Renewal Guide. We ve got you covered! Small Business Group

Transcription

1 Commercial Small Business Group Renewal Guide We ve got you covered! Geoffrey Gomez, Health Net We put the pieces together for sustainable affordability.

2 Hello! It s time to renew your small business group (SBG) coverage with Health Net of California, Inc. and/ or Health Net Life Insurance Company (Health Net). And we have exciting news for you You are among the first to have access to Small Group 2.0 our small business-focused health plans that hit the sweet spot with all-time favorites and simplified selection. Inside you ll find all the details to find perfect-fit coverage for your business: Small Group 2.0 plan choices, featuring new HMO plan designs you can pair with any of the networks we offer in your location. New Enhanced Choice package pairings. Reform Refresher. Your group may be moving to ACA-compliant plans for the first time. This special section is for you! Underwriting guideline summary. Rate overview. Questions? Your account manager is standing by with answers! Thank you for the opportunity to earn your business. We re proud to support the health of your employees and your business, and look forward to continuing our partnership for the coming year. Sincerely, Scott Shaffer Director of SBG Account Management Karen Boyd, Health Net We make a difference, one member at a time.

3 Table of Contents Welcome to Small Group December 2015 Portfolio Highlights...4 Plans At-a-Glance...6 December 2015 changes and additions...6 Choices by Location...7 Benefit Overview by Plan Type New Enhanced Choice Package Pairings Plan Migrations Underwriting Guideline Summary Understanding Rates Reform Refresher SBG Ancillary Programs Health Net Dental Health Net Vision Chiropractic Life and Accidental Death & Dismemberment Rate Guide More Than an ID Card Decision Power : Health & Wellness Focus on early access and prevention Health Net online and on the go Group Administration Employee additions, changes and more Online billing and enrollment Appendix/Forms Contact Us... Back cover 1

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5 Welcome to Small Group 2.0 Simplified, Sustainable, Small Business-Focused Account management , option 2, then option 1 (for Los Angeles and Orange County), or option 2 (for all other counties). 3

6 December 2015 Portfolio Highlights Keeping businesses like yours healthy and growing was the inspiration behind our December 2015 portfolio. HMO favorites the easy way to mix and match! Now you have the flexibility of picking an HMO plan design, then pairing it with any of the networks we offer in your location. The plan design stays the same. Simple. Step 1: Pick your plan design. Platinum $10 $$$ Platinum $20 Gold $30 Gold $40 $ Step 2: Pair your plan with any of the networks we offer in your location. Full Network Network size WholeCare SmartCare Salud HMO y Más Transition tip Full Network HMO is back! If you have a Full Network HMO plan now, under transitional relief, you can move to our Full Network HMO ACA-compliant plan with no disruption! Same network pairs with any of our Gold or Platinum HMO plans! 4

7 Go for Silver in L.A. and Orange counties our lowest cost plans Meet CommunityCare HMO plans We re introducing a pair of CommunityCare Silver-level plans 1 for employers in Los Angeles and Orange counties. Offered by Health Net of California, Inc., these HMO designs come with our locallybased CommunityCare network and the convenience of CVS MinuteClinics. Members choose a primary care physician from the CommunityCare network to coordinate their care. Other health-boosting benefits include: A no-cost preventive care visit each year (like with all ACA-compliant health plans). $0 copayment for the first doctor visit (for whatever reason). 2 Low copayments and $0 deductible for generic drugs. Plus! CommunityCare plans feature our lowest premiums. So, a Silver-level CommunityCare plan might just be the answer for groups looking to save. SmartCare redesign The SmartCare you know today is different than what we re offering beginning 12/1/15. We ve redesigned SmartCare plans for consistency with our other HMOs. For example, chiropractic care is available as an optional rider and no longer an included benefit. Beyond HMO We ve got the whole alphabet Our, EPO and HSP choices for 12/1/15 We do more than HMO. For employers interested in insurance plans, we have one in every metal level. Plus! The EPO and HSP plans we introduced in January 2015 are available for groups renewing on December 1, The duo is the newest of our tailored network products. For groups interested in an HSA-compatible plan, the Health Net Silver 70 HSA EPO Alternate is one to consider. Bonus! CVS MinuteClinics are now a benefit with all of our HMOs, making it that much easier for members to get care for common illnesses, wellness screenings, vaccinations, and more. 1Pending regulatory approval. 2 Copayment waived for the cost of the office visit only. Costsharing applies for all services related to the first office visit. Andre Hamil, Health Net We partner with you to promote workforce health. 5

8 Plans At-a-Glance December 2015 changes and additions Plan and network availability varies by county. See Choices by Location for plans by region. New! Still available for 12/1/15 Not available for 12/1/15 Plan All-new tailored network HMO plan designs can be paired with a choice of the SmartCare HMO, WholeCare HMO or Salud HMO y Más networks. These plan designs are also available with Full Network HMO! Platinum $10 Platinum $20 Gold $30 Gold $40 CommunityCare HMO plans Silver $30 Silver $45 Health Net Platinum 90 Health Net Gold 80 Health Net Silver 70 Health Net Bronze 60 WholeCare HMO Platinum Standard Copay Transitional relief plans WholeCare HMO Gold Standard Copay PureCare HSP Silver Standard Coinsurance PureCare HSP Bronze Standard Coinsurance Health Net Gold 80 EPO Alternate Health Net Gold 70 HSA EPO Alternate Health Net HMO and HSP health plans are offered by Health Net of California, Inc. Health Net and EPO insurance plans are underwritten by Health Net Life Insurance Company. 6

9 Choices by Location Find Your Fit Region We offer In this metal tier With this network Region 1 Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba counties Platinum, Gold, Silver, and Bronze Nevada County HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 2 Marin, Napa, Solano, and Sonoma counties Region 3 Sacramento, Placer, El Dorado, and Yolo counties HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 4 San Francisco County HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 5 Contra Costa County HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze 7

10 Region We offer In this metal tier With this network Region 6 Alameda County HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 7 Santa Clara County HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 8 San Mateo County HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 9 Santa Cruz County HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Monterey and San Benito counties Platinum, Gold, Silver, and Bronze Region 10 Mariposa County Platinum, Gold, Silver, and Bronze San Joaquin, Stanislaus, Merced, and Tulare counties HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 11 Fresno, Kings and Madera counties HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze 8

11 Region We offer In this metal tier With this network Region 12 Santa Barbara and Ventura counties HMO Platinum, Gold Your choice of: Full Network WholeCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze San Luis Obispo County Platinum, Gold, Silver, and Bronze Region 13 Mono, Inyo and Imperial counties Platinum, Gold, Silver, and Bronze Region 14 Kern County HMO Platinum, Gold Your choice of: Full Network WholeCare Salud y Más EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 15 Los Angeles County: ZIP codes starting with , 915, 917, 918, 935 Region 16 Los Angeles County: ZIP codes not in Region 15 Region 17 San Bernardino and Riverside counties HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare Salud y Más Silver CommunityCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare Salud y Más Silver CommunityCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare Salud y Más EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze 9

12 Region We offer In this metal tier With this network Region 18 Orange County HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare Salud y Más Silver CommunityCare EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze Region 19 San Diego County HMO Platinum, Gold Your choice of: Full Network WholeCare SmartCare Salud y Más EPO Gold, Silver (HSA) PureCare One HSP Silver and Bronze PureCare Platinum, Gold, Silver, and Bronze 10

