and Health Crossroads® Web            the emergency room in a life-
                                                                              that are right for you.
Modules, which explain the pros       threatening situation.
and cons of various treatments.
                                      Pointers for setting achievable
Know your numbers with our            health goals; guidance on
health trackers (cholesterol, diet,   evaluating treatment options.
fitness), treatment cost estimator
                                      Guidance and support for living
and hospital comparison reports.
                                      with an ongoing illness such as
Talk to a Health Coach to get:        asthma, diabetes, heart disease, etc.
1-to-1 consultations and a single     Specialized consultation from
point of contact for any and every    nurse case managers to help both
health question, goal or situation.   patients and family members deal
You can talk to the same Health       with the complexity of end-stage
Coach every time you call, and        illnesses.
about any health goal or challenge.




                                                       13
                                          CONsuMER
                                               TOOLs
Health care is about more than                My Claim History – you can             QuICk LINks:
just health care benefits. It’s about     view prescription claims history           jusT CLICk ANd gO
giving you the tools and support          and medical Explanation of                 Using the Quick Links featured to
you need to make the most of your         Benefits (EOB). You can even go            the left of the page, you can find
health through every stage of life.       paperless by updating your                 a pharmacy, print temporary ID
                                          EOB document delivery process              cards, change your primary care
sELF-sERvICE AT
                                          at www.healthnet.com.                      physician or view benefit details.
WWW.HEALTHNET.COM
Once you enroll with Health Net,          Decision PowerSM Health &                  My HEALTH NET:
you’ll have a go-to online resource       Wellness – the connection to               AT yOuR FINgERTIps
for your health plan information –        member discounts, wellness                 Exclusively for members,
quick and easy.                           programs, hospital and medical             My Health Net is a personal menu
                                          group comparison tools, treatment          of the information you use and
MENu OF CHOICEs
                                          cost estimator and more.                   need most. It takes you right
    My Medical Benefits – includes                                                   where you want to go with just a
your specific benefit details and prior   Doctor & Hospital Information
                                                                                     click of a mouse.
authorization list.                       – search engine locates specific
                                          doctors, the nearest hospital or           Healthnet.com – the source for
My Pharmacy Benefits – the                                                           all things Health Net and an easy
                                          specific services. Visual maps show
place to manage prescriptions and                                                    way to get more done fast!
                                          the precise location of the office or
view your medication history,
                                          hospital.
order prescriptions by mail, see our
Recommended Drug List, and more.              Manage My Account – you
                                          can change your PCP, get ID cards
                                          and forms, manage your account
                                          details and view medical treatment
                                          policies.




         Just as we are committed to our customers’ well-being, we are equally committed to our environment. Throughout this
         brochure you will see the Health Net leaf icon representing how we have eliminated a paper process and created the
         same function online.



                                                            14
pART 3




         AppLyINg
           FOR HEALTH NET
          COvERAgE




           15
HOW TO AppLy
      3 EAsy sTEps
                 TO A BETTER dECIsION

Applying for Health Net Individual & Family Plan coverage is as easy as         IF yOu HAvE
1-2-3:
                                                                                ANy QuEsTIONs,
1. Apply online at www.healthnet.com > Enroll Now > Arizona                     pLEAsE CALL yOuR
   or through your authorized broker.
                                                                                AuTHORIZEd BROkER
  Note that the application MUST be completed, signed and dated                 OR HEALTH NET OF
  by the applicant even if you’re working with a broker. Neither the
                                                                                ARIZONA INdIvIduAL
  broker nor any other person may complete or sign the application and
  agreement on behalf of the applicant(s).                                      & FAMILy pLANs
  After your application is complete:
                                                                                AT 1-888-463-4875,
                                                                                option 3.
  •	 Include	your	payment	for	the	first	month’s	premium	amount	by	
     check, automatic bank draft or credit card.
  •	 Mail	the	completed	application	and	check	(within	30	days	of	the	date	
     you signed the application) to your broker or directly to Health Net at:

    Health Net Individual & Family Plans
    1230 W. Washington Street, Suite 401
    Tempe, AZ 85281-9603
                                                                                Easy. Affordable.
2. You’ll receive notification of the underwriting status of your
   application.                                                                 Health Net Individual
			•		 o	not	cancel	any	other	coverage	you	may	have	until	you	receive	
     D
                                                                                & Family Plans
     approval of your application in writing from Health Net’s
     Underwriting Department.
3. Once approved, look for your Health Net ID card and plan
   materials to come in the mail. Then enjoy the benefits of
   membership – large doctor networks, personal service and
   wellness resources.


