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«EVIDENCE OF COVERAGE AND PLAN DOCUMENT A complete explanation of your plan HMO (Plan [ ]) Important benefit information – please read Dear Health ...»

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SMALL BUSINESS GROUP (2-50 employees)

EVIDENCE OF COVERAGE

AND PLAN DOCUMENT

A complete explanation of your plan

HMO (Plan [ ])

Important benefit information – please read

Dear Health Net Member:

Thank you for choosing Health Net to provide your health care benefits. We look forward to ensuring a

positive experience and your continued satisfaction with the services we provide.

This is your new Health Net Evidence of Coverage.

If your Group has requested that we make it available, you can access this document online through Health Net’s secure website at www.healthnet.com. You can also elect to have a hard copy of this Evidence of Coverage mailed to you. Please call the telephone number on the back of your Member identification card to request a copy.

If you’ve got a web-enabled smartphone, you’ve got everything you need to track your health plan details.

Take the time to download Health Net Mobile. You’ll be able to carry your ID card with you, easily find details about your plan, store provider information for easy access, search for doctors and hospitals, or contact us at any time. It’s everything you need to track your health plan details – no matter where you are as long as you have your smartphone handy.

We look forward to serving you. Contact us at www.healthnet.com 24 hours a day, seven days a week for information about our plans, your benefits and more. You can even submit questions to us through the website, or contact us at one of the numbers below. Our Customer Contact Center is available from 8:00 a.m. to 6:00 p.m., Monday through Friday, except holidays. You’ll find the number to call on the back of your Member ID card.

This document is the most up-to-date version. To avoid confusion, please discard any versions you may have previously received.

Thank you for choosing Health Net.

PLEASE READ THIS IMPORTANT NOTICE ABOUT THE HEALTH NET HMO

WHOLECARE NETWORK HEALTH PLAN SERVICE AREA AND OBTAINING

SERVICES FROM WHOLECARE NETWORK PHYSICIAN AND HOSPITAL

PROVIDERS

Except for Emergency Care, benefits for Physician and Hospital services under this Health Net HMO WholeCare Network ("WholeCare Network") plan are only available when you live or work in the WholeCare Network service area and use a WholeCare Network Physician or Hospital. When you enroll in this WholeCare Network plan, you may only use a Physician or Hospital who is in the WholeCare Network and you must choose a WholeCare Network Primary Care Physician. You may obtain ancillary, Pharmacy or Behavioral Health covered services and supplies from any Health Net Participating ancillary, Pharmacy or Behavioral Health Provider.

Obtaining Covered Services under the Health Net HMO WholeCare Network Plan

TYPE OF HOSPITAL PHYSICIAN ANCILLARY PHARMACY BEHAVIORAL

PROVIDER HEALTH

*Only

–  –  –

The WholeCare Network service area and a list of its Physician and Hospital providers are shown in the Health Net WholeCare Network Provider Directory. In addition, WholeCare Network Physicians and Hospitals are listed online at our website www.healthnet.com. The WholeCare Network Provider Directory is different from other Health Net Provider Directories. A copy of the Health Net WholeCare Network Provider Directory may be ordered online or by calling Health Net Customer Contact Center at 1-800-361-3366.

Note: Not all Physician and Hospitals who contract with Health Net are WholeCare Network providers. Only those Physicians and Hospitals specifically identified as participating in the WholeCare Network may provide services under this plan, except as described in the chart above.

Unless specifically stated otherwise, use of the following terms in this Evidence of Coverage solely refers to the WholeCare Network as explained above.

 Health Net  Health Net Service Area  Hospital  Member Physician, Participating Physician Group, Primary Care Physician, Physician, participating provider, contracting Physician Groups and contracting Providers  Network  Provider Directory Health Net WholeCare Network Alternative Access Standards The WholeCare Network includes participating primary care and Specialist Physicians, and Hospitals in the WholeCare service area. (CVS MinuteClinic are not available throughout the entire WholeCare Network service area but enrollees have access to all CVS MinuteClinic, where located, regardless of geographic area.).

However, WholeCare Members residing in the following zip codes will need to travel as indicated to access a participating PCP and/or receive non-emergency Hospital services.

