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Commercial
Employer Manual
Administrative guide for employers in Oregon and Washington
2014
Susan Potthoff,
Health Net
We make health
care easy to
understand.
Contents
Welcome to the Employer Manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Understanding Our Customers Is Just the Beginning. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Health Net Directory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Health Net Reform Changes: What’s New in 2014?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Enrollment Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Employer Group Enrollment and Change Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Probationary period.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Rehires.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
An important reminder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
IRS Section 125. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Oregon and Washington law on domestic partnership.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Annual open enrollment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Enrolling new employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Enrolling rehired employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Enrolling formerly ineligible employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Enrolling dependents.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Enrolling newly eligible dependents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Selecting a PPG and PCP for EPO, HNCC and POS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Selecting a participating or preferred provider (for PPO
and the PPO level of benefits for POS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Health Net ID card.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Ongoing Care Assistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
Who may benefit from the Ongoing Care Assistance services?... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Employer Portal and IBilling... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
Employer portal – full online access for all your needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
IBilling – enrollment and billing via the Internet.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Employer capabilities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Canceling Employee/Dependent Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
Continuation of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
Overview.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
COBRA and Oregon State Continuation administration.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
(continued)
Termination of coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Leave of absence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Oregon State Continuation coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Group policyholders offering Oregon State Continuation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Oregon State Continuation eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Administering Oregon State Continuation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Oregon State Continuation limitations and deadlines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Oregon State Continuation coverage termination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
COBRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Employers offering COBRA.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
COBRA eligibility.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Administering COBRA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
COBRA limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
COBRA notification and payment deadlines.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Washington State Conversion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Washington State Conversion eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Medicare coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Billing Procedures.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
Monthly billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Electronic Funds Transfer (EFT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29
Appeals and Grievances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Appeals – request for reconsideration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Complaint – expression of dissatisfaction (Oregon)/grievances (Washington). . . . . . . . . . . . . . . . . 31
Independent medical review of grievances/complaints/appeals
involving a disputed health care service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Eligibility.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Notice of Privacy Practices.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
Summary of Benefits and Coverage to Eligible and Covered Persons. . . . . . . . . .
39
Glossary of Terms.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
Welcome to the
Employer Manual
This employer manual is a guide to administering your Health Net
employer group health plans. It contains updates and enhancements
to our guidelines and procedures. Use the table of contents to find
what you need quickly and easily.
This guide includes:
• Enrollment procedures
• Membership information
• Billing procedures
• And more
At Health Net, we strive to provide you with
our best service and keep you informed on
current Health Net policies. If you have any
questions, please contact your Health Net
Account Manager or Health Net Sales at
1-888-802-7001 (option 2).
For the purposes of this manual, the term
“Health Net” means Health Net Health Plan of
Oregon, Inc., except where specifically stated.
Thank you for your continued business.
Carol Kim,
Health Net
We help make whole
health possible.
1
Understanding
Our Customers
Is Just the Beginning
At Health Net, we approach our business with a need to develop a
deep understanding of our customers. We look for the chance to make
a positive difference in the lives of the people we serve. This allows us
to create relevant and affordable solutions, driven by collaboration with
all clients and partners. The result is that we more efficiently meet the
needs of our customers.
Janis E. Carter,
Health Net
We’re here for members
when they need us.
2
Health Net Directory
Website: www.HealthNet.com
Customer Contact Center
Account Service Unit
The Customer Contact Center is here to
assist you and your groups with any claims
or benefit questions about our medical plans.
This department can answer the majority of
all questions. (Please include the applicable
Health Net member ID in your email
message.)
Phone:1-888-802-7001, option 2,
then option 4
Fax:1-866-848-6715
Email: [email protected]
Phone:1-888-802-7001
Email: www.healthnet.com
(Click on Contact Us at the top of the page.)
Para los que hablan español:1-800-331-1777
Pharmacy Customer Service
The Pharmacy Customer Service
Department is available to answer any
questions related to pharmacy benefits
or our Rx mail-order service.
Sales and Account Management
The Sales Department can assist you with
questions about any of the plans that we offer.
Phone:1-888-802-7001, option 2
Fax:1-855-607-0977
Address
Health Net Claims
PO Box 14130
Lexington, KY 40512
Phone:1-888-802-7001, option 1,
then option 4
Email: [email protected]
Membership/Accounting
Ask Membership Accounting questions
about enrollment and billing.
Mail group premium payments to:
Health Net
File 749393
Los Angeles, CA 90074-9393
Mail enrollment applications to:
Health Net
PO Box 9103
Van Nuys, CA 91409-9103
Fax:1-855-607-0982
Email: [email protected]
3
Health Net
Reform
Changes: What’s New
in 2014?
Coverage changes and consumer protections are among the biggest
provisions of the Patient Protection and Affordability Care Act (ACA).
Many new provisions will take effect January 1, 2014. This snapshot gives
you and your clients an easy quick-reference guide.
Essential Health Benefits
Guaranteed issue and renewability
• Effective January 1, 2014, Small Group and
Individual and Family plans must cover
Essential Health Benefits items and services
as defined under the ACA.
• Requires guaranteed issue and renewability
of health insurance for individuals and
business groups.
• Essential Health Benefits have been
identified as a comprehensive package of
items and services which fit in 10 categories:
–Ambulatory patient services
–Emergency services
–Hospitalization
–Maternity and newborn care
–Mental health and substance use disorder
services, including behavioral health
treatment
–Prescription drugs
–Rehabilitative and habilitative services
and devices
–Laboratory services
–Preventive and wellness services, and
chronic disease management
–Pediatric services, including dental and
vision care
4
Lifetime limits and restrictions on
annual limits
• Effective January 1, 2014, a group health
plan cannot place lifetime limits on the
dollar value of coverage.
• In addition, a group health plan cannot
have annual limits on the dollar value of an
Essential Health Benefit.
Out-of-pocket maximums
• Nongrandfathered plans must meet the
following requirements upon the group’s
renewal, effective January 1, 2014, and later:
–The out-of-pocket maximum may not be
greater than the limit for HSA-compatible
plans. In 2014, the out-of-pocket
maximum may not be greater than $6,350
for an individual or $12,700 for a family.
–Deductibles, copayment and coinsurance
for all medical benefits, including mental
health and chiropractic benefits, must
accumulate toward the member’s out-ofpocket maximum.
Pre-existing conditions
• Effective upon renewal on or after
January 1, 2014, plans are prohibited
from excluding coverage for any eligible
enrollee, regardless of age, health status,
or pre-existing conditions.
• Previously, health plans could not impose a
pre-existing condition exclusion on children
under 19 years old for plan years beginning
on or after September 23, 2010.
Already in place are
provisions on:
•No lifetime limits and restrictions
on annual limits.
•100 percent coverage for
preventive care on nongrandfathered plans.
•Over-age dependent coverage up
to 26 years of age.
•No pre-existing conditions
exclusion for children.
• Emergency services standards.
• Coverage rescission restrictions.
• This change applies to all grandfathered and
nongrandfathered plans.
Probationary period/Waiting period
• Effective upon renewal on or after
January 1, 2014, federal law requires that the
waiting/probationary period cannot exceed
90 days.
• Available probationary periods are the
first of the month following date of hire,
the first of the month following 30 days
from the date of hire, and the first of the
month following 60 days from the date of
hire. Large Groups may have other options
with Underwriting approval.
• Groups that have a waiting period that falls
outside the new limits must change their
waiting period at renewal.
5
Enrollment Procedures
In this section, you will find
information about:
• Your annual open enrollment.
• How to enroll new and rehired employees.
• How to enroll existing and newly eligible
dependents.
• Selecting a participating primary care
provider (PCP) for EPO (exclusive provider
organization), Health Net CommunityCare
(HNCC) and Triple Option (POS) plans.
• The Health Net ID card.
Employer Group Enrollment and
Change Form
This form can be used in the following ways:
1. To be completed by employees to initially
enroll in Health Net for coverage for
themselves and their dependents. You must
carefully review this form for completeness
before submitting it to Health Net.
2. To delete/add dependents, change address/
name or make a plan change.
Probationary period
Probationary periods are the length of time
that all employees must wait before they are
covered by Health Net. The effective date
of coverage is always the first of the month
following the completion of the probationary
period, if applicable. The probationary period
is determined by the employer, not Health Net.
Recent changes under ACA limit probationary
periods to be no longer than 90 calendar days.
The longest period Health Net offers is first of
the month following 60 days from the date of
6
hire. Large Groups may have other
options with Underwriting approval.
When the 60th day falls on the first of the
month, the employee will be enrolled on the
60th day in order to ensure compliance.
Probationary periods are applied to:
• New full-time employees.
• Employees whose status changes from
ineligible to eligible.
• Former Oregon group employees rehired
due to layoff after 9 months of the last
day worked.
• Former Washington group employees
rehired due to layoff after 6 months of the
last day worked.
Rehires
If a terminated employee is rehired
within 30 days, he or she and dependent(s)
will be reinstated without a coverage lapse
(i.e., a period where there is no coverage).
Example:
Terminated: 8/25/13
Coverage ends: 9/01/13
Rehired: 9/18/13
Coverage reinstated: 9/01/13
Since the period between termination
and rehire is less than 30 days, continuous
coverage is provided.
If more than 9 months in Oregon and
6 months in Washington have elapsed
between the termination and rehire dates,
the employee must again fulfill your group’s
probationary period as if she or he were a
new hire. This will produce a coverage
lapse. The probationary period varies
with each group.
Example:
Terminated: 8/25/12
Coverage ends: 9/01/12
Rehired: 10/09/13
Probationary period: two months
(Varies by employer group)
Coverage reinstated: 1/01/14
An important reminder
Please send a notice of new enrollments
throughout the month as they occur.
For Small Business Groups, we must receive
notification within 31 days of eligibility or
the employee must wait until the next open
enrollment.
Prompt submission of membership changes
will allow Health Net to better serve your
account in the following ways.
• The effective dates of coverage for your
employees and their dependents will be
recorded sooner, resulting in the member
receiving the ID card sooner.
• Eligibility will be visible to providers sooner.
• There will be fewer billing adjustments.
