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«A complete explanation of Your plan POLICY A complete explanation of Your plan Individual and Family Catastrophic Plan Policy PureCareOne EPO Plan ...»

-- [ Page 1 ] --

Member Coverage Documents

Individual and Family Policy PureCareOne EPO Policy

and

Vision and Dental PPO Policy (for Covered Persons age 19 and older)

(506131)

A complete explanation of Your plan

POLICY

A complete explanation of Your plan

Individual and Family Catastrophic Plan Policy PureCareOne EPO Plan

Important benefit information – please read

Notice of Right to Examination for individuals age 65 and older: The Policyholder or

certificateholder has the right to return the Policy or certificate, by mail or other delivery method, within 30 days after its receipt, and to have the full premium and any policy or membership fee paid refunded.

P34401(CA1/16)OE PO Box 10196 Van Nuys, CA 91410-0196 Amendment to Your Insurance Coverage (Attach this Amendment to Your Individual and Family EPO Policy) Please read the following amendment to your Health Net Life Insurance Company (“HNL”) Policy carefully.

It contains changes to your health coverage.

THIS AMENDMENT is made part of the Policy that has been issued for the coverage effective date of April 1, 2016 and later. Unless otherwise indicated herein, all terms initially capitalized herein shall have the same meaning attributed to such terms in the Policy and references to applicable sections of the Policy. This Amendment, combined with your Policy, explain the details of your health care coverage. All other terms and conditions shown in your Policy will continue to apply.

The following language has been added to the “Term of Policy and Premiums” section of your Policy.

PAYMENT OF PREMIUMS

The Policyholder is responsible for payment of Premiums to HNL. Except as required by law, HNL does not accept payments of Premiums on behalf of the Policyholder directly or indirectly from a Hospital, Home Health Care Agency, Hospice, Outpatient Surgical Center, Physician, Qualified Autism Provider, Residential Treatment Center, Skilled Nursing Facility, or other entities or persons which provide Cov- ered Services and Supplies. Upon discovery of such a payment, HNL will return it and inform the Policy- holder that the payment is rejected and that the Premium remains due. A 30-day Grace Period will be allowed for payment of the Premium due, beginning on the date that HNL notifies the Policyholder that the payment was rejected. If HNL does not receive payment on or before the last day of the Grace Period, HNL will cancel coverage after the end of the Grace Period. Refer to the “Grace Periods” provision in the “Term of Policy and Premiums” section of the Policy for further information.

Page 1 of 1 R34401(CA 04/16)OE

NOTICE OF PROTECTION PROVIDED BY

CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION

This notice provides a brief summary regarding the protections provided to policyholders by the California Life and Health Insurance Guarantee Association (“the Association”). The purpose of the Association is to assure that policyholders will be protected, within certain limits, in the unlikely event that a member insurer of the Association becomes financially unable to meet its obligations. Insurance companies licensed in California to sell life insurance, health insurance, annuities and structured settlement annuities are members of the Association. The protection provided by the Association is not unlimited and is not a substitute for consumers' care in selecting insurers. This protection was created under California law, which determines who and what is covered and the amounts of coverage.

Below is a brief summary of the coverages, exclusions and limits provided by the Association. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations or the rights or obligations of the Association.

–  –  –

● Persons Covered Generally, an individual is covered by the Association if the insurer was a member of the Association and the individual lives in California at the time the insurer is determined by a court to be insolvent. Coverage is also provided to policy beneficiaries, payees or assignees, whether or not they live in California.

● Amounts of Coverage The basic coverage protections provided by the Association are as follows.

● Life Insurance, Annuities and Structured Settlement Annuities For life insurance policies, annuities and structured settlement annuities, the Association will provide the

following:

–  –  –

The maximum amount of protection provided by the Association to an individual, for all life insurance, annuities and structured settlement annuities is $300,000, regardless of the number of policies or contracts covering the individual.