16– 30 Miles  Contra Costa County: 94505 – Discovery Bay (Hospital), 94513 – Brentwood (Hospital), 94514 – Byron (Hospital), 94561 – Oakley (Hospital)  Eldorado County: 95614 – Cool (Hospital), 95684 – Somerset (PCP and Hospital), 95726 - Pollock Pines (Hospital)  Fresno County: 93606 – Biola (Hospital), 93609 – Caruthers (Hospital), 93630 – Kerman (Hospital), 93656 – Riverdale (Hospital), 93675 - Squaw Valley (Hospital),  Madera County: 93610 – Chowchilla (Hospital), 93614 – Coarsegold (Hospital)  Marin County: 94937 – Inverness (Hospital), 94956 - Point Reyes Station (Hospital)  Merced County: 93620 - Dos Palos (Hospital), 95301 - Atwater (Hospital), 95303 - Ballico (Hospital), 95315 Delhi (Hospital), 95322 – Gustine (PCP), 95324 - Hilmar (Hospital), 95333 - Le Grand (Hospital), 95334 Livingston (Hospital), 95374 - Stevinson (Hospital)  Napa County: 94558 – Napa (Hospital)  Nevada County: 95949 - Grass Valley (Hospital), 95959 - Nevada City (Hospital)  Placer County: 95602 – Auburn (Hospital), 95603 – Auburn (Hospital), 95604 – Auburn (Hospital), 95631 Foresthill (Hospital), 95648 - Lincoln (Hospital), 95681 – Sheridan (Hospital), 95703 - Applegate (Hospital), 95722 - Meadow Vista (Hospital)  Sacramento County: 95632 – Galt (Hospital), 95638 - Herald (Hospital), 95683 - Sloughhouse (Hospital), 95693 - Wilton (Hospital)  San Joaquin County: 95227 - Clements (Hospital), 95230 - Farmington (Hospital), 95236 - Linden (Hospital), 95304 - Tracy (Hospital), 95320 - Escalon (Hospital), 95376 - Tracy (Hospital), 95377 - Tracy (Hospital), 95385 - Vernalis (Hospital), 95391 - Tracy (Hospital)  San Mateo County: 94020 - La Honda (Hospital), 94021 - Loma Mar (Hospital), 94074 - San Gregorio (Hospital)  Santa Barbara County: 93434 Guadalupe (PCP), 93440 Los Alamos (PCP), 93454 - Santa Maria (PCP), 93455 - Santa Maria (PCP), 93456 - Santa Maria (PCP), 93458 - Santa Maria (PCP)  Santa Cruz County: 95006 - Boulder Creek (Hospital), 95017 - Davenport (Hospital), 95033 - Los Gatos (Hospital)  Solano County: 94571 - Rio Vista (PCP and Hospital)  Sonoma County: 94923 - Bodega Bay (Hospital), 95421 – Cazadero (PCP and Hospital), 95425 – Cloverdale (Hospital), 95430 - Duncans Mills (Hospital), 95431 – Eldridge (Hospital), 95450 - Jenner (PCP and Hospital)  Tulare County: 93219 - Earlimart (Hospital), 93265 - Springville (Hospital), 93271 - Three Rivers (Hospital)  Yolo County: 95606 - Brooks (PCP), 95607 - Capay (PCP and Hospital), 95627 - Esparto (PCP and Hospital), 95937 – Dunnigan (PCP and Hospital) Beyond 30 Miles  Fresno County: 93602 – Auberry (Hospital: 39 miles), 93605 - Big Creek (Hospital: 52 miles), 93608 Cantua Creek (PCP and Hospital: 50 miles), 93622 – Firebaugh (PCP and Hospital: 49 miles), 93627 – Helm (Hospital: 41 miles), 93628 – Hume (PCP and Hospital: 73 miles), 93634 – Lakeshore (PCP and Hospital: 62 miles), 93640 – Mendota (Hospital: 48 miles), 93641 – Miramonte (Hospital: 44 miles), 93664 - Shaver Lake ( PCP and Hospital: 57 miles), 93667 – Tollhouse (Hospital: 34 miles), 93668 – Tranquillity (Hospital: 39 miles)  Kings County: 93204 – Avenal (Hospital: 43 miles)  Madera County: 93601 – Ahwahnee (Hospital: 42 miles), 93604 - Bass Lake (Hospital: 44 miles), 93643 North Fork (Hospital: 34 miles), 93644 – Oakhurst (Hospital: 65 miles),  Merced County: 93635 - Los Banos (Hospital: 44 miles), 95322 – Gustine (Hospital: 34 miles)  Napa County: 94558 – Napa (PCP: 59 miles)  Santa Barbara County: 93254 - New Cuyama (PCP and Hospital: 75 miles)  Sonoma County: 95412 – Annapolis (Hospital and PCP: 43 miles), 95441 - Geyserville (Hospital: 31 miles), 95480 - Stewarts Point (PCP and Hospital: 44 miles), 95497 - Gualala (PCP and Hospital: 53 miles)  Tulare County: 93207 - California Hot Springs (PCP and Hospital: 41 miles), 93208 - Camp Nelson (PCP and Hospital: 33 miles), 93260 – Posey (PCP and Hospital: 41 miles), 93262 - Sequoia National Park (Hospital: 51 miles), 93603 - Badger (Hospital: 42 miles)  Yolo County: 95637 - Guinda (PCP and Hospital: 32 miles), 95679 - Rumsey (PCP and Hospital: 36 miles) If you have any questions about the WholeCare Network Service Area, choosing your WholeCare Network Primary Care Physician, how to access Specialist care or your benefits, please contact the Health Net Customer Contact Center at 1-800-361-3366.