To ensure that your employees receive their
Health Net ID cards as close as possible to
the effective date of coverage, forms must
be submitted no later than 10 business days
before the effective date of the enrollment.
Enrollment forms may be submitted as early
as two months prior to the effective date of
coverage; however, enrollment forms must
be received no later than 31 days after the
effective date of enrollment for Small Business
Groups.
Washington: it is 31 days after marriage and
60 days after birth, adoption, or placement
of adoption.
IRS Section 125
Under IRS Section 125 rules, individuals using
pre-tax deductions to secure benefits may not
change their enrollment or benefits election
effective mid-year unless there is a qualified
change to the individual’s family status. But
even when such deductions are being taken
out on an after-tax basis, employees who do
not experience a qualified change in family
status may not make mid-year changes except
to cancel coverage. They must still wait until
open enrollment.
Under the IRS regulations, changes in family
status include:
1. Marriage, divorce, legal separation,
or annulment of the employee.
2. Death of the employee’s spouse or
dependent.
3. Birth or adoption of the employee’s child or
placement for adoption.
4. Commencement or termination of
employment of the employee’s spouse.
5. A switch from part-time to full-time status
by the employee.
6. An unpaid leave of absence taken by the
employee or employee’s spouse.
7. A significant change in the health coverage
of the employee or spouse attributable to
the spouse’s employment.
8. Changes in work schedule for employee
or any qualified dependent including strike
or lockout or return from an unpaid leave
of absence.
Oregon: it is 31 days after marriage, birth,
adoption, and placement of adoption.
7
9.An event that causes an employee’s
dependent to satisfy or cease to satisfy
the requirements for coverage due to
attainment of age, student status or any
similar circumstances as provided under
the accident or health plan under which
the employee receives coverage.
10.A change in the place of residence or
worksite of the employee, spouse or
dependent.
The regulations to Section 125 also added
the following three new events upon which
a change in election can occur under an
accident and health plan or group term life
insurance component of a flex plan:
1. If an employee, spouse or dependent
becomes eligible for COBRA continuation
coverage, the employee may increase his or
her flex plan election amount to pay for the
COBRA coverage on a pre-tax basis.
Andre Hamil,
Health Net
We’re committed to being
more than a vendor for you.
8
2. If the employee, spouse or dependent
becomes entitled to Medicare or Medicaid
(other than the program solely for
pediatric vaccines), the employee may elect
to cancel the coverage of the employee,
spouse or dependent.
3. If the plan receives a qualified medical
child support order (QMED) pertaining
to an employee’s dependent, the employee
may elect to add the child to the plan (if
the QMED requires coverage) or drop the
child from the plan (if the QMED requires
the ex-spouse to provide coverage).
The above guidance may change in the future,
as the regulations to Section 125 allow but do
not require benefit plans to permit employees
to make many of the mid-year changes
discussed above.
Oregon and Washington law on
domestic partnership
Annual open enrollment
Oregon law grants registered domestic partners
the same rights as a legal spouse for group
health insurance coverage. The creation or
dissolution of a registered domestic partnership
is considered a qualified family status change
where mid-year election changes are allowed.
• Employers must conduct an annual open
enrollment for Health Net.
Under Oregon and Washington law,
individuals of the same sex can register as
domestic partners as long as the requirements
set forth in Oregon and Washington law are
met. In Washington, opposite sex individuals
can register as domestic partners only when
one or both is above the age of 62 and one or
both meet specified eligibility requirements
under the Social Security Act.
• The open enrollment coincides with the
employer’s anniversary date and occurs
during the same month each year.
Based on verification of domestic partnership
by the employer, Health Net will process
the enrollment of the domestic partner as
a spouse for coverage under the employerselected health plan. The eligible unmarried
dependent children of the domestic partner
must also be allowed to enroll under the same
terms as eligible unmarried children of the
employee and/or employee’s legal spouse.
Additionally, Health Net’s employer group
plans allow enrollment of nonregistered
domestic partners of the same or opposite sex
who do not meet Oregon’s legal requirements.
The employer must determine whether to
add this option by discussing it with their
Health Net sales representative prior to initial
enrollment. Enrollment of the nonregistered
domestic partner (and eligible dependent
children of the nonregistered domestic
partner) who does not meet Oregon’s
domestic partner requirements is allowed only
at the time of the employee’s initial enrollment
or at the annual open enrollment period.
Requirements
• The employer determines date for first
open enrollment.
• The open enrollment period must last at
least ten (10) days.
• In subsequent years, the open enrollment
should occur during the same month as the
first open enrollment.
What is accomplished during the open
enrollment period?
• Eligible employees and their dependents
may join Health Net for the first time.
• Transfer from one health carrier offered by
the employer to Health Net.
• Members may add or remove eligible
dependents.
• Transfer from one product line to another
if the employer group offers more than
one product.
• Employer group may add another product
line if eligible.
What if an employee will not be at work
during the open enrollment because of
vacation or leave of absence?
We suggest that you present the open
enrollment opportunity to that individual
before he or she departs. If this is not possible,
we suggest mailing the individual information
regarding the open enrollment.
9
What if an employee has not met the
probationary period? May he or she enroll
during open enrollment?
No, the probationary period is not waived
because the annual open enrollment occurs.
All employees must meet the probationary
period as specified on the Signature Sheet
(Oregon contracts) and the Agreement
Signature Sheet (Washington contracts) of
your group contract.
Missing or incomplete
information will cause
a delay in enrollment.
How does Health Net help during open
enrollment?
Health Net account managers are available
to assist you during open enrollment. They
can provide services ranging from supplying
enrollment kits and forms, conducting
conference calls with employer groups for
question-and-answer sessions, or arranging
for a Health Net representative to conduct an
open enrollment meeting. Please contact your
account manager in advance to arrange the
best program for your company.
Enrolling new employees
When does a new employee become eligible
for Health Net membership?
New employees are eligible to become
Health Net members if they are permanent
employees working the minimum number
of hours per week and have satisfied the
probationary period for your group.
See the Group Master Application. If you
have any questions concerning eligibility
requirements, please contact your Health Net
account manager.
How are eligible new employees enrolled?
To enroll eligible new employees, you must
submit an Enrollment and Change Form.
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All new employees who wish to enroll must
complete, sign and date their own Enrollment
and Change Form. Missing or incomplete
information will cause a delay in enrollment.
Health Net does not require that payment
be submitted when you enroll newly eligible
members. Payment is due when you receive
your statement.
When can an eligible employee enroll outside
of the employer’s open enrollment period?
An employee may enroll with Health Net or
add dependents outside of the open enrollment
period due to a change in, or loss of, benefits
or contribution levels in current coverage
from another group-sponsored plan.
In Oregon, the individual must request
enrollment within 30 days of the change.
In Washington, the individual must request
enrollment within 60 days of the change.
Your group’s benefits administrator or
Human Resources representative must
submit an Enrollment and Change Form,
and a letter to Health Net explaining the
change in benefits or contribution level,
including the effective date of that change
and proof of prior coverage.
Example:
Permissible: The subscriber/dependent(s) is
enrolled with another carrier. That carrier’s
plan changes (e.g., copayment increase,
contribution increase, benefit dropped, etc.),
effective June 30. Due to a change in or loss of
benefits, the subscriber/dependent(s) is eligible
to enroll in your group’s Health Net plan
effective July 1 provided the member submits
all documentation affirming the change no
later than July 30. If the submission deadline
is missed, the subscriber must wait until the
group’s open enrollment period to enroll.
• The subscriber of the other plan has ceased
being covered except for either failure to
pay premium contribution, a “for cause”
termination such as fraud or intentional
misrepresentation of an important fact or
voluntary termination.
Not permissible: The subscriber or
dependent(s) is enrolled with another
carrier and sees that Health Net offers a better
benefit and requests to change to Health Net.
Since there was no change in benefits or
contribution level, the request will be denied.
• The other group-sponsored plan is
terminated and not replaced with other
group coverage.
Enrolling rehired employees
• The employee loses coverage as a dependent
under the spouse’s plan due to divorce or
legal separation.
• If an employee is enrolled as a dependent
in another group sponsored health plan,
and the subscriber of the plan chooses a
different plan.
• If an employee gains new dependents due
to birth, adoption, marriage, or addition
of a domestic partner, the employee may
enroll himself or herself, and the new
dependent. For a new spouse, the effective
date of coverage will be the first of the
month following the date of marriage/
domestic partnership, according to the rules
established by the group. For a newborn,
coverage will commence at the moment of
birth. A case coordinator must review the
paperwork.
Employees on Washington group plans
also have the option to enroll during the
qualifying events.
Your group’s benefit administrator or Human
Resources representative must submit a letter
to Health Net explaining the change in benefits
or contribution level, including the effective
date of that change. Proof of prior coverage
must also be submitted with this letter.
Who qualifies as a rehired employee?
Generally, former state employees who have
been rehired within 9 months in Oregon
and 6 months in Washington of the last day
previously worked.
Do probationary periods affect the rehire’s
effective date of coverage?
Generally, if rehired within 30 days, the
probationary period is waived. If rehired
after 9 months in Oregon and 6 months in
Washington, the probationary period
must be met.
How are rehired employees enrolled?
Submit a completed Enrollment and Change
Form for each rehire you wish to enroll.
The rehire option should be indicated.
If the rehire is not a former Health Net
member, please follow the instructions found
in the Enrolling New Employees section.
If the employee is rehired after 9 months of
the last day previously worked, the employee
does not qualify as a rehire and is not eligible
to enroll in Health Net until he or she
completes the probationary period according
to the Enrolling New Employees section in
this manual.
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Enrolling formerly ineligible
employees
What effect will probationary periods have
on a formerly ineligible employee’s effective
date of coverage?
If an existing employee was previously
ineligible for Health Net coverage, the
probationary period ordinarily imposed
on newly hired employees must be met.
The probationary period begins on the date
the employee begins employment as an
eligible employee.
How are formerly ineligible employees
enrolled?
Please follow the instructions found in the
Enrolling New Employees section.
Enrolling dependents
What is the definition of a dependent?
Health Net defines eligible dependents
of the employee as individuals who meet
the eligibility requirements for coverage
listed below and who are included on the
Enrollment and Change Form completed
and signed by the subscriber.