13 Benefit Overview by Plan Type Available through Health Net and Covered California TM Plan name 1, 2 Office visit Deductible (single / family) Coinsurance Member(s) responsibility Inpatient hospital Outpatient surgery Out-of-pocket maximum (single / family) Emergency room Rx brand deductible Pharmacy Rx drug copayments Health Net Platinum 90 $20 None 10% / 50% 10% 10% $4,000 / $8,000 $150 None $5 / $15 / $25 Health Net Gold 80 $30 None 20% / 50% 20% 20% $6,250 / $12,500 $250 None $15 / $50 / $70 Health Net Silver 70 $45 3 $1,500 / $3,000 20% / 50% 20% 20% 3 $500 single / $6,250 / $12,500 $250 $1,000 family $15 / $50 / $70 Health Net Bronze 60 $60 4 Subject to $5,000 / $10,000 30% / 50% 30% 30% $6,250 / $12,500 $300 annual ded. $15 / $50 / $75 PureCare One EPO 1, 2 Health Net Gold 80 EPO Alternate $20 3 $1,000 / $2,000 20% 20% 20% $4,500 / $9,000 $175 3 $250 $5 / $15 / $20% Health Net Silver 70 Subject to 30% $1,500 / $3,000 30% 30% 30% $6,000 / $12,000 30% HSA EPO Alternate annual ded. 30% 1 Counties available: Full HMO, WholeCare HMO, PureCare HSP, PureCare One EPO: All or parts of Alameda, Contra Costa, El Dorado, Fresno, Kern, Kings, Los Angeles, Madera, Marin, Merced, Napa, Nevada, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Ventura, and Yolo counties. SmartCare HMO: All or parts of Los Angeles, Orange, Riverside, San Diego, San Bernardino, Santa Clara, and Santa Cruz counties. Salud HMO y Más: All or parts of Kern, Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties. CommunityCare: Los Angeles and Orange counties. : Available in all counties. 2 Infertility benefits are available on all plans at an additional cost. 3 Deductible waived. 4 Deductible waived for first three visits. 5 Five-day copayment maximum per admission. 11

14 Available through Health Net Plan name Office visit Inpatient hospital Outpatient surgery (hospital / ASC) Member(s) responsibility Out-of-pocket maximum (single / family) Emergency room Rx brand deductible Pharmacy Rx drug copayments These 4 HMO plans are available with Full HMO, WholeCare HMO, SmartCare HMO and Salud HMO y Más 1, 2 Platinum $10 $10 $300/admission $100 / $40 $3,000 / $6,000 $100 $0 $5 / $30 / $50 Platinum $20 $20 $500/admission $300 / $120 $4,250 / $8,500 $150 $0 $5 / $30 / $50 Gold $30 $30 $600/admission $400 / $160 $6,000 / $12,000 $300 $0 $15 / $50 / $70 Gold $40 $40 $800/admission $600 / $240 $6,500 / $13,000 $300 $0 $15 / $50 / $70 Standard WholeCare HMO 1, 2 Platinum Standard Copay $20 $250/day 5 $250 / $250 $4,000 / $8,000 $150 $0 $5 / $15 / $25 Gold Standard Copay CommunityCare HMO 1 Silver $30 Silver $45 $30 $600/day 5 $600 / $600 $6,250 / $12,500 $250 $0 $15 / $50 / $70 1st visit $0 3 / Visit 2+ $ % 30% / 30% $6,500 / $13,000 $150 $200 $5 / $20 / $30 1st visit $0 3 / Visit 2+ $ % 45% / 45% $6,500 / $13,000 $300 $200 $5 / $20 / $30 Plan name PureCare HSP 1 Silver Standard Coinsurance Bronze Standard Coinsurance Office visit Deductible (single / family) Coinsurance Member(s) responsibility Inpatient hospital Outpatient surgery Out-of-pocket maximum (single / family) Emergency room Rx brand deductible Pharmacy Rx drug copayments $45 3 $1,500 / $3,000 20% 20% 20% 3 $6,250 / $12,500 $250 $500 $15 / $50 / $70 $60 4 $5,000 / $10,000 30% 30% 30% $6,250 / $12,500 $300 Subject to annual ded. $15 / $50 / $75 1 Counties available: Full HMO, WholeCare HMO, PureCare HSP, PureCare One EPO: All or parts of Alameda, Contra Costa, El Dorado, Fresno, Kern, Kings, Los Angeles, Madera, Marin, Merced, Napa, Nevada, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Ventura, and Yolo counties. SmartCare HMO: All or parts of Los Angeles, Orange, Riverside, San Diego, San Bernardino, Santa Clara, and Santa Cruz counties. Salud HMO y Más: All or parts of Kern, Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties. CommunityCare: Los Angeles and Orange counties. : Available in all counties. 2 Infertility benefits are available on all plans at an additional cost. 3 Deductible waived. 4 Deductible waived for first three visits. 5 Five-day copayment maximum per admission. 12

15 Enhanced Choice A New Spin Two packages for offering multiple plans Health Net invites your clients to be choosy! Health Net s package pairings give small business groups the choice to offer multiple plans to their employees. It s a new spin on Enhanced Choice. Your clients have their choice of Enhanced Choice A or Enhanced Choice B. Then they can offer any number or combination of plans which are within that package and available in their location. Enhanced Choice A Full Network HMO CommunityCare HMO PureCare One EPO PureCare HSP Enhanced Choice B WholeCare HMO SmartCare HMO Salud y Más HMO CommunityCare HMO PureCare One EPO PureCare HSP Whether you go for Enhanced Choice A or Enhanced Choice B, the set-up works the same! Enhanced Choice 1 5 eligible employees + 70% employee participation minimum 6 50 eligible employees + 50% employee participation minimum + Employer pays minimum of 50% of base plan monthly (excluding Salud) or Employer pays a minimum of $100 per employee toward the employee-only rate 13

16 Plan Migrations Plans Migration plan Platinum $20/$0 Health Net Platinum 90 Gold $30/$0 Health Net Gold 80 Silver $45/$1500 Health Net Silver 70 Bronze $60/$5000 Health Net Bronze 60 WholeCare HMO Platinum Standard Copay WholeCare HMO Platinum Standard Copay WholeCare HMO Gold Standard Copay WholeCare HMO Gold Standard Copay WholeCare HMO Platinum $10 WholeCare HMO Platinum $10 WholeCare HMO Platinum $25 WholeCare HMO Platinum $20 WholeCare HMO Gold $35 WholeCare HMO Gold $30 WholeCare HMO Gold $45 WholeCare HMO Gold $40 Salud HMO y Más Platinum $10 Salud HMO y Más Platinum $10 Salud HMO y Más Platinum $20 Salud HMO y Más Platinum $20 Salud HMO y Más Platinum $25 Salud HMO y Más Platinum $20 Salud HMO y Más Gold $35 Salud HMO y Más Gold $30 Salud HMO y Más Gold $45 Salud HMO y Más Gold $40 SmartCare HMO Platinum 10 SmartCare HMO Platinum 10 SmartCare HMO Platinum 20 SmartCare HMO Platinum 20 SmartCare HMO Platinum 30 SmartCare HMO Platinum 20 SmartCare HMO Gold 40 SmartCare HMO Gold 30 SmartCare HMO Gold 50 SmartCare HMO Gold 40 Plans with infertility will be migrated to a new plan with infertility. 14

