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«Small Business Group CommunityCare HMO Gold $5 Plan C9P DELIVERING CHOICES When it comes to your health care, the best decisions are made with the ...»

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Summary of Benefits

and Disclosure Form

Small Business Group

CommunityCare HMO Gold $5 Plan C9P


When it comes to your health care, the best decisions are made with the best choices. Health Net of California,

Inc. (Health Net) provides you with ways to help you receive the care you deserve. This Summary of Benefits and

Disclosure Form (SB/DF) answers basic questions about this versatile plan.

The coverage described in this SB/DF 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 SB/DF 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.

If you have further questions, contact us:

 By phone at1-800-361-3366,  Or write to: Health Net of California P.O. Box 10348 Van Nuys, CA 91410-0348 Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely.

This Summary of benefits/disclosure form (SB/DF) is only a summary of your health plan. The plan’s Evidence of Coverage (EOC), which you will receive after you enroll, contains the exact terms and conditions of your Health Net coverage. You have the right to view the EOC prior to enrollment. To obtain a copy of the EOC, contact the Customer Contact Center at 1-800-361-3366. You should also consult the Group Hospital and Professional Service Agreement (issued to your employer) to determine governing contractual provisions. It is important for you to carefully read this SB/DF and the plan’s EOC thoroughly once received, especially those sections that apply to those with special health care needs. This SB/DF includes a matrix of benefits in the section titled "Schedule of benefits and coverage."





Except for Emergency Care, benefits for Physician and Hospital services under this Health Net HMO CommunityCare Network ("CommunityCare Network") plan are only available when you live or work in the CommunityCare Network service area and use a CommunityCare Network Physician or Hospital. When you enroll in this CommunityCare Network plan, you may only use a Physician or Hospital who is in the CommunityCare Network and you must choose a CommunityCare 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 CommunityCare Network Plan

–  –  –

The CommunityCare Network service area and a list of its Physician and Hospital providers are shown in the Health Net CommunityCare Network Provider Directory, which is available online at our website www.healthnet.com. You can also call the Health Net Customer Contact Center at 1-800361-3366 to request provider information. The CommunityCare Network Provider Directory is different from other Health Net Provider Directories.

Note: Not all Physician and Hospitals who contract with Health Net are CommunityCare Network providers. Only those Physicians and Hospitals specifically identified as participating in the CommunityCare 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 CommunityCare 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 If you have any questions about the CommunityCare Network Service Area, choosing your Community Care 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.

Health Net CommunityCare Network Alternative Access Standards This section pending resolution of CommunityCare Network Recertification filing.

The CommunityCare Network includes participating primary care and Specialist Physicians, and Hospitals in the CommunityCare service area. However, CommunityCare 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 Los Angeles County: 90263 –Malibu (Hospital), 90264 – Malibu (Hospital), 90265 - Malibu (PCP and Hospital), 91301 – Agoura Hills (Hospital), 91310 – Castaic (Hospital), 91350 - Santa Clarita (Hospital), 91354 – Valencia (Hospital), 91355 – Valencia (Hospital), 91383 – Santa Clarita (Hospital), 91384 – Castaic (Hospital), 91390 – Santa Clarita (Hospital), 93535 – Lancaster (PCP and Hospital), 93536 – Lancaster (PCP), 93543 – Littlerock (Hospital), 93544 – Llano (Hospital), 93553 – Pearblossom (Hospital), 93563 – Valyermo (Hospital), 93591 – Palmdale (Hospital) Orange County: 92607 – Laguna Niguel (Hospital), 92610 – Foothill Ranch (Hospital), 92624 – Capistrano Beach (Hospital), 92629 – Dana Point (Hospital), 92630 – Lake Forest (Hospital), 92651 – Laguna Beach (Hospital), 92653 – Laguna Beach (Hospital), 92656 – Aliso Viejo (Hospital), 92673 – San Clemente (Hospital), 92674 – San Clemente (Hospital), 92675 – San Juan Capistrano (Hospital), 92677 – Laguna Niguel (Hospital), 92678 – Trabuco Canyon (Hospital), 92679 – Trabuco Canyon (Hospital), 92688 – Rancho Santa Margarita (Hospital), 92690 – Mission Viejo (Hospital), 92691 – Mission Viejo (Hospital), 92692 – Mission Viejo (Hospital), 92693 – San Juan Capistrano (Hospital), 92694 – Ladera Ranch (Hospital) Beyond 30 Miles Los Angeles County: 93532 – Lake Hughes (Hospital: 37 miles), 93536 – Lancaster (Hospital: 35 miles) Orange County: 92672 – San Clemente (Hospital: 31 miles)


How the plan works

Schedule of benefits and coverage

Limits of coverage

Benefits and coverage

Utilization management

Payment of fees and charges


Renewing, continuing or ending coverage

If you have a disagreement with our plan

Additional plan benefit information

Behavioral health services

Prescription drug program

Acupuncture care program

Pediatric vision care program

Pediatric dental program

Notice of language services

HMO SB/DF 3 How the plan works Please read the following information so you will know from whom health care may be obtained, or what physician group to use.