• The subscriber’s lawful spouse or State
Registered Domestic Partner.
• A child of the subscriber, spouse or
State Registered Domestic Partner,
who is under age 26. The child may be a
natural child, adopted child, legal
dependent, or stepchild. A case coordinator
must review newly eligible adoptive and
legal dependent documentation.
• An unmarried child who is mentally or
physically handicapped and is incapable of
self-sustaining employment and remains
dependent upon the subscriber, spouse or
State Registered Domestic Partner for at
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least 50 percent of his or her support.
The disability must have been present prior
to the dependent reaching this limiting age
where he or she would have ceased to be
an eligible dependent.
Newborns of the subscriber, spouse or
State Registered Domestic Partner will be
enrolled if the additional dependent does not
cause a rate change. If a rate change will occur,
an enrollment form must be submitted to
add the dependent under an Oregon contract
within 31 days from birth or 21 days from
birth if covered under a Washington contract.
In the case of a newly adopted child, the date
that the child is placed with a subscriber,
spouse or State Registered Domestic Partner
for the purposes of adoption.
Only newborns or adopted children who are
eligible for enrollment under the Health Net
plan, and who are enrolled within 31 (Oregon
contracts) or 60 (Washington contracts)
days of the date of birth will continue to be
covered after the initial coverage period.
The subscriber must enroll the child
through the employer by completing and
submitting an Enrollment and Change Form
to receive coverage beyond the initial 31/60
day coverage period. The assigned effective
date is the date of birth, or the date the child
was placed with the subscriber, spouse or State
Registered Domestic Partner for the purposes
of adoption. Following the qualifying event,
a copy of the court order establishing the
guardianship must accompany enrollment
requests for children who have become wards.
How are dependents enrolled?
To enroll eligible dependents, you must
submit a fully completed Enrollment and
Change Form. All the dependents the
subscriber wishes to add must be indicated
on the form, and it must be signed and dated
by the subscriber. Remember that, except in
the case of a loss or change in other coverage
or a family status (marriage, addition of a
State Registered Domestic Partner, birth, or
adoption), existing dependents may only be
enrolled at initial enrollment or subsequent
open enrollment periods.
Enrolling newly eligible dependents
What is the definition of a newly eligible
dependent?
A newly eligible dependent is a spouse,
State Registered Domestic Partner or child
who joins the family as an eligible dependent
after the date the subscriber’s coverage
becomes effective.
Note: When a subscriber’s covered dependent
child gives birth to a child, the newborn
grandchild of the subscriber is not eligible
for coverage under Washington contract.
Exception for members covered under an
Oregon contract. Newborns are covered for
the first 31 days after birth. After the first
31 days, a newborn child must meet the
definition of dependent in the plan contract in
order to continue coverage under the plan.
When may newly eligible dependents be
enrolled in a Health Net plan?
If a newly eligible dependent is not enrolled
within 31 (Oregon contract)/60 (Washington
contract) days from the date of acquisition,
the newly eligible dependent is not eligible
for membership until the next open
enrollment period. When the employer allows
enrollment of domestic partners who are not
state-registered, the domestic partner and
dependent children of the domestic partner
cannot be enrolled until the next annual open
enrollment period.
When does coverage become effective for
a newly eligible dependent?
Spouses/Domestic Partners: A new spouse
or State Registered Domestic Partner must
be enrolled within 30 days of marriage or
domestic partner registration with the state.
Coverage begins on the first day of the
calendar month following the date of marriage
(domestic partner registration).
Michael McClusky, RPh,
Health Net
We help members get the
most from their benefits.
13
How are premiums affected by adding newly
eligible dependents?
There will be additional premiums for
the newly eligible dependent if his or her
enrollment causes the subscriber’s contract
to become a two-party (employee + spouse/
domestic partner or employee + child(ren)) or
family (employee + spouse/domestic partner
+ child[ren]) contract type. The premiums
will start on the dependent’s effective date.
If the subscriber is already on a family or
employee + child(ren) contract, there will be
no additional premium. Some groups may not
be impacted by adding dependents and should
contact their account manager to verify.
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How are newly eligible dependents enrolled?
To enroll newly eligible dependents,
you must submit a completed, signed and
dated new Enrollment and Change Form
for each employee who wishes to enroll
newly eligible dependents.
Important: Completion/submission of an
Enrollment and Change Form is required.
Health Net will require that enrollment
requests for children who have been placed in
the subscriber’s or spouse/domestic partner’s
custody for adoption be accompanied by a
copy of the signed consent form.
All adoptions have to be submitted to our
case coordinator for approval.
Selecting a participating physician
group and primary care physician
for exclusive provider organization
(EPO), Health Net CommunityCare
(HNCC), and POS
As part of the enrollment process for EPO,
HNCC and POS, the subscriber and each
dependent must choose a Health Net
participating primary care physician (PCP)
from the EPO or HNCC Provider Directory.
We are constantly updating our EPO and
HNCC provider networks so please confirm
a physician’s participation and availability
prior to receiving service. For up-to-date
provider availability, please visit our website
at www.healthnet.com and follow the
instructions for our ProviderSearch tool.
If you do not have web access, please call the
Customer Contact Center at 1-888-802-7001
for assistance in selecting a primary care
physician or to request a Health Net EPO
or HNCC Provider Directory.
Each member must select his or her own
primary care physician. However, if members
do not select a PCP, Health Net will assign
them one. Notification will be mailed to the
member reflecting the assignment, including
instructions on changing the PCP, if desired.
All newborn infants are assigned to the
mother’s PCP for the first 31 days after birth.
If the mother is not enrolled on the plan, the
infant will be assigned to the subscriber’s PCP.
If a new member chooses a primary care
physician who is currently his or her primary
care provider, please indicate “Current
Patient” on the Enrollment and Change Form.
Selecting a participating or preferred
provider (For PPO and the PPO level
of benefits for POS)
Employees and their dependents do not have
to select a participating or preferred provider
at the time of enrollment under the PPO
plan or to access benefits on the PPO level
of the POS plans. However, benefits may be
more cost-effective for the member under the
PPO or POS plans if they choose a network
preferred provider at the time they receive
health care.
Members should check the ProviderSearch
tool on www.healthnet.com for information
on contracted health care providers who
are members of the PPO network. Also,
members should refer to the Plan Contract
for information on benefits.
Health Net ID card
Soon after enrollment, members will receive
their Health Net ID card. This card should be
carried by the member at all times to be used
when obtaining medical or hospital care and
when purchasing covered prescription drugs.
ID cards will be issued under the following
conditions:
• Enrollment in Health Net
• Change of PCP (EPO, HNCC and POS only)
• Change in medical plans
• Transfer to COBRA or conversion coverage
• Member name change
• As requested by the member
As dependents are added to an existing
subscriber’s contract or replacement cards
are ordered, a card will be issued for that
member only.
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Ongoing
Care Assistance
The Ongoing Care Assistance process can assist new members in
understanding their plan benefits, learn about receiving services and
learn about Health Net’s processes including pharmacy benefits, medical
services and the Plan’s prior authorization/precertification processes.
This service supports members by introducing them to the Plan and by
allowing members to discuss options available to them regarding any
ongoing care needs. To request this service, the member should first call
the Customer Care Center or submit a copy of the Health Net Ongoing
Care Assistance Request form. Members may complete the form and
return it to the Customer Contact Center, either by mail or fax, as listed
on the Ongoing Care Assistance Request form.
Who may benefit from the Ongoing
Care Assistance services?
All new Health Net members are welcome to
access the Ongoing Care Assistance service,
including but not limited to:
• If the new member is pregnant and desires
information about Health Net’s benefits.
• If the member had a planned surgery
scheduled with their prior carrier (within
the next 60 days) and would like to learn
about the Plan’s prior authorization/
precertification process, if applicable.
• If the member has a terminal illness
and desires information about
Health Net’s benefits.
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• If the member has an acute or serious
chronic condition of an ongoing nature
and needs assistance.
All services must be coordinated and
authorized through the member’s
Health Net primary care provider for EPO,
POS and CommunityCare plans. Use of the
Ongoing Care Assistance Request form is
not a guarantee of coverage or payment for
health care services. Health care benefits are
processed according to the member’s Plan
Contract. Cases are considered for Ongoing
Care Assistance based on plan benefit, medical
appropriateness and clinical needs.
Employer Portal and
IBilling
Employer portal – full online access
for all your needs
Registering your group on HealthNet.com
gives you access to a full line of helpful
resources. Process enrollment and changes,
pay your bill, download forms, view your
benefits, and much more!
Manage enrollment
IBilling – enrollment and billing
via the Internet
• Process enrollments, changes or
cancellations via the Internet. You keep
the form!
Health Net’s IBilling is a free, user-friendly,
password-protected web portal for enrolled
employer groups and their employees.
The IBilling website is available 24 hours
a day, seven days a week, excluding
pre-scheduled downtime necessary for
system maintenance (usually posted on the
online Message Board in advance).
Employer capabilities
Billing
• View your bill.
• Print your bill.
• Adjust the total amount due shown
on the bill.
• Download your current membership to
your own PC as an Excel spreadsheet.
• Process current activity for group-paid
Actives, COBRA or Retirees.
• Most updates are available to view online
within 24–48 hours.
• Reduce or eliminate faxes for rush
enrollments.
To register for IBilling, go to:
www.healthnet.com. Employer groups
click on Employers, Manage My Enrollment,
then log in. Or, if you have any questions,
please call (818) 676-6247.
Forms
Most forms, such as Enrollment and Change
Forms, are available online. Contact your
broker or account manager if the form you
need isn’t available.
• Pay via an online bank account.
17
Canceling Employee/
Dependent Coverage
When should Health Net be notified
of a cancellation?
Health Net must be notified as soon as
possible prior to the last day that the member
is eligible for coverage, but no later than 30
days after the effective date of the cancellation.
Premium credit cannot be issued for more
than 90 days retroactively. Permitted days are
subject to contract agreement.
Why is timely notification important?
Members who are no longer eligible, but
who have not, in fact, been cancelled by their
employer, may incur substantial medical
expenses between the time they cease to meet
eligibility requirements and the time they are
actually removed from the plan. According to
the eligibility rules of your Health Net plan,
if you notify us of a cancellation more than
90 days after what should have been the last
day of coverage, Health Net will require that
you pay premiums for the affected member
up to the time that you provided us with proper
notification. Any request outside of the 90 days
has to be approved by our management.