17 Transitional relief plans Plans Migration plan Standard HMO and EOA 10 NG Full Network HMO Platinum $10 + Infertility Standard HMO and EOA 15 NG Full Network HMO Platinum $10 + Infertility Standard HMO and EOA 20 NG Full Network HMO Platinum $20 + Infertility Standard HMO and EOA 25 NG Full Network HMO Platinum $20 + Infertility Standard HMO and EOA 30 NG Full Network HMO Gold $30 + Infertility Standard HMO and EOA 35 NG Full Network HMO Gold $30 + Infertility Standard HMO and EOA 40 NG Full Network HMO Gold $40 + Infertility Standard HMO and EOA 50 NG Full Network HMO Gold $40 + Infertility Value HMO and EOA 10 NG Full Network HMO Platinum $10 + Infertility Value HMO and EOA 20 NG Full Network HMO Platinum $20 + Infertility Value HMO and EOA 30 NG Full Network HMO Gold $30 + Infertility Value HMO and EOA 40 NG Full Network HMO Gold $40 + Infertility Value HMO and EOA 50 NG Full Network HMO Gold $40 + Infertility Advantage HMO and EOA 25 NG Full Network HMO Platinum $20 + Infertility Advantage HMO and EOA 35 NG Full Network HMO Gold $30 + Infertility Advantage HMO and EOA 45 NG Full Network HMO Gold $40 + Infertility Options HMO and EOA 25 NG Full Network HMO Platinum $20 + Infertility Options HMO and EOA 35 NG Full Network HMO Gold $30 + Infertility Standard HMO and EOA 10 ExcelCare Network NG WholeCare HMO Platinum $10 + Infertility Standard HMO and EOA 15 ExcelCare Network NG WholeCare HMO Platinum $10 + Infertility Standard HMO and EOA 20 ExcelCare Network NG WholeCare HMO Platinum $20 + Infertility Standard HMO and EOA 25 ExcelCare Network NG WholeCare HMO Platinum $20 + Infertility Standard HMO and EOA 30 ExcelCare Network NG WholeCare HMO Gold $30 + Infertility Standard HMO and EOA 35 ExcelCare Network NG WholeCare HMO Gold $30 + Infertility Standard HMO and EOA 40 ExcelCare Network NG WholeCare HMO Gold $40 + Infertility Standard HMO and EOA 50 ExcelCare Network NG WholeCare HMO Gold $40 + Infertility Value HMO and EOA 10 ExcelCare Network NG WholeCare HMO Platinum $10 + Infertility Value HMO and EOA 20 ExcelCare Network NG WholeCare HMO Platinum $20 + Infertility Value HMO and EOA 30 ExcelCare Network NG WholeCare HMO Gold $30 + Infertility Value HMO and EOA 40 ExcelCare Network NG WholeCare HMO Gold $40 + Infertility Value HMO and EOA 50 ExcelCare Network NG WholeCare HMO Gold $40 + Infertility Advantage HMO and EOA 25 ExcelCare Network NG WholeCare HMO Platinum $20 + Infertility Advantage HMO and EOA 35 ExcelCare Network NG WholeCare HMO Gold $30 + Infertility Advantage HMO and EOA 45 ExcelCare Network NG WholeCare HMO Gold $40 + Infertility Options HMO and EOA 25 ExcelCare Network NG WholeCare HMO Platinum $20 + Infertility Options HMO and EOA 35 ExcelCare Network NG WholeCare HMO Gold $30 + Infertility Standard HMO 20 Dual Network NG WholeCare HMO Platinum $20 + Infertility Standard HMO 30 Dual Network NG WholeCare HMO Gold $30 + Infertility Value HMO 30 Dual Network NG WholeCare HMO Gold $30 + Infertility Value HMO 40 Dual Network NG WholeCare HMO Gold $40 + Infertility Standard HMO 10 SmartCare Network NG SmartCare Platinum $10 + Infertility Standard HMO 10 SmartCare NorCal Network NG SmartCare Platinum $10 + Infertility Standard HMO 20 SmartCare Network NG SmartCare HMO Platinum $20 Standard HMO 20 SmartCare NorCal Network NG SmartCare HMO Platinum $20 Standard HMO 30 SmartCare Network NG SmartCare HMO Gold $30 Standard HMO 30 SmartCare NorCal Network NG SmartCare HMO Gold $30 Standard HMO 40 SmartCare Network NG SmartCare HMO Gold $40 Standard HMO 40 SmartCare NorCal Network NG SmartCare HMO Gold $40 Standard HMO 50 SmartCare Network NG SmartCare HMO Gold $40 15

18 Transitional relief plans (continued) Plans Migration plan Standard HMO 50 SmartCare NorCal Network NG SmartCare HMO Gold $40 Value HMO 50 SmartCare Network NG SmartCare HMO Gold $40 Value HMO 50 SmartCare NorCal Network NG SmartCare HMO Gold $40 Salud HMO y Más 15 NG Salud HMO y Más Platinum $10 + Infertility Salud HMO y Más 25 NG Salud HMO y Más Platinum $20 + Infertility Salud HMO y Más 35 NG Salud HMO y Más Gold $30 + Infertility Salud Mexico NG - Imperial County Health Net Silver 70 Salud Mexico NG - All other counties Salud HMO y Más Gold $40 Salud con Health Net EPO NG Health Net Gold 80 EPO Alternate + Infertility POS 10 NG Full Network HMO Platinum $10 + Infertility POS 20 NG Full Network HMO Platinum $20 + Infertility Standard 10 NG Health Net Platinum 90 + Infertility Standard 15 NG Health Net Platinum 90 + Infertility Standard 20 NG Health Net Platinum 90 + Infertility Standard 25 NG Health Net Platinum 90 + Infertility Standard 30 NG Health Net Gold 80 + Infertility Standard 35 NG Health Net Gold 80 + Infertility Standard 40 NG Health Net Gold 80 + Infertility Standard 45 NG Health Net Gold 80 + Infertility Value 10 NG Health Net Gold 80 + Infertility Value 15 NG Health Net Gold 80 + Infertility Value 20 NG Health Net Gold 80 + Infertility Value 25 NG Health Net Gold 80 + Infertility Value 30 NG Health Net Gold 80 + Infertility Value 35 NG Health Net Gold 80 + Infertility Value 40 NG Health Net Gold 80 + Infertility Value 45 NG Health Net Gold 80 + Infertility Value HSA 4500 NG Health Net Silver 70 + Infertility Advantage 45 NG Health Net Silver 70 + Infertility Options 250 NG Health Net Platinum 90 + Infertility Options 500 NG Health Net Platinum 90 + Infertility Options 1500 NG Health Net Silver 70 + Infertility Options 1750 NG Health Net Silver 70 + Infertility Options HSA 3000 NG Health Net Silver 70 + Infertility Options HSA 4000 NG Health Net Silver 70 + Infertility HRA 3000 NG Health Net Silver 70 + Infertility HRA 5000 NG Health Net Silver 70 + Infertility 16

19 Underwriting Guideline Summary Effective on the first day of your renewal month, you can choose between any of our plans as a standalone option or use our Enhanced Choice program to offer multiple plans to your employees. Enhanced Choice program Requirements and guidelines: Minimum 1 5 eligible employees and minimum 70% participation, or minimum 6 50 eligible employees and 50% participation. Can be written as sole carrier or alongside another carrier. Minimum employer contribution of 50% of the lowest cost plan or $100 per employee toward the employee-only rate. Composite rates are not available. If selected, the chiropractic rider will be applied to all HMO, EPO and HSP plans within the package. Note: Chiropractic is no longer embedded within SmartCare medical plans. Employers who wish to pair SmartCare with chiropractic must select the chiropractic rider. Medicare secondary payer data collection Please see the Taxpayer Identification and Worldwide Employee Count Verification Form to record any changes to your TIN and to update your worldwide employee counts. This request is the result of a new federal reporting requirement for health plans to provide CMS (Centers for Medicare & Medicaid Services) with certain information that will enable CMS to more effectively pay for the health insurance benefits of Medicare beneficiaries who also have coverage under group health plan arrangements. We appreciate your assistance and timely response to our data request so that we may comply with this mandate. Group number assignments Certain plan changes will result in a new group number assignment. 17

20 Understanding Rates At Health Net, our goal always is to minimize rate adjustments, so you can continue to provide health care benefits to your employees. Rates take into account many variables, such as new technologies and rising health care costs. Small Group premiums have been affected by the following changes related to the Affordable Care Act for ACA-compliant health plans: Age limited to a 1:3 ratio. Example: The rate for a 64-year-old can t be more than three times (300%) the rate for a 21-year-old. Each family member is rated individually based on his/her age. For the purpose of rating, the member s age is determined at the time a policy is issued or renewed. Only the first three children under age 21 are charged. Rate based on the geographic rating region of the employer. Regional rating areas are now grouped together for rating based upon the regions chosen by the state of California. Health status has been removed as a rating factor. Your premium is priced as part of one Health Net rating pool. Your pricing is adjusted to reflect the average risk in the state of California. In addition, your premium reflects the following new taxes and fees: Health Insurer Fee 1.84 percent of premium in Additionally, there is another $0.25 per participant per month charge to cover two other new federal fees. CA Exchange Fee Applies only on our and EPO business, a $2.43 per participant per month charge to fund Covered California TM for Small Business (formerly called the Small Business Options Program, or SHOP). In the event additional federal or state legislative guidance or regulatory requirements emerge that result in a modification of the estimated impact of the benefit mandates, taxes or fees, Health Net reserves the right to further adjust its premium schedule. While rate increases are typically necessary for us to continue providing quality care, we realize that higher health expenditures have an impact on small businesses, especially in today s challenging economy. You may be able to offset a renewal rate increase or even save over current rates by switching to a different plan or plans. For example, a plan with a deductible or a higher office visit copayment could lower rates. We ve included an overview of our Small Business Group plans in SBG Plans At-a- Glance to make it easy for you to evaluate your options. Reinsurance Fee $3.67 per participant (including dependents) per month based on 2015 membership. 18