When you enroll with Health Net, you choose a contracting physician group. From your physician group, you select one doctor to provide basic health care; this is your Primary Care Physician (PCP).

Health Net requires the designation of a Primary Care Physician. A Primary Care Physician provides and coordinates your medical care. You have the right to designate any Primary Care Physician who participates in our network and who is available to accept you or your family members, subject to the requirements of the physician group. For children, a pediatrician may be designated as the Primary Care Physician. Until you make this designation, Health Net designates one for you. For information on how to select a Primary Care Physician and for a list of the participating Primary Care Physicians, refer to your Health Net Group HMO Directory (Health Net HMO Directory). The Health Net HMO Directory is also available on the Health Net website at www.healthnet.com.

Whenever you or a covered family member needs health care, your PCP will provide the medically necessary care. Specialist care is also available, when referred by your PCP or physician group.

You do not have to choose the same physician group or PCP for all members of your family.

Physician groups, with names of physicians, are listed in the Health Net HMO Directory.


Choosing a PCP is important to the quality of care you receive. To be comfortable with your choice, we

suggest the following:

Discuss any important health issues with your chosen PCP;

Ask your PCP or the physician group about the specialist referral policies and hospitals used by the physician group; and Be sure that you and your family members have adequate access to medical care, by choosing a doctor located within 30 miles of your home or work.


If you need medical care that your PCP cannot provide, your PCP may refer you to a specialist or other health care provider for that care. Refer to the "Mental Disorders and Chemical Dependency Care" section below for information about receiving care for Mental Disorders and Chemical Dependency.

You do not need prior authorization from Health Net or from any other person (including a Primary Care Physician) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, refer to your Health Net Group HMO Directory (Health Net HMO Directory). The Health Net HMO Directory is also available on the Health Net website at www.healthnet.com.



Health Net offers Rapid Access®, a service that makes it easy for you to quickly connect with a specialist in Health Net’s network. Ask your group or check the Health Net HMO Directory to see if your physician group allows "self-referrals" or "direct referrals" to specialists within the same group. Self-referral allows you to contact a specialist directly for consultation and evaluation. Direct referral allows your doctor to refer you directly to a specialist without the need for physician group authorization. Information about your physician group’s referral policies is also available to you on our web site at www.healthnet.com.


Health Net contracts with MHN Services, an affiliate behavioral health administrative services company (the Behavioral Health Administrator), which administers behavioral health services for mental disorders and chemical dependency conditions. For more information about how to receive care and the Behavioral Health Administrator's prior authorization requirements, please refer to the "Behavioral Health Services" section of this SB/DF.


The CVS MinuteClinic is a health care facility, generally inside CVS/pharmacy stores, which is designed to offer an alternative to a Physician’s office visit for the unscheduled treatment of non-emergency illnesses or injuries such as strep throat, pink eye or seasonal allergies. Visits to a CVS MinuteClinic are covered as shown in the "Schedule of Benefits and Coverage" section.

You do not need prior authorization or a referral from your primary care physician or contracting physician group in order to obtain access to CVS MinuteClinic services. However, a referral from the contracting Physician Group or Primary Care Physician is required for any Specialist consultations. For more detailed information about CVS MinuteClinics, please refer to the plan's EOC or contact Health Net at the telephone number shown on the back cover.


Complete the enrollment form found in the enrollment packet and return the form to your employer. If a form is not included, your employer may require you to use an electronic enrollment form or an interactive voice response enrollment system. Please contact your employer for more information.

Some hospitals and other providers do not provide one or more of the following services that may

be covered under the plan's Evidence Of Coverage and that you or your family member might need:

–  –  –

Schedule of benefits and coverage This MATRIX is intended TO BE USED to help you compare coverage benefits and is a summary only.

The PLAN CONTRACT AND evidence of coverage (EOC) should be consulted for a detailed description of coverage benefits and limitations.

The copayment amounts listed below are the fees charged to you for covered services you receive.

Copayments can be either a fixed dollar amount or a percentage of Health Net's cost for the service or supply and is agreed to in advance by Health Net and the contracted provider. Fixed dollar copayments are due and payable at the time services are rendered. Percentage copayments are usually billed after the service is received.

Principal benefits and coverage matrix Deductibles

For certain medical services and supplies under this plan, except as specifically noted below, a calendar-year deductible applies, which must be satisfied before these services and supplies are covered. You must pay an amount of covered expenses for these services equal to the Calendar Year Deductible shown above before the benefits are paid by your Plan.

Lifetime maximums

Out-of-Pocket maximum One member

Family (two or more members)

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