How does cancellation of the subscriber’s
coverage affect the coverage of his or her
dependents?
When the subscriber’s coverage is cancelled,
all covered dependents also lose eligibility
and are cancelled automatically.
18
How is employee coverage cancelled?
The group administrator must indicate the
cancellation and effective date on the Current
Membership and Membership Changes
pages of their monthly billing statement
(membership invoice). If the billing statement
has already been sent, written notification of
the cancellation on the group’s letterhead may
be mailed to Health Net at PO Box 9103,
Van Nuys, CA 91409-9103 or faxed to
1-855-607-0982. Any written request from a
group or broker will be accepted.
How can a dependent’s coverage be cancelled
if the subscriber continues to be covered?
Follow the same procedure as when canceling
an employee, or to cancel a dependent’s
coverage when the subscriber continues to be
covered, you must submit the following form:
Enrollment and Change Form
The “Delete Self or Dependent” change option
should be indicated below “Enrollment
Reasons.” A completed, signed and dated
Enrollment and Change Form must be
submitted for each subscriber who is
canceling a dependent’s coverage.
Continuation
of Coverage
Employees and/or their dependents who are no longer eligible for
coverage under normal guidelines may be qualified to continue
coverage under Federal COBRA, Oregon State Continuation or
Washington Conversion.
Overview
Generally, any company with 20 or more
employees on an average day during the
previous calendar year may be required by
federal law to offer continuing coverage
under COBRA. A company with fewer than
20 employees on an average day during the
previous calendar year may be required to
offer continuing coverage under Oregon State
Continuation or Washington Conversion.
Continuation of Coverage forms can be found
in the Forms section of your administration kit.
Note: The following guidelines are general
and not intended to be complete. For complete
information about COBRA, Oregon State
Continuation or Washington Conversion,
contact the regulatory agencies listed under the
applicable section.
COBRA and Oregon State
Continuation administration
The employer is responsible for providing
and administering COBRA and Oregon State
Continuation for eligible employees and their
dependents. Those responsibilities include
notifying the subscriber of his or her right to
continued coverage, notifying Health Net that
a subscriber has elected continued coverage,
submitting the subscriber’s completed form
to Health Net, collecting premiums from the
subscriber and remitting those premiums to
Health Net, and informing Health Net when a
subscriber and/or their dependents terminate
continued coverage.
Termination of coverage
Continuing coverage is not available to
subscribers who have had group coverage
terminated by Health Net for any of the
following reasons:
• The subscriber fails to provide necessary
information or documentation about
other insurance under which the subscriber
is covered.
19
• The subscriber knowingly permits another
person to use his or her identification card
or has otherwise misused the Health Net
health plan.
• The subscriber knowingly presents
a claim for a payment that falsely
represents the services or supplies as
“Medically Necessary” in accordance with
professionally accepted standards.
• The subscriber knowingly makes a false
statement or false representation of a material
fact to Health Net for use by Health Net in
determining rights to a health care payment.
• The subscriber establishes residence outside
of the Health Net service area.
Leave of absence
Typical employee leave of absence policies
will permit absences between three and
six months. If an employee is on a leave
of absence consistent with the company’s
personnel policy, Health Net does not require
any special action to be taken. If it is company
policy to require that the person on leave
pay for his or her coverage during the leave
period, this type of arrangement will remain
transparent to the health plan. The employer
must continue to pay Health Net for that
employee’s coverage in the usual manner.
The health plan expects that employers will
terminate the employment and coverage of
employees on leave if there is no reasonable
expectation that they will return to work
within a rational period of time. Health Net
may need to inquire further about the
specific details.
20
If an employee on a leave of absence is
terminated from employment, they qualify
for all forms of continuation coverage for
which they are eligible. Please read the detailed
description of each of the continuation coverage
plans presented in this section.
If you are an Oregon employer with less
than 20 employees, this section generally
applies to you.
Oregon State Continuation coverage
The following are general guidelines for
Oregon State Continuation. Complete
information regarding this coverage is
outlined in the Group Agreement under the
section entitled “Oregon State Continuation”
and is governed by ORS 743.610.
Group policyholders offering Oregon State
Continuation
Group policyholders with Oregon contracts
who are not required by federal law to offer
COBRA coverage must offer Oregon State
Continuation to eligible subscribers and
surviving or divorcing spouses and dependents
who are losing eligibility for coverage.
Please note that it is the policyholder’s
obligation to be aware of its responsibilities in
administering state continuation.
Oregon State Continuation eligibility
Subscribers and their covered dependents
may be eligible for continued uninterrupted
coverage upon payment of applicable monthly
premiums if the member was covered for at
least three consecutive months prior to loss of
group coverage and the subscriber’s coverage
will terminate because of loss of employment or
eligibility for coverage. A surviving spouse may
also continue coverage for himself or herself
and any covered dependents in the event of the
employee’s death or divorce. Continuation of
coverage for the subscriber is not available if
the subscriber is eligible for Medicare coverage;
however, dependents and spouses are eligible
for Oregon State Continuation.
Administering Oregon State Continuation
The plan administrator administers Oregon
State Continuation. Those responsibilities
include:
• Informing the subscriber or surviving
or divorcing spouse of his or her right to
continued coverage.
• Instructing the subscriber or surviving or
divorcing spouse to complete an Oregon
Continuation of Group Coverage Form and
submitting it to Health Net.
• Collecting premium from the subscriber or
surviving or divorcing spouse and remitting
it to Health Net with the group’s premium.
• Informing Health Net when a member
under continuation is no longer eligible or
terminates coverage.
Oregon State Continuation limitations
and deadlines
The subscriber, surviving or divorcing
spouse or dependents must elect coverage
and submit his or her first month’s premium
within 31 days of when group coverage ends.
Continuation coverage is available for all
dependents enrolled at the time coverage
would otherwise terminate.
The subscriber, surviving or divorcing spouse
or dependents may continue coverage for up
to nine months provided premium payments
are remitted in a timely manner. The group
administrator may request the subscriber or
surviving or divorcing spouse to submit their
premium in advance of due date to allow time
to process and send the payment as part of the
group’s monthly premium payment.
Oregon State Continuation coverage
termination
Termination of subscriber coverage may occur
at the end of any premium period for any of
the following reasons:
• The subscriber or surviving or divorcing
spouse ceases to pay premiums as required.
• The policyholder ceases to provide any
group coverage.
• The member becomes eligible for Medicare.
Important: If the policyholder terminates
coverage with Health Net and obtains
coverage with another carrier, all members
on Oregon State Continuation will be covered
by the new carrier for the remainder of their
continued coverage eligibility period.
When a subscriber or surviving or divorcing
spouse and any covered family member(s)
have been enrolled for the maximum
nine-month period of continuation coverage,
the covered members may be eligible for
Portability plan coverage.
This section applies to either Oregon or
Washington employer groups.
COBRA
The following are general guidelines for
COBRA. This information is not intended
to be comprehensive.
For complete information, contact:
U.S. Department of Labor
Frances Perkins Building
200 Constitution Ave. NW
Washington, DC 20210
1-866-487-2365
www.dol.gov
21
Employers offering COBRA
Generally, companies who employed 20 or
more people on an average day during the
previous year will offer COBRA coverage.
Please note that it is the employer’s obligation
to be aware of their responsibilities in
administering COBRA.
COBRA eligibility
COBRA coverage is available to subscribers
(employees and family members) who
continue to reside in the service area, but who
cease to be eligible for group coverage because
of one of the following events:
• The covered employee’s termination or
separation from employment for reasons
other than gross misconduct.
• Reduction of hours below the employment
requirement for group coverage eligibility.
• Divorce or legal separation from a covered
employee.
• Death of a covered employee.
• Covered employee becomes entitled to
Medicare.
• A dependent child ceases to be eligible.
• The employer declares bankruptcy (applies
to retirees only).
Benefits of the continuation plan are identical
to the group plan (excluding life insurance if
the group offers it). Evidence of good health
is not required. Members must continue with
the same benefits that she or he was receiving
immediately prior to the qualifying event.
For example, if a member had both medical
and dental coverage just before going onto
COBRA, the member must continue with
both the medical and dental coverage while
on COBRA.
22
Note: Domestic partners are not eligible for
COBRA. Please see the terms on the Domestic
Partner Amending Attachment contract
document.
Administering COBRA
The employer
administers COBRA.
The employer’s
responsibilities include
the following:
• Notifying the subscribers of his or her right
to continued coverage through COBRA.
• Notifying Health Net that the subscriber
has elected COBRA. The subscriber may
complete the employer’s form or use
a Health Net Federal Continuation
Election Form.
• Collecting premiums from the subscriber
and remitting them to Health Net.
• Informing Health Net when a subscriber
terminates COBRA.
COBRA limitations
The allowable length of COBRA continuation
coverage is as follows:
• Up to 18 months from the termination
of employment, or reduction of hours, or
Medicare entitlement occurs prior to the
qualifying event.
• Up to 29 months for certain disabled
individuals.
• Up to 36 months for other qualifying
events, or medical entitlement occurs after
qualifying event.
• No limit, for retirees whose employers
declare bankruptcy.
COBRA notification and
payment deadlines
When COBRA becomes effective for an
employer’s plan, the employer or plan
administrator must immediately notify all
employees and dependents of their rights.
Thereafter, the employer or plan administrator
must notify each newly covered employee
and spouse of his or her rights. Persons with
continued coverage have the status of active
employees and are entitled to choose all
options available during open enrollment.
Furthermore, changes in the group plan would
be extended to those with continued coverage.
In the case of:
Loss of employment, reduction in hours,
death of covered employee, covered employee
becomes entitled to Medicare, or employer
bankruptcy,
The following deadlines apply:
• The employer must notify a plan
administrator within 30 days of the
qualifying event.
• The plan administrator has 14 days from the
date of the qualifying event to give notice of
COBRA election rights to employees. (If the
employer is the plan administrator, it is
best to provide notice to employees within
14 days of the qualifying event.)