21 Reform Refresher Term Definition Essential Health Benefits All health plans offered in the individual and small group markets must provide a comprehensive package of items and services that are called Essential Health Benefits, 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 100% coverage for Plans must cover, without cost-sharing, a variety of preventive services as preventive care determined by organizations such as the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention. Expands women s preventive health services to include, without member costsharing, FDA-approved contraception methods, contraceptive counseling, breastfeeding support, supplies and counseling, and others. No annual or lifetime limits Prohibits annual limits and lifetime limits on the dollar value of coverage. Annual limitation on 2016 annual cost-sharing incurred must not exceed the maximum out-of-pocket cost-sharing and amounts of $6,850 for self-only / $13,700 for family coverage. deductibles For Health Savings Account (HSA)-compatible plans, the 2016 minimum annual deductible is $1,300 for self-only / $2,600 for family coverage. The annual out-of-pocket expenses may not exceed $6,550 for self-only / $13,100 for family coverage. Rating variation limits Allows rating variation in the individual and small group market and Health Insurance Exchanges based only on: Age limited to a 3:1 ratio. This means that the rate for a 64-year-old can t be more than three times (i.e., 300 percent) the rate for a 21-year-old. Geographic area Family composition with member-level rating applied. Instead of composite rating, each family member will be rated individually. Carriers can charge only for the three oldest children in the family who are under 21. For example, in a family of six, the rate would be the subscriber rate + spouse rate + the 0 21 rate x 3. Tobacco use (limited to 1.5:1 ratio) Note: Health Net does not factor tobacco use into our rates. Over-age dependent coverage Limits on waiting periods No pre-existing conditions exclusions Guaranteed availability of insurance Emergency services Group and individual market health plans providing coverage for dependent children must continue to make coverage available for an adult child until the child turns 26 years of age. Group health plans and health insurers may not apply a waiting period that exceeds 90 days. Plans are prohibited from excluding from coverage all individuals with preexisting conditions. Requires guaranteed issue and renewability of health insurance for individuals and business groups. Plans covering emergency services must meet standards such as not requiring prior authorization, covering services from nonparticipating providers and not allowing out-of-network cost-sharing to exceed in-network rates. ACA Plan Requirements Groups on transitional relief plans will move to ACA-compliant plans for the coming benefit year. This is an at-a-glance summary of what it means to be ACA-compliant. 19

22 Term Choice of provider Wellness programs Rescinding coverage Definition Enrollees may designate any available participating primary care provider as their provider. Plans must also provide notice to enrollees informing them of the terms of the plan regarding designation of primary care providers. Permits employers to offer employees rewards of up to 30%, potentially increasing to 50%, of the cost of coverage for participating in a wellness program and meeting certain health-related standards. If certain conditions are met, health plans may provide a discount or rebate when an individual satisfies a standard related to a health factor. Insurers and group health plans may not rescind an enrollee s coverage unless the individual has performed an act that constitutes fraud against the plan or has intentionally misrepresented a material fact to the plan. Grandfathered status Group health plans that were in effect on March 23, 2010, and have not been significantly changed, are considered grandfathered plans. This means they do not need to comply with certain health care reform provisions, such as no cost-sharing for preventive services. If your plan was in effect on March 23, 2010, and you have not made significant changes that reduce benefits or increase cost-sharing for your employees, then you can renew a grandfathered plan without losing grandfathered status. Many plan changes, including an increase of more than 5 percentage points in your employees medical premium contribution rates (since March 23, 2010), may cause your plan to lose grandfathered status. When a plan loses grandfathered status, it must comply with some additional health reform changes. Please carefully review the impact of maintaining or losing grandfathered status when making your selections. By renewing your plan, you certify that you have not made any changes, including increases to your employees medical premium contribution rates, which would result in the loss of your plan s grandfathered status. Please also continue to notify Health Net of any future changes that may affect the grandfathered status of your selected plan(s), including changes in your contribution rates. Notice of the exchange All employers subject to FSLA Section 18 must provide written notice about the health insurance exchange Covered California TM for Small Business (formerly called the Small Business Health Options Program, or SHOP) to each new employee at the time of hire. The written notification must include information about the Exchange and whether or not the employer s lowest cost health plan meets minimum value and affordability standards as defined under ACA. A plan meets minimum value if it covers at least 60% of allowable costs, and is considered affordable if the employee s share of the premium for the lowest cost plan available to the employee is not more than 9.5% of the employee s W-2 wages. Employers may use model notices provided by the Department of Labor to meet this requirement. Model notices are available at Changes to Health Savings Accounts (HSAs) This section applies to groups that currently have or are considering an HSA plan. Only those drugs obtained with a prescription (whether or not such drugs are available without a prescription) and insulin are qualified tax-free medical expenses that can be covered by HSAs. If amounts are distributed from an HSA for any medicine or drugs that do not meet this requirement, those amounts will be considered nonqualified medical 20

23 expenses and thus includable in gross income, generally subject to a 20% additional tax. Small business tax credits To assist small employers in providing health insurance for their employees, Section 1421 of the ACA creates a tax credit program. To be eligible for the tax credit, small employers must enroll through Covered California for Small Business (formerly called the Small Business Health Options Program, or SHOP) and must pay at least 50% of the health insurance premium, employ 25 full-time equivalent employees or less, and have an average annual full-time equivalent wage that is $50,000 or less. The maximum available credit applies to firms with 10 or fewer fulltime equivalent employees and average a fulltime equivalent wage that is $25,000 or less. A sliding scale reduces the credit as average full-time equivalent compensation and the number of full-time equivalent employees increases. The maximum proportion is currently 50%. Finally, small employers must file the IRS Form 8941 to receive the tax credit. Form 8941 and more information about the tax credit can be found on the IRS website: Employer mandate While the ACA does not specifically mandate that all employer groups with 50 or more full-time employees offer medical coverage, employers may be subject to potential tax penalties if they do not offer affordable coverage to employees and at least one employee receives a premium tax credit or cost-sharing subsidy for an Exchange plan. Under the Affordable Care Act (ACA) employer mandate, employer groups with 100 or more full-time or full-time equivalent employees (FTEs) may be subject to a tax penalty if they do not offer affordable medical coverage to their employees in Employer groups with 50 to 99 full-time or full-time equivalent employees must report to the IRS on their workers and coverage for 2015, but are not subject to any employer shared responsibility penalty until Note: To be subject to the mandate, an employer group must have at least 50 fulltime employees or a combination of full-time and part-time employees that is equivalent to at least 50 full-time employees (for example, 100 half-time employees equals 50 full-time employees). As defined by the statute, a fulltime employee is an individual employed on average at least 30 hours per week. Appeals processes Under Section 2719 of the Public Health Service Act (PHSA), group health plans and health insurance issuers offering group health insurance coverage must maintain an effective appeals process. As part of this requirement, upon renewal on or after September 23, 2010, plans must maintain written internal and external appeals procedures. Summary of Benefits and Coverage document requirements 1 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 All ACA-compliant group health plans must allow their enrollees to designate any available participating primary care provider as their provider. 126 C.F.R ; 29 C.F.R ; and 45 C.F.R This information 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. 21

24 provided to you by Health Net. To search for an SBC, go to and follow the instructions as indicated. 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., or Internet posting). 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. 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 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 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 in the box on the right for an e-card or postcard in connection with a website posting of an SBC: 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: sbc.action or at <[group s website.com]>. A paper copy is also available, free of charge, by calling the toll-free number on your ID card. Timing of SBC distribution 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 enrollees 3, 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. 2Such requirements can be found at 29 C.F.R b-1(b). 3 Special 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 and 26 C.F.R , and 29 C.F.R

25 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. Uniform glossary Employees and family members can access a glossary of bolded terms used in the SBC by visiting 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 Account Manager. 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. 23

26 24

27 SBG Ancillary Programs Account management , option 2, then option 1 (for Los Angeles and Orange County), or option 2 (for all other counties). 25