–  –  –

The maximum amount of protection provided by the Association to an individual, as of April 1, 2011, is $470,125. This amount will increase or decrease based upon changes in the health care cost component of the consumer price index to the date on which an insurer becomes an insolvent insurer.

P34401(CA1/16)OE

------------------------------------------------------------------------------------------------------------------------------COVERAGE LIMITATIONS AND EXCLUSIONS FROM COVERAGE The Association may not provide coverage for this policy. Coverage by the Association generally requires residency in California. You should not rely on coverage by the Association in selecting an insurance company or in selecting an insurance policy.





The following policies and persons are among those that are excluded from Association coverage:

● A policy or contract issued by an insurer that was not authorized to do business in California when it issued the policy or contract ● A policy issued by a health care service plan (HMO), a hospital or medical service organization, a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society ● If the person is provided coverage by the guaranty association of another state ● Unallocated annuity contracts; that is, contracts which are not issued to and owned by an individual and which do not guaranty annuity benefits to an individual ● Employer and association plans, to the extent they are self-funded or uninsured ● A policy or contract providing any health care benefits under Medicare Part C or Part D ● An annuity issued by an organization that is only licensed to issue charitable gift annuities ● Any policy or portion of a policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as certain investment elements of a variable life insurance policy or a variable annuity contract ● Any policy of reinsurance unless an assumption certificate was issued ● Interest rate yields (including implied yields) that exceed limits that are specified in Insurance Code Section 1607.02(b)(2)(C).

–  –  –

Insurance companies or their agents are required by law to give or send you this notice. Policyholders with additional questions should first contact their insurer or agent. To learn more about coverages provided by the

Association, please visit the Association’s website at www.califega.org, or contact either of the following:

–  –  –

P34401(CA1/16)OE Insurance companies and agents are not allowed by California law to use the existence of the Association or its coverage to solicit, induce or encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and California law, then California law will control.

–  –  –

to provide benefits as defined in this Policy to the Policyholder and their eligible Dependents according to the terms and conditions of this Policy. Payment of Premium by the Policyholder in the amount and manner provided for in the Policy shall constitute the Policyholder's acceptance of the terms and conditions of the Policy. This Health Net Life Insurance Company Policy, the Application for Individual and Family Policy and the enrollment forms of Policyholder's Dependents, inclusively shall constitute the entire agreement between the parties.

–  –  –

Notice of Right to Examination: If You are not satisfied with Your coverage under this Policy, You may return it within 10 days of receipt. The Policy must be mailed or delivered to HNL. If the Policy is returned to HNL within 10 days of receipt, HNL will refund any Premium paid and the Policy will be considered void from the beginning as if it had never been issued.

–  –  –

Benefits under this medical plan are restricted to Covered Services and Supplies provided by providers in the Health Net Life Exclusive Provider Organization (EPO) network within California (see “Preferred Providers” defined under this section). Except for Emergency Care, this medical plan does not cover services provided outside California or provided by providers outside the EPO network.

HEALTH NET LIFE INSURANCE COMPANY (herein called HNL) agrees to provide benefits as described in this Policy to the Policyholder (herein called "You" or "Your") and Your eligible Dependents.

The coverage described in this Policy 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 Policy do not discriminate on the basis of race, ethnicity, color, nationality, ancestry, gender, gender identity, gender expression, age, disability, sexual orientation, genetic information, marital status, domestic partner status or religion, and are not subject to any pre-existing condition or exclusion period.

HNL will provide 60 days advance notice to Policyholders before the effective date of any material modification to this Policy, including changes in Preventive Care Services.

PLEASE READ THE FOLLOWING INFORMATION TO KNOW FROM WHOM OR WHICH GROUP OF

PROVIDERS HEALTH CARE MAY BE OBTAINED.

Service Area is the geographic area within which HNL markets and sells Individual EPO insurance plans, and is defined as the following counties in the state of California: Contra Costa, Marin, Merced, Napa, Orange, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus and Tulare.