• The subscriber has 60 days from the date
of notice or date coverage terminates,
whichever is later, to elect COBRA.
• The subscriber has 45 days from date of
election to submit all premiums due from
start of COBRA to present.
In the case of:
Divorce, legal separation or loss of
dependent status,
The following deadlines apply:
• Employee must notify employer within
60 days of occurrence.
• The plan administrator has 14 days to
give notice of COBRA election rights to
the subscriber.
• The subscriber has 60 days from the date
of notice or date coverage terminates,
whichever is later, to elect COBRA.
• The subscriber has 45 days from date
of election to submit all premiums due
from start of COBRA to present.
Note: Continuation of coverage will begin at
the time group coverage ends, provided the
application is submitted within 60 days after
receiving notice of eligibility and the required
premiums are paid within 45 days of election.
Coverage thereby elected will be retroactively
reinstated to the date of loss of coverage from
the qualifying event. An enrollee who waives
continued coverage during the election period
may revoke that waiver before the end of the
election period. Coverage will not be provided
retroactively (i.e., from the date of the loss of
coverage until the waiver is revoked), but will
be provided from the date of revocation of the
waiver forward.
If the qualifying event is a termination or
reduction in hours, the maximum period of
continuation is 18 months. If the qualifying
event is the filing of a bankruptcy proceeding,
the maximum period of coverage for each
covered retiree or surviving spouse is their
lifetime. For other qualifying events, the
maximum period is 36 months.
23
Coverage may be continued
up to 29 months for certain
employees who are deemed
disabled within 60 days of date
of termination or reduction in
hours. If a second qualifying
event occurs during the 18
months following termination or reduction in
hours, the period of coverage may be extended
to a total of 36 months.
Continuation of coverage will terminate early
if any of the following events occur prior to
the expiration of the 18- or 36-month period:
• Termination of all group health plans
provided by the employer.
• Failure to pay monthly premiums on time.
Premiums are due on or before the first day
of the month for which coverage is to be
provided, and payment must be received
by the plan by the thirtieth day of the
coverage month.
• An employee or family member becomes
covered under any other group health plan.
• An employee or family member becomes
entitled to Medicare coverage.
Washington State Conversion
Washington State residents who lose their
Washington group coverage may be eligible
to receive coverage through a Washington
Conversion policy.
Washington State Conversion eligibility
Members are eligible for conversion if they are
Washington State residents covered for three
consecutive months under a group plan and
have met the maximum period of eligibility
under COBRA (if applicable).
Members may apply for coverage if any one of
these criteria is met:
• Subscriber and dependents are no longer
eligible under the group or any other
medical plan.
• The subscriber is just deceased and results
in the loss of coverage for dependents.
• A covered dependent has reached the
maximum age under the group plan.
• In the case of extensions due to disability, a
final determination that the individual is no
longer disabled.
Washington State Conversion plan coverage
is available to a domestic partner whose
coverage terminates.
If any of the above events occur, continuation
of coverage will be terminated on the last day
of the month in which the event occurs.
Members are not eligible if:
Per federal regulations, a Registered Domestic
Partner and the Registered Domestic Partner’s
covered children losing group coverage under
this agreement are not entitled to federal
continuation of coverage.
24
If you are a Washington-based employer
with a Washington contract, this section
applies to you.
• The group health plan was discontinued.
• The employer’s group plan has ended and
another group plan replaced it.
• The member or the employer has failed to
pay the required health plan premium.
• A member is age 65 or older.
• A member is covered or eligible for
Medicare or other medical benefit plans
offered by a group, individual policy,
prepayment plan, government program, or
other plan that results in over-insurance.
• The member fails to apply for conversion
coverage within 31 days after group or
COBRA coverage terminates or within 31
days following the receipt of the notice of
termination of coverage, whichever is later.
Medicare coverage
• When former employees elect COBRA
coverage for themselves and their covered
dependents, they are entitled to 18 months
of coverage. If within the 18-month period
of COBRA coverage, the former employee
becomes covered by Medicare, the former
employee loses coverage pursuant to plan
rules. The former employees’ Medicare
entitlement is a second qualifying event
for the covered dependents and they are
entitled to a total of 36 months of COBRA
coverage from the date of the original
qualifying event.
Given that (1) loss of group plan coverage
due to retirement is a qualifying event, and
(2) enrollment in Medicare after the election
of COBRA coverage is a reason to end
COBRA coverage, the age of a retiree and
his or her spouse is very significant.
• A person who is 65 at the time of retirement
will usually be enrolled in Medicare. COBRA
coverage may be terminated for members
who are enrolled in Medicare after electing
COBRA continuation coverage. However,
members who enroll in Medicare before the
date that COBRA is elected are qualified
to make a COBRA election as well as their
dependents who lose coverage as a result.
• When the retiring employee or a covered
dependent is under age 65 and elects
COBRA continuation coverage, he or
she will lose the COBRA coverage upon
reaching age 65, that is, if he or she becomes
entitled to Medicare benefits.
Examples:
A. Former employee is 65/spouse is 63. It
is confirmed that the former employee
is covered under Medicare. The spouse,
who is not yet 65, is not covered under
Medicare for any other reason. Both the
former employee and the spouse have the
right to make a COBRA election.
B. Former employee is 65/spouse is 63.
Social Security advises that the former
employee does not qualify for Medicare
coverage. The spouse, who is not yet 65, is
not covered under Medicare for any other
reason. Both the former employee and the
spouse have the right to make a COBRA
election.
C. Former employee is 64/spouse is 63.
Neither person is over age 65, and neither
has Medicare coverage for any other
reason. Both can make a COBRA election.
In example A above, COBRA continuation
coverage for the former employee will end
after 18 months. COBRA continuation
coverage for the spouse will end either
36 months from the former employee’s
entitlement to Medicare or 18 months from
the former employee’s reduction in work
hours, whichever is longer.
In example B above, COBRA continuation
coverage for the former employee and spouse
will end after 18 months.
25
In example C above, COBRA continuation
coverage for the former employee will end
after one year, that is, if he or she becomes
covered under Medicare at age 65. COBRA
continuation for the spouse will end after
two years, once again, if he or she becomes
covered under Medicare at age 65.
Health Net offers a selection of Medicare
Supplement plans. Eligible members who
are interested in these plans may contact
Health Net’s Customer Contact Center.
Nicole daLomba,
Health Net
We put community into
health care coverage.
26
Billing Procedures
Monthly billing
Your group number
Your company has been assigned a group
number that has two or more suffixes as
shown below. If your company has selected
more than one type of product (i.e., EPO
and PPO), generally, you will have a different
group number assigned for each product.
Example:
00000A
00000B
00000C
00000D
Active Single, Employee +
Spouse/Domestic Partner and
Family contracts
Active Employee + Child(ren)
contracts
COBRA members, Single,
Employee + Spouse/Domestic
Partner and Family contracts
COBRA members; Employee +
Child(ren) contracts
Every month your company will receive
a Membership Invoice that consolidates
all suffixes. Groups may request to unconsolidate their bills.
Please note: As you look at the group
numbers shown above, notice that the actual
sequence of numbers is the same for each
group within this company. In the Health Net
accounting system, these numbers indicate the
name and products selected by this company.
Please notice that a separate letter of the
alphabet designates each type of group
within this company.
How should payment be submitted?
Please make your check payable to Health Net.
In addition, we ask that you provide us with
the following information:
On the face of the check:
• Write group bill ID. This will allow
Health Net to properly credit your company
with your payment. In the example above,
P5234 would be written on the front of
the check.
• Write the billing
period for which
payment is being
submitted.
On the check stub:
• Write group bill ID
if you are paying for
more than one invoice.
• Next to each letter,
indicate the portion of
the total check you want to apply to each of
your groups.
What should be submitted with payment?
• A copy of your membership invoice along
with any documentation that supports your
payment amount.
• The Membership Changes and Current
Membership pages from your Membership
Invoice identifying changes to your
current billing.
27
In this example, the total amount of the
check Health Net received from this company
was $4,000. The following information was
provided on the check stub:
A$1,000
B$1,000
C$1,000
D$1,000
Health Net would credit each of this
company’s four groups with $1,000.
Please mail monthly payments to the address
on your Membership Invoice:
Health Net
File #749393
Los Angeles, CA 90074-9393
Enrollment and Change forms should be
included with the check at this address, but
please do not send Enrollment and Change
forms by themselves (without a check) to this
address. If you have already mailed payment
and must submit a new Enrollment and
Change Form, mail it to:
Health Net
PO Box 9103
Van Nuys, CA 91409-9103
Or fax to 1-855-607-0982
Or email to
[email protected]
Do not mail payments to the Van Nuys
address as it will delay credit to your account.
Please make your payments to Health Net
before the due date indicated on your
Membership Invoice.
28
What happens if payments are
submitted late?
As a prepaid carrier, Health Net prepays
each of our medical groups on a monthly
basis for the care of all our subscribers and
their covered dependents. We depend on
your cooperation in making your payment
on or before the due date indicated on your
Membership Invoice.
Premium payment is due on the first of each
month while the Group Agreement is in effect.
If payment is not made by the due date,
Health Net will send a reminder notice in
hopes that this will result in immediate
payment. If, however, we have not received
payment by the dates outlined in the reminder,
the account may be subject to cancellation.
If a termination is required, Health Net will
send a written notice of termination effective
on the last day of the month for which full
premiums were paid. If the delinquent amount
is paid within 25 days of the due date, the
Group Agreement will be considered for
reinstatement. However, a reinstatement fee
will be added to the outstanding charges.
Health Net will review requests for reinstatement
if an account has not been previously cancelled
as a result of nonpayment within a 12-month
period. To be considered for reinstatement,
all outstanding balances through the current
month plus a reinstatement fee will be required
to be paid in full. Health Net values your
business and Health Net representatives are
available to assist you with any questions.
Health Net allows retroactive eligibility
changes and premium adjustments up to
1–2 months prior to the current month
depending on the terms of your contract.
Employer groups are required to provide
Health Net with advance notice of their
intent to cancel per the contract.
Electronic Funds Transfer (EFT)
Employer groups may have the option of Electronic Funds Transfer, or EFT,
wire transfer for remitting payment.