28 Dental Plans That Make You Smile Does your plan include optional dental and vision coverage for your family? With Health Net, you can choose from a full line of affordable dental and vision coverage products and have a single point of contact for all your health care needs. Rates for these products, for new sales only, follow this section. For renewal rates, more information or to purchase any of these products, please contact your Health Net Account Manager. Health Net Dental HMO and plans may be purchased separately or as a dual choice when sold in conjunction with Health Net of California, Inc. or Health Net Life Insurance Company medical coverage products. Pediatric dental coverage (ages newborn through 18) is automatically included on all of our plans purchased directly through Health Net. Dental HMO key plan benefits An extensive network of Dental HMO (DHMO) providers. Many dental procedures are covered at listed copayments. In addition to the procedures already covered in the plan, additional cleanings and adult fluoride are covered. Material upgrades, such as porcelain and semiprecious or precious metal molar crowns, are included as a covered benefit. General anesthesia, cosmetic and elective dentistry are covered. These procedures are typically not covered under most other carriers dental plans. Teeth whitening is covered at the listed copayment. DHMO plans may be purchased separately or as a dual choice with Dental plans. Some of the key advantages of these products are listed here. Footnotes found at the end of this section. 26

29 Dental key plan benefits Health Net makes available a range of affordable, flexible Dental plans (D). From Classic to the feature-packed Essential plans, Health Net D plans will make you smile. These plans include the following features: Large statewide and national network of Dental providers. Periodontics, endodontics and oral surgery are covered in general services. Classic plans reimburse out-of-network benefits at Usual, Customary and Reasonable (UCR) 1 amounts. May be purchased separately or as a dual choice with dental HMO. All of our D plans offer pregnant women additional cleanings and periodontal maintenance when medically necessary (not subject to the deductible, and does not apply to the calendar year maximum). Employees and dependents receive the full amount of the orthodontia lifetime maximum, even if they have begun treatment under another carrier s dental plan (applies only to D Classic with orthodontia coverage). Essential plans reimburse out-of-network benefits on a limited fee schedule. No waiting periods. 27

30 D plan features Classic plan This plan has a $1,500 calendar year maximum. Classic offers full coverage for preventive, general and major services. Classic covers orthodontia with a $1,500 lifetime maximum. Essential plan This plan has a $1,000 calendar year maximum. Essential plans reimburse out-of-network benefits on a limited-fee schedule. All plans offer full coverage for preventive, general and major services. Benefits Classic In-network Out-of-network 2 Calendar year maximum $1,500 Calendar year deductible $50 single / $150 family $75 single / $225 family Preventive services 100% deductible waived 80% deductible waived (initial/routine oral exam, teeth cleaning and routine scaling, fluoride treatment, sealant children under 15, space maintainers, X-rays as part of a general exam, emergency exam) General services 80% after deductible 80% after deductible (fillings, general anesthetics, oral surgery, periodontics, endodontics) Major services 50% after deductible 50% after deductible (crowns, removable and fixed bridges, complete and partial dentures) Orthodontia 3 Classic 5 (adult and child) 50% after deductible / $1,500 lifetime maximum 28 Health Net Dental plans may be purchased on a standalone basis or in conjunction with a Health Net medical plan. This is only a summary of benefits. Please refer to the Certificate of Insurance for terms and conditions of coverage, including which services are limited or excluded from coverage. Footnotes found at the end of this section.

31 Essential plan Same features as Essential plan, with a $1,500 calendar year maximum. Underwriting highlights Dual option available Group may select 2 D plans, 2 DHMO plans or 1 DHMO and 1 D plan. (Please see Small Business Group Dental and Vision buy-up guidelines on page 39 to determine if the group qualifies for dual option.) Voluntary D plans without orthodontia are available to groups with a minimum of 2 enrolled. Voluntary D plans with orthodontia are available to groups of 10 or more enrolled employees. Essential Essential In-network Out-of-network 4 In-network Out-of-network 4 $1,000 $1,500 $50 single / $150 family $75 single / $225 family $50 single / $150 family $75 single / $225 family 100% deductible waived 100% deductible waived 80% after deductible 80% after deductible 80% after deductible 80% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible Essential 2 Not covered Essential 6 Not covered Limitations Initial / routine oral exam Teeth cleaning Fluoride treatment Sealants Emergency treatment 2 per consecutive 12 months 2 per consecutive 12 months (additional services available for pregnant members) 2 per consecutive 12 months, children under 16 years only 1 per 36 months, children under 16 years on permanent molars only For relief of pain only Health Net Dental plans may be purchased on a standalone basis or in conjunction with a Health Net medical plan. This is only a summary of benefits. Please refer to the Certificate of Insurance for terms and conditions of coverage, including which services are limited or excluded from coverage. Footnotes found at the end of this section. 29

32 Vision Plans with a Clear Advantage Providers can be found by calling Health Net Vision Member Services toll-free number at Or visit us online at Pediatric vision coverage (ages newborn through 18) is automatically included on all plans. We also offer adult Health Net Vision insurance plans (ages 19 and older) which provide the convenience of a large national network, our hasslefree implementation, administrative processing, and: A diverse network of independent and retail providers, including LensCrafters. Low copayments. Employees and dependents can see any provider they choose, either in-network or out-of-network, and be covered under the plan. Discounts of 5 15% on LASIK and PRK from U.S. Laser Network. 5 The only difference between the full service plans, Preferred and , is the replacement of lenses, contact lenses or frames either every 12 or 24 months, respectively. In addition, Health Net offers the Preferred Value 10-2 plan, which covers materials only. Schedule of benefits and coverage Vision exam copayment Lens copayment Frequency Exam Eyeglass or contact lenses Frames Retail frame allowance (in-network) Contact lens allowance (in-network) Health Net Vision plan benefits Vision exam (Preferred and Preferred plans only) Exam (with dilation as necessary) Standard contact lens fit and follow-up exam Standard plastic lenses Single vision Bifocal Trifocal Standard progressive (add-on to bifocal) Premium progressive (add-on to bifocal) Lens options (in-network only) UV coating Tint (solid and gradient) Standard scratch-resistant Standard polycarbonate Standard anti-reflective Other add-ons and services Frames (any frame available at a provider location) Contact lenses (materials only) Medically necessary Conventional Disposable Laser vision correction (in-network only) LASIK or PRK from U.S. Laser Network Secondary purchase plan (in-network only) Discounts on eyewear purchases after initial benefits 30 Footnotes found at the end of this section.

33 Preferred Plan Preferred Plan Preferred Value Plan 10-2 $10 $10 Not covered $25 $25 $10 Every 12 months Every 12 months Not covered Every 12 months Every 24 months Every 12 months Every 24 months Every 24 months Every 24 months $100 $100 $100 $90 $90 $90 In-network (member cost) Out-of-network (maximum benefit allowed) $0 after copay Up to $40 Up to $55 Not covered $0 after copay Up to $40 $0 after copay Up to $60 $0 after copay Up to $80 $65 copay (in addition to lens copay) $60 $65 copay (in addition to lens copay), plus $60 80% of retail charge less $120 allowance $15 copay Not covered $15 copay Not covered $15 copay Not covered $40 copay Not covered $45 copay Not covered 20% discount Not covered Up to plan allowance, plus 20% discount Up to $45 off balance over allowance $0 Up to $210 Up to plan allowance, plus 15% discount Up to $105 off balance over allowance Up to plan allowance, plus balance Up to $105 over allowance 15% off retail price or 5% off Not covered promotional price 40% off retail Not covered Employees and dependents will receive a 20 percent discount on remaining balance beyond plan coverage at participating providers, which may not be combined with any other discounts or promotional offers, and the discount does not apply to provider s professional services or to contact lenses. Retail prices vary by location. Discounts do not apply for benefits provided by other group benefit plans. Allowances are one-time-use benefits; no remaining balance. Lost or broken materials are not covered. This is only a summary of benefits. Please refer to the Certificate of Insurance or Evidence of Coverage for terms and conditions of coverage, including which services are limited or excluded from coverage. 31

34 Chiropractic Care That Won t Put You in a Pinch You may choose to add chiropractic care to your HSP, EPO or HMO medical plans. We work with American Specialty Health Plan of California, Inc. 6 (ASH Plans) to offer this additional coverage that more employees are seeking. Ultimately, this type of care often adds to increased employee satisfaction and retention. Acupuncture care is a covered benefit on all medical plans. Chiropractic Office visits $10 There is a $50 annual chiropractic appliance allowance toward the purchase of medically necessary items such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts, and home traction units. Services or supplies excluded under the chiropractic care program may be covered under the medical benefits portion of the plan. Consult the plan s Evidence of Coverage for more information. Other covered services Medically necessary laboratory tests 32