About This Booklet Please read the following information so you will know from whom or what group of providers health care may be obtained.

Method of Provider Reimbursement Health Net uses financial incentives and various risk sharing arrangements when paying providers. You may request more information about our payment methods by contacting the Customer Contact Center Department at the telephone number on your Health Net ID Card, your Physician Group or your Primary Care Physician.

Summary of Plan This Evidence of Coverage constitutes only a summary of the health Plan.

The health Plan contract must be consulted to determine the exact terms and conditions of coverage.

Please read this Evidence of Coverage carefully.

–  –  –

The following words are used frequently:

 "You" refers to anyone in your family who is covered; that is, anyone who is eligible for coverage in this Plan and who has been enrolled.

 “Employee” has the same meaning as the word "you" above.

 "We" or "Our" refers to Health Net.

 "Subscriber" means the primary covered person, generally an Employee of a Group.

 "Physician Group" or "Participating Physician Group (PPG)" means the medical group the individual Member selected as the source of all covered medical care.

 "Primary Care Physician" is the individual Physician each Member selected who will provide or authorize all covered medical care.

 "Group" is the business entity (usually an employer) that contracts with Health Net to provide this coverage to you.

–  –  –

INTRODUCTION TO HEALTH NET

How to Obtain Care

Emergency and Urgently Needed Care

SCHEDULE OF BENEFITS AND COPAYMENTS

OUT-OF-POCKET MAXIMUM

ELIGIBILITY, ENROLLMENT AND TERMINATION

Who Is Eligible for Coverage

How to Enroll for Coverage

Special Reinstatement Rule For Reservists Returning From Active Duty

Special Reinstatement Rule Under USERRA

Transferring to Another Contracting Physician Group

When Coverage Ends

Small Employer Cal-COBRA Continuation Coverage

Extension of Benefits

COVERED SERVICES AND SUPPLIES

Medical Services and Supplies

Prescription Drugs

Acupuncture Services

Pediatric Vision Services (birth through age 18)

Pediatric Dental Services (birth through age 18)

Mental Disorders and Chemical Dependency

EXCLUSIONS AND LIMITATIONS

General Exclusions and Limitations

Services and Supplies

Prescription Drugs

Acupuncture Services

Pediatric Vision Services (birth through age 18)

Pediatric Dental Services (birth through age 18)

GENERAL PROVISIONS

When the Plan Ends

When the Plan Changes

Customer Contact Center Interpreter Services

Members’ Rights and Responsibilities Statement

Grievance, Appeals, Independent Medical Review and Arbitration

Department of Managed Health Care

Medical Malpractice Disputes

Relationship of Parties

Coordination of Benefits

Government Coverage

Workers’ Compensation

MISCELLANEOUS PROVISIONS

DEFINITIONS

–  –  –

INTRODUCTION TO HEALTH NET

The coverage described in this Evidence of Coverage shall be consistent with the Essential Health Benefits coverage requirements in accordance with the Affordable Care Act (ACA). The Essential Health Benefits are not subject to any annual dollar limits.

The benefits described under this Evidence of Coverage do not discriminate on the basis of race, ethnicity, nationality, gender, gender identity, gender expression, age, disability, sexual orientation, genetic information, or religion, and are not subject to any pre-existing condition or exclusion period.

How to Obtain Care When you enroll in this Plan, you must select a contracting Physician Group where you want to receive all of your medical care. That Physician Group will provide or authorize all medical care. Call your Physician Group directly to make an appointment. For contact information on your Physician Group, please call the Customer Contact Center at the telephone number on your Health Net ID card.

In addition, CVS MinuteClinic licensed practitioners are available to provide you with treatment of common illnesses, vaccinations and other health services inside CVS/pharmacy stores. However, Specialist referrals following care from CVS MinuteClinic must be obtained through the contracting Physician Group. Members traveling in another state which has a CVS Pharmacy with a MinuteClinic can access MinuteClinic covered services under this Plan at that MinuteClinic under the terms of this Evidence of Coverage.



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