When a group requests Electronic Funds
Transfer to remit payment for premiums due,
the membership accounting representative
supplies the following information which is
then provided by the employer group to
their bank:
• Health Net’s bank name and address
The name and group number of the requesting
employer group must be referenced on the
transmittal.
Should you have further questions about
Electronic Funds Transfer, please contact
your Health Net membership accounting
representative.
• Bank contact
• Account name (Health Net)
• Health Net’s account number
• ABA number
Sharyl Barney,
Health Net
We speak your language.
29
Appeals and
Grievances
Overview
Health Net’s appeal and grievance process
allows members 180 days to file a grievance
following any incident or action that is the
subject of the member’s dissatisfaction. The
member, his or her doctor, or authorized
representative, may request that Health Net
conduct a review of a concern under the appeal
and grievance process described in the Plan
Contract, in the section titled “Grievances and
Appeals.” The plan will work with the member
to arrive at a mutually satisfactory solution.
If the member remains unsatisfied with the
outcome of the review, Health Net offers
binding arbitration as the final step to resolve
grievances. However, if the employer’s plan is
subject to ERISA, the member has the right to
bring civil action under ERISA Section 502 (a)
following an adverse benefit determination on
review, as further discussed below.
Health Net’s Appeal and Grievance
Department is our established unit dedicated
to addressing members’ issues in a timely
manner. A grievance or complaint is a type of
dissatisfaction. An appeal is the member’s right
to challenge an adverse benefit determination
or denial decision made by Health Net
concerning health care benefits.
For Oregon: An appeal is a written or
oral request to review an adverse benefit
determination. These can be submitted by the
member or provider on behalf of the member.
30
For Washington: An appeal is any oral
or written member request to reconsider
an adverse benefit determination. A member,
their physician, or other member representative
may file an appeal. The appeal process applies
to the denial of a claim (in whole or in partial),
the denial of benefits, or other denial of
coverage for service.
Washington only: If you choose to appeal
an adverse benefit determination and the
appeal is related to services you are currently
receiving as an inpatient, or for which a
continuous course of treatment is medically
necessary, coverage for those services must
be continued while an adverse benefit
determination is reviewed; however, you may
be responsible for the cost of services if the
adverse benefit determination is upheld.
Information about this process is also available
in the member handbook, under the section
titled “Your rights and responsibilities,” and,
as always, our Customer Contact Center
representatives are available to assist members.
Appeals – request for reconsideration
An appeal is a written or oral request to
change a previous decision or adverse benefit
determination. In Oregon, an appeal can be
submitted orally or in writing. A member
can obtain assistance to put it in writing from
Health Net Member Services. In Washington,
an appeal can be submitted orally or in
writing. The member, or his or her authorized
representative’s request for a review of the
denial will be handled in a timely manner.
When an appeal is requested, the plan will
send the member a written acknowledgement
letter within 7 calendar days for Oregon and
72 hours for Washington. This letter indicates
the A&G Department has received the request
and that a Health Net Appeals and Grievances
case coordinator has been assigned to the
case. We will review the member’s appeal and
send the member a decision within thirty (30)
calendar days for Oregon and 14 calendar
days for Washington, with an extension to
30 calendar days for good cause from receipt
of their appeal. For Washington, cases
involving experimental/investigational issues
are completed within 21 business days. If we
are unable to reach a decision within the time
frame, we will write to the member and tell
them why there is a delay and when we hope
to resolve their appeal. This process is known
as the Standard Appeal Process.
Another type of appeal is for cases involving
an imminent and serious threat to the health
of the member, including, but not limited to,
severe pain, potential loss of life, limb or major
bodily function. Health Net will respond to
an expedited issue no later than 72 hours after
receipt of the issue. In these situations, we
encourage the member to speak with his or her
doctor to discuss this process. This process is
known as an Expedited Review.
Complaint – expression of dissatisfaction
(Oregon)/grievances (Washington)
A grievance or complaint is an oral or
written statement, made by the member,
expressing dissatisfaction regarding any aspect
of Health Net or its provider’s operations,
contractual issues, activities, or behavior.
In Oregon, the grievance or complaint can be
submitted orally or in writing. Members can
also request help from Health Net Member
Services to put the grievance or complaint
in writing. In Washington, the grievance
or complaint can be submitted orally or in
writing. These are generally further classified
as either quality of service or quality of care.
An example of a quality of service grievance
or complaint is excessive waiting time in a
doctor’s office. A quality of care grievance or
complaint would concern the health care the
member is receiving. To express a grievance or
complaint, the member or his or her authorized
representative may contact Health Net by
telephone, fax, mail, or email. The member
can call our Customer Contact Center at the
toll-free number printed on their identification
(ID) card.
When a grievance or complaint is requested,
the plan will send the member a written
acknowledgement letter within 7 calendar
days for Oregon. This letter indicates the A&G
Department has received the request and that
a Health Net Appeals and Grievances case
coordinator has been assigned to the case.
We will review the member’s issue and send the
member a resolution letter within thirty (30)
calendar days for Oregon.
The Customer Contact Center will help to
address the member’s grievance/complaint,
but it is important to note that some
information may be protected by peer review
laws and Health Net may not be able to legally
give the member details of our actions taken
to address the grievance/complaint.
Independent medical review of
grievances/complaints/appeals
involving a disputed health care service
Members may request an independent medical
review (IMR) of disputed health care services
upon exhaustion of the internal review
process. A “disputed health care service” is any
health care service eligible for coverage and
payment under the plan that has been denied,
31
modified or delayed by Health Net or one of
its contracting providers, in whole or in part
because the service is not medically necessary,
or is experimental or investigational.
The IMR process is in addition to any
other procedures or remedies that may be
available to the member. Members pay no
application or processing fee of any kind for
IMR. Members have the right to provide
information in support of the request for IMR.
Health Net will provide members with an IMR
application form with any appeal resolution
letter that denies, modifies or delays health
care services. A decision not to participate
in the IMR process may cause the member
to forfeit any statutory right to pursue legal
action against the plan regarding the disputed
health care service.
Eligibility
Members’ applications for IMR will be
reviewed by the the Oregon Insurance
Division (OID) or the Washington Office
of the Insurance Commissioner (OIC) to
confirm that:
1. (A) The provider has recommended a
health care service as medically necessary,
or (B) The provider has recommended an
experimental or investigational treatment,
or (C) The member has been seen by
an in-plan provider for the diagnosis or
treatment of the medical condition for
which they seek independent review;
32
2. The disputed health care service has
been denied, modified or delayed by the
plan or one of its contracting providers,
based in whole or in part on a decision
that the health care service is not
medically necessary, or is experimental or
investigational; and
3. The member has filed a grievance/
complaint/appeal with the plan and
the disputed decision is upheld or
the grievance/complaint remains
unresolved after thirty (30) days. If the
member’s grievance/complaint requires
expedited review, the member may
bring it immediately to the department’s
attention. The OID or OIC may waive
the requirement that the member follow
the plan’s grievance/complaint process in
extraordinary and compelling cases.
If the member’s case is eligible for IMR,
the dispute will be submitted to a medical
specialist who will make an independent
determination of whether or not the care is
medically necessary. The member will receive
a copy of the assessment made in their case.
If the IMR determines that the service is
medically necessary, the plan will provide
coverage for the health care service.
For non-urgent cases, the IMR organization
designated by the OID/OIC must provide
its determination within thirty (30) days
of receipt of the member’s application. For
urgent cases involving imminent and serious
threat to the member’s health, including, but
not limited to, severe pain, the potential loss
of life, limb or major bodily function, or the
immediate and serious deterioration of the
member’s health, the IMR organization must
provide its determination within three (3)
days for Oregon and seventy-two (72) hours
for Washington.
Notice of
Privacy Practices
This notice describes how medical information about you may be used
and disclosed and how you can get access to this information. Please
review it carefully.
This notice tells you about the ways in which
Health Net1 (referred to as “we” or “the Plan”)
may collect, use and disclose your protected
health information and your rights concerning
your protected health information. “Protected
health information” is information about you,
including demographic information, that can
reasonably be used to identify you and
that relates to your past, present or future
physical or mental health or condition, the
provision of health care to you, or the
payment for that care.
We are required by federal and state laws to
provide you with this notice about your rights
and our legal duties and privacy practices with
respect to your protected health information,
and notify you in the event of a breach of
your unsecured protected health information.
We must follow the terms of this notice while
it is in effect. We reserve the right to change
this notice. We reserve the right to make the
revised or changed notice effective for your
protected health information we already
have as well as any of your protected health
information we receive in the future. We will
promptly revise and distribute this notice
whenever there is a material change to the
uses or disclosures, your rights, our legal
duties, or other privacy practices stated in the
notice. We will make any revised
notices available on our website at
www.healthnet.com. Some of the uses and
disclosures described in this notice may be
limited in certain cases by applicable state
laws that are more stringent than the federal
standards.
I. How we may use and disclose your
protected health information
We may use and disclose your protected
health information for different purposes.
The examples below are provided to illustrate
the types of uses and disclosures we may
make without your authorization for payment,
health care operations and treatment.
• Payment. We use and disclose your protected
health information in order to pay for your
covered health expenses. For example, we
may use your protected health information to
process claims, to be reimbursed by another
insurer that may be responsible for payment
or for premium billing.
1This
Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc.’s affiliated covered entities: Health Net
Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company,
Health Net of Arizona, Inc., Health Net of California, Inc., and Managed Health Network.
33
• Health care operations. We use and disclose
your protected health information in order
to perform our plan activities, such as quality
assessment activities or administrative
activities, including data management or
customer service.
• Treatment. We may use and disclose your
protected health information to assist your
health care providers (doctors, pharmacies,
hospitals, and others) in your diagnosis and
treatment. For example, we may disclose your
protected health information to providers
to provide information about alternative
treatments.
• Plan sponsor. In addition, we may
disclosure your protected health
information to a sponsor of the group health
plan, such as an employer or other entity
that is providing a health care program
to you. We can disclose your protected
health information to that entity if it has
contracted with us to administer your health
care program on its behalf.