35 Plan for the Unexpected For many small businesses, an attractive employee benefits package includes Group Term Life and Accidental Death & Dismemberment (AD&D) insurance offering desirable benefit levels. This allows a small business employer to: Increase the attractiveness of the company s benefit package to employees. Offer employees life insurance benefits at economical rates. One way you can enhance your benefits package and minimize administrative costs is to consolidate health and life insurance carriers. Carrier consolidation eliminates unnecessary administrative costs related to managing an employee benefits package. Health Net Life Insurance Company underwrites Group Term Life Benefit Insurance, Accidental Death & Dismemberment and Dependent Life Insurance. Group Term Life Insurance Life options For new business effective January 1, 2014, Health Net no longer offers dependent Life as a coverage option, and we have simplified our Life offerings. Option A $15,000 flat amount for all employees. Option B $25,000 flat amount for all employees (15 50 employees). Option C $50,000 flat amount for all employees (25 50 employees). Group Life plan features Waiver of premium provision A life benefit can be extended during a period of total disability under terms specified in the group Certificate of Insurance. Accelerated death benefit Provides financial protection to the insured in time of need, while also protecting the interest of the beneficiary. The accelerated benefit is a portion of the basic life insurance amount and is payable in a lump sum. Conversion privilege A conversion privilege to whole life insurance is available to certain individuals whose coverage terminates due to reasons specified in the group policy. Accidental Death & Dismemberment (AD&D) These benefits are usually included as part of the group life insurance policy. Health Net Life Insurance Company does not offer Accidental Death & Dismemberment benefits on a standalone basis. Benefit is payable as a result of an accident, loss of life or any of the physical losses specified in the group policy. The maximum benefit amount is equal to the basic life amount shown in the policy. This maximum benefit amount is payable for loss of life. It can also be payable for the loss of sight in both eyes, loss of both hands or both feet, or any two or more of these physical losses in the same accident. One-half of the maximum benefit amount is payable for loss of one hand, loss of one foot or the loss of sight in one eye. 33

36 Rate Guide Dental rating regions by area These are the rating regions by ZIP codes for the plans. Note: Health Net Dental HMO plans are not available in Alpine, Amador, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, San Benito, Sierra, Siskiyou, Tehama, Trinity, Tuolumne, and Yuba counties. rating area by ZIP codes Area 1 contains the ZIP codes starting with and Area 2 contains the ZIP codes starting with Area 3 contains the ZIP codes starting with 931, and Area 4 contains the ZIP codes starting with and Area 5 contains the ZIP codes starting with 934, 939 and Area 6 contains the ZIP codes starting with 942. Area 7 contains the ZIP codes starting with Area 8 contains the ZIP codes starting with Note: Area is determined by the employer s home-office ZIP code. Rates apply to new dental groups with effective dates between September 1, 2015, and November 1, Russell C. Whitney, Health Net We work quickly to resolve issues. 34

37 Dental HMO Employer-paid group plan Plus DHMO 150-S (Plan code TW) Plus DHMO 225-S (Plan code TX) Voluntary group plan Plus DHMO 150 (V)-S (Plan code U1) Plus DHMO 225 (V)-S (Plan code U2) Specialty referral Minimum enrolled Minimum participation Employee Employee and spouse/ domestic partner Employee and child(ren) Family Yes 2 50% $17.02 $32.34 $34.02 $48.49 Yes 2 50% $14.57 $27.69 $29.15 $41.53 Yes 2 Less than 50% $17.95 $34.09 $35.87 $51.15 Yes 2 Less than 50% $15.12 $28.73 $30.23 $43.10 Voluntary DHMO rates apply to groups with less than 50% participation, less than 50% contribution or who do not have proof of prior group coverage. Dental Plan benefit details Plan code Plan name Deductible Coinsurance (preventive / general / major services) In-network Employer Voluntary In-network Out-ofnetwork TV U0 Classic with ortho Out-ofnetwork Calendar year maximum $50 / $150 $75 / $ / 80 / 50% 80 / 80 / 50% $1,500 $1,500 Orthodontia lifetime maximum TT TY Essential $50 / $150 $75 / $ / 80 / 50% 100 / 80 / 50% $1,000 Not covered TU TZ Essential $50 / $150 $75 / $ / 80 / 50% 100 / 80 / 50% $1,500 Not covered Voluntary D rates apply to groups with less than 75% participation, less than 50% contribution or who do not have proof of prior group coverage. D orthodontia is available as follows: For employer-paid groups of 10 or more enrolled employees OR for groups of 2 9 enrolled employees with proof of immediately prior indemnity orthodontic coverage. For voluntary groups of 10 or more enrolled employees. 35

38 Rate Guide Employer-paid dental D plans Area 1 Area 2 Area 3 Area 4 Plan code TV Classic with ortho Employee $61.36 $58.50 $62.28 $48.27 Employee and spouse/domestic partner $ $ $ $96.54 Employee and child(ren) $ $ $ $99.37 Family $ $ $ $ Plan code TT Essential Employee $38.80 $38.67 $33.18 $34.34 Employee and spouse/domestic partner $77.60 $77.34 $66.35 $68.69 Employee and child(ren) $74.72 $74.49 $64.15 $66.36 Family $ $ $ $ Plan code TU Essential Employee $44.68 $44.28 $39.02 $37.73 Employee and spouse/domestic partner $89.35 $88.56 $78.03 $75.45 Employee and child(ren) $85.76 $85.02 $75.11 $72.71 Family $ $ $ $ Employer-paid dental D plans Area 5 Area 6 Area 7 Area 8 Plan code TV Classic with ortho Employee $59.22 $56.62 $63.82 $52.87 Employee and spouse/domestic partner $ $ $ $ Employee and child(ren) $ $ $ $ Family $ $ $ $ Plan code TT Essential Employee $35.00 $28.57 $33.60 $32.86 Employee and spouse/domestic partner $69.99 $57.14 $67.20 $65.72 Employee and child(ren) $67.57 $55.47 $64.95 $63.57 Family $ $87.63 $ $ Plan code TU Essential Employee $40.10 $31.91 $39.68 $36.44 Employee and spouse/domestic partner $80.21 $63.81 $79.37 $72.89 Employee and child(ren) $77.17 $61.73 $76.37 $70.30 Family $ $97.61 $ $ The above rates are effective when the employer contributes 50% or more of the premium. Requires a minimum of 75% employee participation. Area is determined by group s home-office ZIP code. Details on dental rating areas found on page 34.

39 Voluntary dental D plans Area 1 Area 2 Area 3 Area 4 Plan code U0 Classic with ortho Employee $65.45 $62.38 $66.43 $51.44 Employee and spouse/domestic partner $ $ $ $ Employee and child(ren) $ $ $ $ Family $ $ $ $ Plan code TY Essential Employee $41.31 $41.17 $35.29 $36.54 Employee and spouse/domestic partner $82.62 $82.34 $70.58 $73.08 Employee and child(ren) $79.43 $79.18 $68.12 $70.48 Family $ $ $ $ Plan code TZ Essential Employee $47.60 $47.17 $41.54 $40.16 Employee and spouse/domestic partner $95.19 $94.34 $83.08 $80.32 Employee and child(ren) $91.24 $90.45 $79.85 $77.27 Family $ $ $ $ Voluntary dental D plans Area 5 Area 6 Area 7 Area 8 Plan code U0 Classic with ortho Employee $63.15 $60.38 $68.07 $56.36 Employee and spouse/domestic partner $ $ $ $ Employee and child(ren) $ $ $ $ Family $ $ $ $ Plan code TY Essential Employee $37.24 $30.36 $35.75 $34.95 Employee and spouse/domestic partner $74.47 $60.72 $71.49 $69.90 Employee and child(ren) $71.78 $58.83 $68.97 $67.49 Family $ $92.99 $ $ Plan code TZ Essential Employee $42.70 $33.93 $42.25 $38.79 Employee and spouse/domestic partner $85.40 $67.86 $84.51 $77.57 Employee and child(ren) $82.05 $65.53 $81.19 $74.70 Family $ $ $ $ Voluntary rates apply to those cases with less than 50% contribution, or less than 75% participation, or who do not have proof of prior group coverage. Area is determined by group s home-office ZIP code. 37