                                                         16
pROTECTINg yOuR HEALTH                              PPO Plans Precertification is required                Skilled nursing coverage is limited to 60 days
INFORMATAION                                        for certain services. Failure to obtain               per calendar year.
Once you become a Health Net member,                precertification will result in a reduction
                                                                                                          Expenses you incur for the following cannot be
Health Net uses and discloses a member’s            in benefits. For a comprehensive list of
                                                                                                          used to satisfy the out-of-pocket maximum:
protected health information for purposes of        services requiring precertification see the
                                                                                                          failure to follow prior authorization/
treatment, payment, health care operations,         Policy. Services that must be precertified
                                                                                                          precertification guidelines, mental illness,
and where permitted or required by law.             include, but are not limited to: Hospital
                                                                                                          substance abuse, infertility, use of emergency
Health Net provides members with a Notice           inpatient admissions (non-emergency,
                                                                                                          room for non-emergent care, prescription drugs,
of Privacy Practices that describes how it uses     including acute, subacute or rehabilitation),
                                                                                                          copayments, limitations, exclusions. Check your
and discloses protected health information;         hospital observation stays (less than 24
                                                                                                          Evidence of Coverage or Policy.
the individual’s rights to access, to request       hours), mental health and substance abuse
amendments, restrictions, and an accounting         inpatient admissions, skilled nursing inpatient       Pre-existing Condition Limitation (PPO Plans
of disclosures of protected health information;     facility admissions, transplants/transplant           only): Expenses for conditions for which a
and the procedures for filing complaints.           services, select outpatient procedures, select        member received any medical advice, diagnosis,
Health Net will provide you the opportunity         rehabilitative programs and therapies, select         care or treatment during the six (6) month
to approve or refuse the release of your            durable medical equipment, home health care           period immediately preceding the member’s
information for non-routine releases such           services (including home infusion therapy),           effective date of coverage will be excluded from
as marketing. Health Net provides access            non-emergent ambulance and transportation             coverage the first 12 months of enrollment.
to members to inspect or obtain a copy of           services, prosthetics, oncology services,             High-Deductible PPO Plans Preventive
the member’s protected health information in        podiatry services, sleep studies, oxygen and          health care services are defined as routine
designated record sets maintained by Health Net.    related breathing equipment, epidural steroid         physical, pap smear, mammography and PSA
Health Net protects oral, written and electronic    injections, magnetic resonance imaging (MRI),         screenings. For a complete list see Policy.
information across the organization by using        computerized axial tomography (CAT),
reasonable and appropriate security safeguards.     positron emission tomography (PET) scans,
Health Net releases protected health information    magnetic resonance angiography (MRA), self-
to plan sponsors for administration of self-        injectable medications (except insulin), select
funded plans but does not release protected         in-office pharmacy injectables.
health information to plan sponsors/employers       Coverage for maternity services is limited to
for insured products unless the plan sponsor is     complications of pregnancy.
performing a payment or health care operation
function for the plan.                              HMO and PPO Plans The following
                                                    services and/or procedures are either limited
EXCLusIONs ANd LIMITATIONs                          in coverage or excluded from coverage under
The exclusions and limitations presented in this    these health plans. These services include,
enrollment brochure are not comprehensive.          but are not limited to: Comfort/convenience
For a full list of exclusions and limitations see   items, hearing aids, cosmetic surgery, court
the Evidence of Coverage for HMO Plans or           ordered care, custodial care, experimental/
Policy for PPO Plans. You may obtain a copy         investigational procedures and drugs, gender
of these documents prior to enrolling or at any     alterations, infertility services, inpatient mental
time by contacting us at 1-888-463-4875.            health services, long-term rehabilitative services,
Exclusions and limitations include but              obesity, paternity testing, radial keratotomy,
are not limited to:                                 substance abuse treatment programs, mail
HMO Plans Hospital and professional services        order prescriptions, employment counseling,
for a normal delivery are covered only for          exercise programs, fraudulent services, missed
expectant members who have been enrolled            appointments, temporomandibular joint
for 21 consecutive months when delivery             disorder, vocational programs. For a complete
occurs. Hospital and professional services for      list, refer to either the Evidence of Coverage for
members who have been enrolled less than 21         HMO Plans or Policy for PPO Plans. In- and
consecutive months are limited to prenatal          out-of-network benefits are subject to deductible,
care, after 12 months of enrollment, and            then a percentage of eligible medical expenses.
complications of pregnancy, as defined in the       All drugs covered by your outpatient prescription
Evidence of Coverage.                               benefit are placed in one of four tiers on the
With the exception of emergency care and            Preferred Drug List (PDL). The lower the tier,
direct access benefits, all services and items      the lower your copayment. The Health Net PDL
must be provided or arranged by your primary        is a listing of covered medications. Some drugs
care physician. Selected services require           on the PDL may require prior authorization from
authorization by Health Net of Arizona, Inc.        Health Net. Prescriptions are limited to a 31-day
                                                    supply. Other quantity limitations may apply.




                                                                           17
FOR MORE INFORMATION, CONTACT
Health Net of Arizona, Inc.

1230 W. Washington Street, Suite 401
Tempe, AZ 85281-2145

Customer Contact Center
1-888-463-4875
Monday - Friday, 7:00 a.m. to 6:00 p.m.

Hearing Impaired Assistance
TTY 1-800-977-6757
Monday - Friday, 7:00 a.m. to 6:00 p.m.

www.healthnet.com




You have access to Decision Power through your current enrollment with any of the following Health Net companies: Health Net of Arizona, Inc.;
Health Net Life Insurance Company.
In Arizona, benefits are underwritten and/or administered by Health Net of Arizona, Inc., for HMO plans and Health Net Life Insurance Company
for indemnity plans and life insurance coverage. Decision PowerSM is not part of Health Net’s commercial medical benefit plans nor affiliated
with Health Net’s provider network and it may be revised or withdrawn without notice. Decision Power services, including Health Coaches, are
additional resources that Health Net makes available to enrollees of Health Net of California and Health Net Life Insurance Company.
6020292 AZ62296 (10/09)

				
DOCUMENT INFO