If the plan sponsor provides plan
administration services, we may also
provide access to identifiable health
information to support its performance of
such services which may include but are not
limited to claims audits or customer services
functions. Health Net will only share health
information upon a certification from
the plan sponsor representing there are
restrictions in place to ensure that only plan
sponsor employees with a legitimate need to
know will have access to health information
in order to provide plan administration
functions.
1This
• Person(s) involved in your care or
payment for your care. We may also
disclose protected health information to a
person, such as a family member, relative,
or close personal friend, who is involved
with your care or payment. We may disclose
the relevant protected health information
to these persons if you do not object or we
can reasonably infer from the circumstances
that you do not object to the disclosure;
however, when you are not present or are
incapacitated, we can make the disclosure if,
in the exercise of professional judgment, we
believe the disclosure is in your best interest.
II. Other permitted or required
disclosures
• As required by law. We must disclose
protected health information about you
when required to do so by law.
• Public health activities. We may disclose
protected health information to public
health agencies for reasons such as
preventing or controlling disease, injury,
or disability.
• Victims of abuse, neglect or domestic
violence. We may disclose protected health
information to government agencies about
abuse, neglect or domestic violence.
• Health oversight activities. We may
disclose protected health information
to government oversight agencies (e.g.,
California Department of Health Services)
for activities authorized by law.
Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc.’s affiliated covered entities: Health Net
Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company,
Health Net of Arizona, Inc., Health Net of California, Inc., and Managed Health Network.
34
• Judicial and administrative proceedings.
We may disclose protected health
information in response to a court or
administrative order. We may also disclose
protected health information about you in
certain cases in response to a subpoena,
discovery request or other lawful process.
• Law enforcement. We may disclose
protected health information under limited
circumstances to a law enforcement official
in response to a warrant or similar process,
to identify or locate a suspect, or to provide
information about the victim of a crime.
• Coroners, funeral directors, organ
donation. We may release protected health
information to coroners or funeral directors
as necessary to allow them to carry out
their duties. We may also disclose protected
health information in connection with
organ or tissue donation.
• Research. Under certain circumstances,
we may disclose protected health
information about you for research
purposes, provided certain measures have
been taken to protect your privacy.
• To avert a serious threat to health
or safety. We may disclose protected
health information about you, with some
limitations, when necessary to prevent a
serious threat to your health and safety
or the health and safety of the public or
another person.
• Special government functions. We may
disclose information as required by military
authorities or to authorized federal officials
for national security and intelligence
activities.
• Workers’ compensation. We may disclose
protected health information to the extent
necessary to comply with state law for
workers’ compensation programs.
• Fundraising activities. We may use or
disclose your protected health information
for fundraising activities, such as raising
money for a charitable foundation or similar
entity to help finance its activities. If we do
contact you for fundraising activities, we
will give you the opportunity to opt-out, or
stop, receiving such communications in the
future.
• Underwriting purposes. We may use
or disclosure your protected health
information for underwriting purposes,
such as to make a determination about
a coverage application or request. If we
do use or disclose your protected health
information for underwriting purposes, we
are prohibited from using or disclosing your
protected health information that is genetic
information in the underwriting process.
Other uses or disclosures that require
your written authorization
We are required to obtain your written
authorization to use or disclose your protected
health information, with limited exceptions,
for the following reasons:
• Marketing. We will request your written
authorization to use or disclose your
protected health information for
marketing purposes with limited exceptions,
such as when we have face-to-face
marketing communications with you or
when we provide promotional gifts of
nominal value.
1This
Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc.’s affiliated covered entities: Health Net
Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company,
Health Net of Arizona, Inc., Health Net of California, Inc., and Managed Health Network.
35
• Sale of protected health information.
We will request your written authorization
before we make any disclosure that is
deemed a sale of your protected health
information, meaning that we are receiving
compensation for disclosing the protected
health information in this manner.
• Psychotherapy notes. We will request your
written authorization to use or disclose any
of your psychotherapy notes that we may
have on file with limited exception, such as
for certain treatment, payment or health
care operation functions.
• Other uses or disclosures. All other uses
or disclosures of your protected health
information not described in this notice
will be made only with your written
authorization, unless otherwise permitted
or required by law.
• Revocation of an authorization. You may
revoke an authorization at any time in
writing, except to the extent that we have
already taken action on the information
disclosed or if we are permitted by law to
use the information to contest a claim or
coverage under the Plan.
III. Your rights regarding your
protected health information
You have certain rights regarding protected
health information that the Plan maintains
about you.
• Right to access your protected health
information. You have the right to review
or obtain copies of your protected health
information records, with some limited
1This
exceptions. Usually the records include
enrollment, billing, claims payment, and
case or medical management records. Your
request to review and/or obtain a copy of
your protected health information records
must be made in writing. We may charge a
fee for the costs of producing, copying, and
mailing your requested information, but we
will tell you the cost in advance. If we deny
your request for access, we will provide you
a written explanation and will tell you if the
reasons for the denial can be reviewed and
how to ask for such a review or if the denial
cannot be reviewed.
• Right to amend your protected health
information. If you feel that protected
health information maintained by the Plan
is incorrect or incomplete, you may request
that we amend, or change, the information.
Your request must be made in writing and
must include the reason you are seeking a
change. We may deny your request if, for
example, you ask us to amend information
that was not created by the Plan, as is often
the case for health information in our
records, or you ask to amend a record that
is already accurate and complete. If we deny
your request to amend, we will notify you in
writing. You then have the right to submit to
us a written statement of disagreement with
our decision, and we have the right to rebut
that statement.
• Right to an accounting of disclosures by
the Plan. You have the right to request an
accounting of certain disclosures we have
made of your protected health information.
Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc.’s affiliated covered entities: Health Net
Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company,
Health Net of Arizona, Inc., Health Net of California, Inc., and Managed Health Network.
36
The list will not include our disclosures
related to your treatment, our payment or
health care operations, or disclosures made
to you or with your authorization. The list
may also exclude certain other disclosures,
such as for national security purposes.
Your request for an accounting of
disclosures must be made in writing and
must state a time period for which you want
an accounting. This time period may not be
longer than six years and may not include
dates before April 14, 2003. Your request
should indicate in what form you want the
list (for example, on paper or electronically).
The first accounting that you request
within a 12-month period will be free. For
additional lists within the same time period,
we may charge for providing the accounting,
but we will tell you the cost in advance.
• Right to request restrictions on the use
and disclosure of your protected health
information. You have the right to request
that we restrict or limit how we use or
disclose your protected health information
for treatment, payment or health care
operations. We may not agree to your
request. If we do agree, we will comply
with your request unless the information
is needed for an emergency. Your request
for a restriction must be made in writing.
In your request, you must tell us (1) what
information you want to limit; (2) whether
you want to limit how we use or disclose
your information, or both; and (3) to whom
you want the restrictions to apply.
that we send Plan information to a certain
location if the communication could
endanger you. Your request to receive
confidential communications must be
made in writing. Your request must clearly
state that all or part of the communication
from us could endanger you. We will
accommodate all reasonable requests.
Your request must specify how or where
you wish to be contacted.
• Right to a notice in the event of a breach.
You have a right to receive a notice of a
breach involving your protected health
information (PHI) should one occur.
• Right to a paper copy of this notice.
You have a right at any time to request a
paper copy of this notice, even if you
had previously agreed to receive an
electronic copy.
• Contact information for exercising your
rights. You may exercise any of the rights
described above by contacting our Privacy
Office. See the end of this notice for the
contact information.
IV. Health information security
Health Net requires its employees to follow the
Health Net security policies and procedures
that limit access to health information about
members to those employees who need it to
perform their job responsibilities. In addition,
Health Net maintains physical, administrative,
and technical security measures to safeguard
your protected health information.
• Right to receive confidential
communications. You have the right to
request that we use a certain method to
communicate with you about the Plan or
1This
Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc.’s affiliated covered entities: Health Net
Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company,
Health Net of Arizona, Inc., Health Net of California, Inc., and Managed Health Network.
37
V. Changes to this notice
VII. Contact the Plan
We reserve the right to change the terms of
this notice at any time, effective for protected
health information that we already have
about you as well as any information that we
receive in the future. We will provide you with
a copy of the new notice whenever we make
a material change to the privacy practices
described in this notice. We also post a
copy of our current notice on our website
at www.healthnet.com. Any time we make
a material change to this notice, we will
promptly revise and issue the new notice with
the new effective date.
If you have any complaints or questions
about this notice or you want to submit a
written request to the Plan as required in
any of the previous sections of this notice,
please contact:
VI. Complaints
If you believe that your privacy rights have
been violated, you may file a complaint
with us and/or with the Secretary of the
U.S. Department of Health and Human
Services. All complaints to the Plan must
be made in writing and sent to the Privacy
Office listed at the end of this notice.
Address:Health Net Privacy Office
Attention: Director,
Information Privacy
PO Box 9103
Van Nuys, CA 91409
You may also contact us at:
Telephone:1-800-522-0088
Fax:
(818) 676-8314
Email: [email protected]
We support your right to protect the privacy of
your protected health information. We will not
retaliate against you or penalize you for filing a
complaint.
1This
Notice of Privacy Practices also applies to enrollees in any of Health Net, Inc.’s affiliated covered entities: Health Net
Access, Inc., Health Net Community Solutions, Inc., Health Net Health Plan of Oregon, Inc., Health Net Life Insurance Company,
Health Net of Arizona, Inc., Health Net of California, Inc., and Managed Health Network.
38
Ensure Your Employees Understand Their Health Care
Summary of Benefits and Coverage
to Eligible and Covered Persons
A new Affordable Care Act (ACA)1
requirement for employers that
sponsor group health plans
As required by the ACA, health plans and
employer groups must provide the Summary
of Benefits and Coverage (SBC) to eligible
employees and family members, who are:
• currently enrolled in the group health
plan, or
• eligible to enroll in the plan, but not yet
enrolled, or
• covered under COBRA Continuation
coverage.
Health Net is committed to ensuring
compliance with all timing and content
requirements with regard to the distribution
of the SBC. To meet this goal, you are
required to provide the SBC in the exact and
unmodified form, including appearance and
content, as provided to you by Health Net.
Please follow the instructions below so you
will know how to distribute the SBC.
SBC form and manner
You may provide the SBC to eligible or
covered individuals in paper or electronic
form (i.e., email or Internet posting).