40 Rate Guide Vision Employer-paid Plan Exam Materials Employee and spouse / Employee and Employee copay copay domestic partner child(ren) Family Preferred Value N/A $10 $4.73 $8.99 $9.46 $14.19 (Plan code FO) Preferred $10 $25 $6.29 $11.96 $12.59 $18.88 (Plan code G0) Preferred $10 $25 $5.76 $10.93 $11.51 $17.27 (Plan code GI) Vision Voluntary Plan Preferred (Plan code GO) Preferred (Plan code H0) Chiropractic Paired network WholeCare Full Network WholeCare Salud SmartCare Exam copay Materials copay Employee Employee and spouse / domestic partner Basic Life and Accidental Death & Dismemberment Tier Employee and child(ren) Monthly rate per $1,000 coverage $ $ $ $ $ $ $ $ $ $ $ $ and over $29.24 Family $10 $25 $8.53 $16.20 $17.05 $25.58 $10 $25 $8.06 $15.31 $16.12 $24.18 Paired medical plan HMO Platinum Standard $1.90 Copay HMO Gold Standard Copay $1.90 HMO $10 $1.26 HMO $20 $1.25 HMO $30 $1.21 HMO $40 $1.20 Community Care HMO $30 $0.60 HMO $45 $0.54 PureCare One EPO Health Net Gold 80 Alternate $1.90 Health Net Silver 70 HSA EPO $1.90 Alternate PureCare HSP Silver Standard Coinsurance $1.90 Bronze Standard Coinsurance $1.90 Chiro rate per member, per month 38 Footnotes found at the end of this section.

41 Small Business Group Dental and Vision adult buy-up guidelines Group eligibility: 2 50 eligible employees with over 50% of the total group located in California, subject to out-of-area requirements below. Owner-only groups are not eligible. There must be a minimum of one W-2 employee who is not a spouse of the owner. Out-of-area requirements A maximum of 49% of the total eligible population may be out of California s service area, subject to the following rules. A maximum of 49% of the total enrolled population may be out of California s service area, subject to the following rules. Those employees who are out of the California service area may be written on a plan. Carve-outs are not available. Dental and/or Vision may be written on a standalone basis or in conjunction with Medical. Employee eligibility: Probationary period for new hires can be the first of the month following: date of hire, 1 month, 30 days, or 60 days. Note: The probationary period must match Medical. Eligible employees can be defined as employees working at least 20 or 30 hours per week. Note: The hours per week must match Medical employees are not eligible for coverage. With the exception of owners, all employees must be covered by workers compensation. Dependent eligibility: Although dependents under age 19 have access to pediatric dental benefits through their medical plan, they may also be enrolled in a dental buy-up plan to access enhanced benefits. Note: Cosmetic orthodontia is available through Plus DHMO 150 and 225, and D Classic 5 only. Enrollment details: Groups enrolling in Health Net s Medical with Dental and/ or Vision products or standalone Dental and/or Vision: Employee eligibility is based on the entire group. Minimum participation for the products must be met. Standard paperwork requirements must be met. Existing Health Net Medical groups adding a Dental and/or Vision product: If Dental and/or Vision enrollment is below Medical, paperwork will be required to verify participation on D and employer paid rates on DHMO and Vision. Rate information: 12-month rate guarantee for cases sold/renewed in conjunction with Medical. Cases sold off-cycle from Medical will have their first renewal in conjunction with Medical. Submission: All cases requesting coverage on the 1st of the month must be submitted by the 5th of the month for which coverage is to be effective. Mid-month effective dates are not allowed. Vision details: A minimum participation of 75% of the eligible employees is required for employer paid rates. Note: Unlike Medical, waiving for other coverage will count against participation. A minimum employer contribution of 50% of the employee premium is required for employer paid rates. Voluntary rates apply to those cases with less than 75% participation and/or 50% contribution. A minimum of 2 active subscribers is required. Dual Choice Vision is not available. DHMO details: A minimum participation of 50% of the eligible employees is required for employer paid rates. Note: Employees waiving coverage due to group coverage through another employer (i.e., spousal coverage) will not count against participation. A minimum employer contribution of 50% of the employee premium is required for employer paid rates. Proof of prior group coverage is required for employer paid rates. Voluntary rates apply to those cases with less than 50% participation, less than 50% contribution, or that do not have proof of prior coverage. A minimum of 2 active subscribers is required. Orthodontia is available in all DHMO plans. D details: A minimum participation of 75% of the eligible employees is required for employer paid rates. Note: Employees waiving coverage due to group coverage through another employer (i.e., spousal coverage) will not count against participation. A minimum employer contribution of 50% of the employee premium is required for employer paid rates. Proof of prior group coverage is required for employer paid rates. Voluntary rates apply to those cases with less than 50% contribution, or less than 75% participation, or who do not have proof of prior group coverage. Plans without orthodontia require a minimum of 2 active subscribers for both employer paid and voluntary. Orthodontia is available for employer paid D groups of 10 or more active subscribers or for groups of 2 9 enrollees with proof of immediately prior indemnity orthodontic coverage. Orthodontia is available for voluntary D groups of 10 or more active subscribers. Dual Choice dental: Employer paid rates: A minimum participation of 75% is required. A minimum of 50% contribution is required. Proof of immediately prior group dental coverage is required. Voluntary rates: A minimum participation of 75% is required. No minimum contribution is required. No prior group dental coverage is required. Groups may select 1 DHMO and 1 D with a minimum of 4 active subscribers and 2 on each plan. Groups may select 2 DHMO or 2 D plans with a minimum of 10 active subscribers, with a minimum of 2 on a given plan. Please see D details section to determine eligibility for D plans with orthodontia and/or implant coverage. 39

42 Small Business Group Life underwriting guidelines Coverage requiring EOIs will not become effective until approved in writing by Health Net Life. Some SIC classifications are excluded. Eligibility: 2 50 eligible employees with over 50% of the total group located in California, subject to out-of-area requirements below. Owner-only groups are not eligible. There must be a minimum of one W-2 employee who is not a spouse of the owner or partner. Out-of-area requirements: A maximum of 49% of the group s eligible population may be out of California s service area, subject to the following rules. A maximum of 49% of the group s enrolled population may be out of California s service area, subject to the following rules. Probationary period for new hires can be the first of the month following date of hire, 1 month, 30 days, or 60 days. Note: The probationary period must match Medical. Flat benefit schedules only. Contribution and participation requirements vary by group size. Note: Unlike Medical, waiving for other coverage will count against participation. Carve-outs are not available. Employees must meet the actively-at-work requirement in order to be eligible. Additionally, they must be working full-time at the employer s regular place of business at least 20 hours per week to be eligible. Note: The number of hours must coincide with Health Net medical eligibility guidelines. Retirees, COBRA enrollees, part-time employees, seasonal employees, and 1099s are not eligible for coverage. Medical evidence of insurability: EOIs are necessary: If coverage is applied for later than 31 days after the date of eligibility. Subject to Underwriting Approval: Medical conditions reported on the EOI. Footnotes Submission: All cases requesting coverage on the 1st of the month must be submitted by the 5th of the month for which coverage is to be effective. For medical groups that are effective on the 15th of the month, Life coverage will be effective on the 1st of the month prior to the start of medical coverage. For example, for medical groups that are effective on 1/15/2016, Life coverage will be effective on 1/1/2016. Groups of 2 9 eligible employees: Standalone Life is not available. Life benefit of $15,000. Employer contribution and participation must be 100%. No more than 25% of employees may be 60 or older. Groups of eligible employees: Standalone Life is available. Life benefit of $15,000. Minimum of 50% employer contribution. Minimum participation: 75% if contributory. 100% if non-contributory. Groups of eligible employees: Standalone Life is available. Life benefit of $15,000 or $25,000. Minimum of 50% employer contribution. Minimum participation: 75% if contributory. 100% if non-contributory. Groups of eligible employees: Standalone Life is available. Life benefit of $15,000, $25,000 or $50,000. Minimum of 50% employer contribution. Minimum participation: 75% if contributory. 100% if non-contributory. 1 Usual, Customary and Reasonable (UCR) is the maximum allowable amount for a dental care service, determined by FAIR Health, Inc. on the basis of the fee usually charged by the provider and data obtained by FAIR Health, Inc. regarding fees charged by providers of similar training and experience for the same service within the same geographic area. 2 Out-of-network benefits for Classic plans are reimbursed at the Usual, Customary and Reasonable (UCR) amounts as determined by FAIR Health, Inc. 3 For employer-paid D plans, orthodontia is available for groups with 2 9 enrollees with proof of immediately prior indemnity orthodontia coverage or for groups of 10 or more enrollees. For voluntary D plans, orthodontia is available for groups of 10 or more enrolled employees. 4 Out-of-network benefits for Essential plans are based on the allowable amount applicable for the same service that would have been rendered by a network provider. 5 Members receive a 15% discount off the retail price or 5% off the promotional price of LASIK or PRK laser vision correction procedures. LASIK and PRK correction procedures are provided by U.S. Laser Network, owned by LCA-Vision. Members must first call LASER6 for the nearest facility and to receive authorization for the discount. 6 Chiropractic care is offered by Health Net of California, Inc. for HMO plans, administered by American Specialty Health Plans of California, Inc., a subsidiary of American Specialty Health Incorporated (ASH). 7 Preferred Value Vision Plan may not be offered on a voluntary basis. 8 Basic Life and Accidental Death & Dismemberment are sold together. Both rates apply. Health Net Dental HMO plans are provided by Dental Benefit Providers of California, Inc. (DBP). Health Net Dental and indemnity plans are underwritten by Unimerica Life Insurance Company. Obligations of DBP and Unimerica Life Insurance Company are not the obligations of or guaranteed by Health Net, Inc. or its affiliates. Health Net Vision plans are underwritten by Fidelity Security Life Insurance Company and serviced by EyeMed Vision Care, LLC (together, the Fidelity Entities ). Discounts on vision care services and products are made available by EyeMed. The Fidelity Entities are not affiliated with Health Net of California, Inc. or Health Net Life Insurance Company (together, the Health Net Entities ). Obligations of the Fidelity Entities are not the obligations of or guaranteed by the Health Net Entities. 40