In addition, the Service Area consists of the following partial counties:

 Kern: For ZIP codes 93203, 93205, 93206, 93215, 93216, 93220, 93222, 93224, 93225, 93226, 93238, 93240, 93241, 93243, 93249, 93250, 93251, 93252, 93255, 93263, 93268, 93276, 93280, 93283, 93285, P34401(CA1/16)OE 93287, 93301, 93302, 93303, 93304, 93305, 93306, 93307, 93308, 93309, 93311, 93312, 93313, 93314, 93380, 93383, 93384, 93385, 93386, 93387, 93388, 93389, 93390, 93501, 93502, 93504, 93505, 93516, 93518, 93519, 93523, 93524, 93531, 93560, 93561, 93581, 93596  Los Angeles: For ZIP codes starting with 906 to 912, inclusive, 915, 917, 918 and 935  Riverside: For ZIP codes 91752, 92201, 92202, 92203, 92210, 92211, 92220, 92223, 92230, 92234, 92235, 92236, 92240, 92241, 92247, 92248, 92253, 92254, 92255, 92258, 92260, 92261, 92262, 92263, 92264, 92270, 92274, 92276, 92282, 92320, 92501, 92502, 92503, 92504, 92505, 92506, 92507, 92508, 92509, 92513, 92514, 92515, 92516, 92517, 92518, 92519, 92521, 92522, 92530, 92531, 92532, 92536, 92539, 92543, 92544, 92545, 92546, 92548, 92549, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92567, 92570, 92571, 92572, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92589, 92590, 92591, 92592, 92593, 92595, 92596, 92599, 92860, 92877, 92878, 92879, 92880, 92881, 92882, 92883  San Bernardino: For ZIP Codes 91701, 91708, 91709, 91710, 91729, 91730, 91737, 91739, 91743, 91758, 91761, 91762, 91763, 91764, 91784, 91785, 91786, 92252, 92256, 92268, 92277, 92278, 92284, 92285, 92286, 92301, 92305, 92307, 92308, 92309, 92310, 92311, 92312, 92313, 92314, 92315, 92316, 92317, 92318, 92321, 92322, 92324, 92325, 92327, 92329, 92331, 92333, 92334, 92335, 92336, 92337, 92339, 92340, 92341, 92342, 92344, 92345, 92346, 92347, 92350, 92352, 92354, 92356, 92357, 92358, 92359, 92365, 92368, 92369, 92371, 92372, 92373, 92374, 92375, 92376, 92377, 92378, 92382, 92385, 92386, 92391, 92392, 92393, 92394, 92395, 92397, 92398, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92413, 92415, 92418, 92423, 92427 Preferred Providers are providers who have agreed to "participate" in HNL's Exclusive Provider Organization program ("EPO"), which is called Health Net EPO. They have agreed to provide the Covered Persons under this Policy with Covered Services and Supplies as explained in this Policy and accept a special contracted rate, called the "Contracted Rate" as payment in full. The Covered Person's share of costs is based on that contracted rate.

Preferred Providers are listed on the HNL website at www.healthnet.com and selecting “Provider Search” or one can contact the Customer Contact Center at the telephone number on the HNL ID Card to obtain a copy of the Preferred Provider Directory at no cost. If Medically Necessary care is not available through a Preferred Provider, HNL will arrange for the required care with available and accessible Out-of-Network Providers.

Out-of-Network Providers have not agreed to participate in the Health Net EPO program. You may obtain Covered Services and Supplies from an Out-of-Network Provider only for Emergency Care or pediatric dental

services. THE CONTINUED PARTICIPATION OF ANY ONE PHYSICIAN, HOSPITAL OR OTHER PROVIDER

CANNOT BE GUARANTEED. Covered Services and Supplies received from Out-of-Network Providers will be payable at the Preferred Provider level of coverage when medically appropriate care is not available within the network.



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