126
• If you provide a paper copy, the SBC
must be in the exact format and font
provided by Health Net, and, as required
under the ACA, must be copied on four
double-sided pages.
Instructions for
reproduction
and distribution.
• If you mail a paper copy, you may provide
a single SBC to the employee’s last known
address, unless you know that a family
member resides at a different address. In
that case, you must provide a separate SBC
to that family member at the last known
address.
• For covered individuals, you may
provide the SBC electronically if certain
requirements from the U.S. Department of
Labor are met.2
• If you email the SBC, you must send the
SBC in the exact electronic PDF format
provided to you by Health Net.
• If you post the SBC on the Internet, you
must advise your employees by email or
paper that the SBC is available on the
Internet, and provide the Internet address.
You must also inform your employees
that the SBC is available in paper form,
free of charge, upon request. You may use
the Model Language below for an e-card
or postcard in connection with a website
posting of a SBC:
C.F.R. § 54.9815-2715; 29 C.F.R. § 2590.715-2715; and 45 C.F.R. § 147.200.
requirements can be found at 29 C.F.R. § 2520.104(b).
2Such
This document is provided to you as a customer courtesy and is not intended to be legal advice. Please consult with your own legal counsel to determine your
responsibilities under the SBC regulations of the Affordable Care Act.
39
Availability of Summary Health Information
As an employee, the health benefits
available to you represent a significant
component of your compensation package.
They also provide important protection for
you and your family in case of illness or injury.
Your plan offers a series of health coverage
options. Choosing a health coverage
option is an important decision. To help
you make an informed choice, your plan
makes available a Summary of Benefits
and Coverage (SBC). The SBC summarizes
important information about any health
coverage option in a standard format to
help you compare across options.
The SBC is available online at: <[group’s
website.com]>. A paper copy is also
available, free of charge, by calling the tollfree number on your ID card.
Timing of SBC distribution
Health Net provides an SBC to a group health
plan as soon as practicable following receipt
of an application for coverage, but no later
than 7 business days following receipt of
the application. If there is any change in the
information in the SBC before the first day of
coverage, Health Net will provide a current
SBC to the plan (or its sponsor) no later than
the first day of coverage.
For plan years with open enrollment
beginning on or after September 23, 2012, you
must provide the SBC as follows:
• Upon application. If you distribute written
application materials, you must include
the SBC with those materials. If you do not
distribute written application materials for
enrollment, you must provide the SBC by
the first day the employee is eligible to enroll
in the plan.
• Special enrollees. For special enrollees3,
you must provide the SBCs within 90 days
following enrollment.
• Upon renewal. If open enrollment materials
are required for renewal, you must provide
the SBC no later than the date on which the
open enrollment materials are distributed.
If renewal is automatic, you must provide
the SBC no later than 30 days prior to the
first day of the new plan year. If your group
health plan is renewed less than 30 days
prior to the effective date, you must provide
the SBC as soon as practicable, but no later
than 7 business days after issuance of the new
policy or the receipt of written confirmation
of intent to renew your group health plan.
At the time your plan renews, you are not
required to provide the Health Net SBC to
an employee who is not currently enrolled in
a Health Net plan. However, if an employee
requests a Health Net SBC, you must provide
the SBC as soon as you can, but no later than
7 business days following your receipt of the
request.
Notice of SBC modification
Occasionally, there will be a material
change(s) to the SBCs other than in
connection with a renewal, such as changes
in coverage. You must provide notice of
the material changes to employees no later
than 60 days prior to the date on which
change(s) become effective. You must
provide this notice in the same number,
form and manner as described above. When
such changes are initiated by Health Net,
Health Net will provide you with modified
SBCs for distribution.
3Special
enrollees are individuals who request coverage through special enrollment. Regulations regarding special enrollment are
found in the U.S. Code of Federal Regulations, at 45 C.F.R. 146.117 and 26 C.F.R. 54.9801-6, and 29 C.F.R. 2590.701-6.
This document is provided to you as a customer courtesy and is not intended to be legal advice. Please consult with your own legal counsel to determine your
responsibilities under the SBC regulations of the Affordable Care Act.
40
Uniform glossary
Employees and family members can access
a glossary of bolded terms used in the SBC
by visiting www.cciio.cms.gov, or by calling
Health Net at the number on the ID card to
request a copy. Health Net shall provide a
written copy of the glossary to callers within
7 business days after Health Net receives their
request.
If you have any questions, please contact your
Health Net client manager.
Glossary of Terms
This list of definitions covers terms and phrases used frequently in this
book. It is important that you understand the meaning of these words.
Certificate of Insurance: The certificate
describes the benefits underwritten by
Health Net Life Insurance Company, issued
in connection with the Group Hospital and
Professional Service Agreement/Group Policy.
This booklet provides the subscriber with
a complete statement of his or her benefits.
(This term is used for PPO, life insurance and
indemnity plans.)
Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA):
A law that allows individuals leaving the
company to buy health insurance from the
company at the employer’s group rate rather
than an individual rate.
Continuation coverage: Extended coverage
for a qualified beneficiary following loss of
coverage due to a qualifying event.
However, if a member’s former employer
or Health Net terminates the policy, and it
is replaced with other group coverage, the
continuation coverage is provided by the
replacement group health carrier.
Also, if, during State continuation coverage,
the member selects a different health
plan offered by the employer during open
enrollment, the continuation coverage will
be transferred to the new plan.
Copayment: Copayment means the fixed
dollar amount stated in a Copayment and
Coinsurance Schedule or any applicable
Supplemental Benefit Schedule identified on
the Signature Sheet to be paid by Members
directly to Providers for covered services.
41
Dependent: Any eligible member of a
subscriber’s family who is enrolled in
Health Net and for whom premiums are
paid. Your Health Net Basic Benefit Schedule
and Group Medical and Hospital Service
Agreement will contain important limitations
based on a dependent’s age. Please read
the document to fully understand your
group’s coverage.
Effective date: In this manual, the effective
date refers to the date on which a transaction
becomes effective.
Eligibility: The conditions which entitle an
individual to enroll for coverage.
Enrollment area: That portion of Health Net’s
service area established by Health Net for
each PCP selected by the subscriber to assure
reasonable access to care.
Exclusive provider organizaton (EPO):
An EPO plan, which is an HMO-like product,
is defined as a plan under which members
must use providers from the specified
network of physicians and hospitals to
receive coverage; there is no coverage for
care received from a non-network provider
except in an emergency situation.
Existing dependent: An employee’s spouse,
domestic partner, or child who is already a
family member of the employee on the date
of hire, or the date that the employee met any
required probationary period or at the time of
an open enrollment.
Family member: For the purposes of
enrolling in Health Net, a family member
is defined as the subscriber, and any of the
following: legally married spouse or domestic
partner, unmarried dependent child including
natural or adopted children, stepchildren, and
other children for whom you or your spouse is
the court-appointed guardian.
42
Hospital: A legally operated facility defined
as a hospital and an institution licensed by the
state and approved by the Joint Commission
on Accreditation of Healthcare Organizations
(JCAHO) or by the Medicare program.
Medicare: The name commonly used to
describe health insurance benefits for the aged
and disabled provided under Public Law 89-97
as amended to date or as later amended.
Member: Either a subscriber or dependent
who is enrolled.
Newly eligible dependent: A newly eligible
dependent is a spouse/domestic partner or
child who joins the employee’s family after
the employee was hired or met any required
probationary period.
Overage dependents: Plan contracts contain
provisions that limit the age to which children
of the subscriber are eligible for coverage.
Please check your Plan contract for the
specifics of your plan.
Plan contract: The Plan Contract, including
the Basic Benefit Schedule and the Group
Medical and Hospital Service Agreement
provides the subscriber with a complete
statement of his or her benefits.
The Plan Contract, including the Basic Benefit
Schedule and the Group Medical and Hospital
Service Agreement, is the health care service
agreement that exists between Health Net
and the employer. This contract sets forth the
terms and conditions between Health Net
and the employer.
WA PPO Plan Agreement including the
Basic Benefit Schedule and the Group Medical
and Hospital Service Agreement is the health
care service agreement that exists between
Health Net and the employer. This contract
sets forth the terms and conditions between
Health Net and the employer.
Primary care physician (PCP): A group of
physicians, organized as a legal entity, that
have an agreement in effect with Health Net to
furnish medical care to Health Net members.
Policyholder: The employer to which a policy
has been issued.
Qualified beneficiary: Anyone who, on the
date of a qualifying event, is or was validly
enrolled in this plan or any other group health
plan your employer group sponsors.
Service area (for EPO, HNCC and POS):
Please refer to your plan contract for the
definition of service area.
A subscriber shall be considered totally
disabled when, as a result of bodily injury or
disease, such subscriber is unable to engage
in any employment or occupation for which
he or she is, or becomes, qualified by reason
of education, training or experience and
not, in fact, engaged in any employment or
occupation for wage or profit.
A family member shall be considered totally
disabled when such member is prevented
from performing all regular and customary
activities usual for a person of his or her age
and family status.
We, us, our: Refers to Health Net.
State continuation for small employer:
Employed fewer than 20 eligible employees
who were eligible to enroll in the company’s
health plan on at least 50 percent of its
working days during the preceding calendar
year, has contracted for health care coverage
through a group benefit plan offered by
a health care service plan or a disability
insurer, and is not subject to Section 4980B
of the United States Internal Revenue Code
or Chapter 18 of the Employee Retirement
Income Security Act, 29 U.S.C., Section 1161
et seq. (these describe federal COBRA).
Subscriber: The employee whose employment
allows eligibility under the plan. The subscriber
is the person who is financially responsible
for copayments, deductibles, coinsurance, and
charges for ineligible services for both him/
herself and his or her dependents.
Totally disabled: For the purposes of
Health Net, the following definitions of total
disability will apply:
43
For more information please contact
Health Net Health Plan of Oregon, Inc.
PO Box 9103
Van Nuys, CA 91409-9103
1-888-802-7001
Assistance for the hearing and speech impaired
Monday through Friday, 8:00 a.m. to 5:00 p.m.
TTY: 1-888-802-7122
www.healthnet.com
OR115343 (8/14)
Health Net Health Plan of Oregon, 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 rights reserved.