43 More Than an ID Card Account management , option 2, then option 1 (for Los Angeles and Orange County), or option 2 (for all other counties). 41

44 Health Net Member Extras At Health Net, we re about more than just health care coverage. Sure, comprehensive benefits are essential, but so is making it easy for people to get the most from their health plan. Decision Power : Health & Wellness Decision Power is an integrated program created to engage people in their health. With personalized tools and achievable goals, employees can feel confident in their ability to make positive and lasting behavioral changes. Through Decision Power, we deliver a personalized and accessible approach to wellness. Here are just a few of the ways we help employees achieve improved wellness: Get help with a specific health goal. Learn about treatment options. Try an online improvement program. Assess health risks with the Health Risk Questionnaire. Track diet, exercise or cholesterol. Better manage chronic illness. Focus on early access and prevention Here at Health Net, we don t wait until people get sick to help out. Our job, always, is to connect your clients employees with the care they need We want them to use their benefits! That s why we re doing outreach phone calls, mailings and more to encourage our members to get their annual wellness exam. It costs $0 out-of-pocket, and it s the best way for people to know their health status. It s also the most effective way for Health Net to know how best to meet their health needs. From there, we can connect people to the care and resources to help them be their healthiest. Our resources span the full spectrum of health from timesaving conveniences to in-depth support, such as: Easy access CVS MinuteClinics a benefit with all HMOs to make it easy to get care for common illnesses, minor injuries (like a sprain) and vaccines. Nurse24 SM for around-the-clock advice. Disease management for people living with ongoing health challenges like diabetes, asthma, COPD, heart disease, and heart failure. Our outreach efforts elevate the core Decision Power priority to help reduce highcost service utilization and support workplace productivity by connecting employees with information, resources and support. Boosting health through prevention and early access to care is another way we re doing just that. Health Net online and on the go Self-service at HealthNet.com guides your clients and their employees to the information they need with intuitive navigation and useful links. Bookmark for fast and easy access to benefit information, wellness programs, ID cards, and more! It s also the place to find network doctors, hospitals and other services. ProviderSearch at HealthNet.com delivers results by location, specialty or office hours. Plus, users can print or download search results. On the go with Health Net Mobile Keeping track of the details even critical details like health care information can be daunting with today s jam-packed lives. That s why we created the Health Net Mobile app. All it takes is an iphone, Android or other web-enabled smartphone, and Health Net members have everything they need to track their health plan details no matter where or how busy they are. 42

45 Group Administration Account management , option 2, then option 1 (for Los Angeles and Orange County), or option 2 (for all other counties). 43

46 Group Administration This quick reference section provides tips for applications, handling group changes and using our convenient online billing and enrollment tools. Turn to the appendix for samples of the following forms: Group Service Agreement Application Medical Plan Change Request Form Application tips We ve included a handy submission checklist at the back of the Small Business Application for Group Service Agreement/Group Policy. Use the checklist to cross-check group applications to speed up application processing. For group employee applications, group administrators will want to confirm that the following items are complete: Date of hire Date of birth Signatures Employees accepting coverage must sign the acceptance section. Employees declining coverage must sign the declination section. Handling group changes Adding employees or dependents Groups can add employees at the following times: New hire (after meeting the company s probationary period) Applications must be received within 30 days of member effective date. Example: The probationary period is the first of the month following date of hire. An employee hired January 15 would have a February 1 effective date. Open Enrollment During the annual renewal period, groups can enroll employees and dependents who had previously declined coverage. Outside of Open Enrollment, dependents can only be added if there is a qualifying event, which includes, but is not limited to: Birth Marriage Court order Adoption Loss of coverage All applications for adding new employees and dependents due to a qualifying event must be signed by the subscriber and received by Health Net within 60 days of the event. 44

47 Billing contacts Our Membership Accounting is available to answer any billing or eligibility questions. The number is , option 3, or you can send a fax to (916) California laws and regulations require us to provide notice of the consequences for nonpayment of premium with an explanation of the applicable grace period. We will be including the required notice with each of our monthly bills. Please note that if you have paid timely in the past and have not received a risk of termination notice for nonpayment of premium, this notice will likely not impact your current payment practices. If you intend to cancel or change insurance coverages, Health Net must receive notice on or before the first of the month prior to the effective date of the replacement coverage. Failure to do so may result in continued billing and additional premiums owed. 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 1 after the effective date of the cancellation. Premium credit cannot be issued for more than 30 days 1 retroactively. 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 30 days after what should have been the last day of coverage, Health Net will require that you pay subscription charges/premiums for the affected member up to the time that you provided us with proper notification. 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. How is employee coverage cancelled? The group administrator may indicate the cancellation and effective date on the Current Membership and Membership Changes pages of their monthly billing statement (membership invoice) or process the change through the Online Billing and Enrollment tool at You may also send written notification of the cancellation on the group s letterhead and mail it to Health Net at: PO Box 9103 Van Nuys, CA Or faxed to (916) Any written request from a group or broker will be accepted. 1Permitted days are subject to contract agreement. 45

48 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 Dependent change option should be indicated below Reason for Change. A completed, signed and dated Enrollment and Change Form must be submitted for each subscriber who is canceling a dependent s coverage. Online billing and enrollment Convenience and control 24/7 Health Net makes it easy for you to simplify health plan administration with Online Billing and Enrollment, our free, user-friendly web portal for enrolled employer groups. Visit our website at With Online Billing and Enrollment, groups can: View and print billing statements. Retain up to 18 months of billing and payment history for easy access. Track and update eligibility. View, add and update enrollment information anytime. Utilize convenient reporting features. The Roster Report lists all active employees and their dependents, the plans they re enrolled in and effective dates. The Daily Transaction Report lists all the daily transactions the group administrator has processed online. Both reports are easily downloaded into spreadsheet format. Online Billing and Enrollment is fully integrated to work with the rest of Health Net s systems, so the updates that you make will always be reflected online. Mark Rivera, Health Net We deliver the right coverage at the right price. 46

49 Appendix/Forms Account management , option 2, then option 1 (for Los Angeles and Orange County), or option 2 (for all other counties). 47