Also see: Medical Insurance Kaiser HealthNet HMO  
 

Description Health Net PPO is a preferred provider organization. A PPO is a medical plan that offers you a choice between an in-network group of providers who offer their services at discounted rates and out-of-network providers without discounted rates. With this PPO, you may choose the level of benefits you receive based on the providers you use when you receive care.  How the Plan Works With Health Net PPO, you may obtain care from an in-network or out-of-network provider. It’s your choice. However, when you receive your medical care from in-network, or “PPO providers,” the plan pays 80% of most covered expenses. Some covered expenses are paid only after you have paid the deductible. If you use out-of-network providers, benefits will be 70% of Usual, Customary, and Reasonable (UCR) fees for the area. You will pay 30% of UCR and all charges above UCR. With out-of-network providers, the plan cannot guarantee that your chosen provider will charge UCR fees common to the area, so your out-of-pocket costs could exceed 30%. Deductibles You pay a calendar year deductible of $250 per individual or $750 per family before the plan pays for certain services obtained from an in-network (“participating”) or out-of-network (“nonparticipating”) provider. Hospitalization To avoid a $250 pre-certification deductible, your provider must contact Health Net in advance of hospitalization. While many physicians will arrange pre-certification on behalf of their patients, you are advised to call Health Net at 1-800-676-6976. Emergency Care If you need emergency services, get help immediately. If you are admitted to a hospital, you or your physician must call Health Net at 1-800- 676-6976 as soon as possible. Out-of-State Providers Health Net PPO has created a program which allows Covered Persons access to participating providers outside their state of residence. This program is through the out-of-state provider network shown on your HNL ID Card and is limited to Covered Persons traveling outside their state of residence for a period not exceeding six months. The program is not intended for Covered Persons traveling outside their state of residence solely to receive medical care. If you are traveling outside your state of residence, require medical care or treatment, and use a provider from the out-of-state provider network, your out-of-pocket expenses may be lower than those incurred when you use an Out-of-Network Provider. When you obtain services outside your state of residence through the out-of-state provider network, you will be subject to the same co-payments, coinsurances, deductibles, maximums and limitations as you would be if you obtained services from a Preferred Provider in your state of residence. There is the following exception: covered expenses will be calculated based on the lower of (i) the actual billed charges or (ii) the charge that the out-of-state provider network is allowed to charge, based on the contract between HNL and the network. In a small number of states, local statutes may dictate a different basis for calculating your covered expenses. How to Enroll New employees must complete a Medical Plan Enrollment/Change form within the first 31 days of hire into an eligible position, and return it to their payroll clerk. Please refer to the Eligibility, Enrollment, and Mid-Year Changes sections of this guide for specific details. Call Health Net Member Services if you:  Have a benefits question  Need hospital pre-certification  Need a provider directory  Need a member identification (ID) card  Have an eligibility question  Have a claims question  What’s Covered While covered under the PPO, you can take advantage of comprehensive medical benefits. The plan pays benefits for covered expenses you incur while covered under the plan, subject to the maximum benefit amounts. Please refer to the Medical Plans Comparison Chart in the Employee Benefits Guide for key covered expenses. What’s Not Covered No payment will be made under this EOC for expenses incurred for or in connection with any of the items below, regardless as to whether you utilized the services of a Preferred Provider or an Out-of-Network Provider. Also, services or supplies that are excluded from coverage in the EOC exceed EOC limitations, or are follow-up care (or related to follow-up care) to EOC exclusions or limitations will not be covered. The listing below is not all inclusive, you must refer to your EOC or contact Health Net PPO for a complete listing of all limitations and exclusions.  Excess Charges  Amounts charged by Out-of-Network Providers for covered medical services and treatment which HNL determines to be in excess of Covered Expense, as defined in the “Definitions” section of the EOC. Clinical Trials  Although clinical trials are covered, as described in the “Medical Benefits” portion of the “Plan Benefits” section of this EOC, coverage for clinical trials does not include the following items:  Drugs or devices that are not approved by the FDA;  Services other than health care services, including but not limited to cost of travel, or costs of other non-clinical expenses;  Services provided to satisfy data collection and analysis needs which are not used for clinical management;  Health care services that are specifically excluded from coverage under this EOC; and  Items and services provided free of charge by the research sponsors to Covered Persons in the trial.   Cosmetic Services and Supplies Cosmetic surgery or services and supplies performed to alter or reshape normal structures of the body solely to improve the physical appearance of a Covered Person are not covered. However, the EOC does cover Medically Necessary services and supplies for complications which exceed routine follow-up care that is directly related to cosmetic surgery (such as life-threatening complications). In addition, hair transplantation, hair analysis, hairpieces and wigs, chemical face peels, abrasive procedures of the skin, liposuction or epilation are not covered. However, reconstructive surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or diseases is covered. Breast reconstruction surgery is subject to the Certification requirements described in the “Certification Requirement” portion of the “Plan Benefits” section of the EOC. However, hospital stays related to mastectomies and lymph node dissections will be determined solely by the Physician and Certification for determining the length of stay will not be required. The coverage described above in relation to a Medically Necessary mastectomy complies with requirements under the Women’s Health and Cancer Rights Act of 1998. Contraceptives Vaginal, oral and emergency contraceptives are covered as described in the  “Outpatient Prescription Drug Benefits” portion of the “Plan Benefits” section of this EOC. Vaginal contraceptives include diaphragms and cervical caps, and are only covered when a Physician performs a fitting examination and prescribes the device. Such devices are only available through a prescription from a pharmacy and limited to one fitting and prescription per Calendar Year unless additional fittings or devices are Medically Necessary. Injectable contraceptives (when administered by a Physician) and intrauterine devices (IUDs) are covered as a medical benefit. If Your Physician determines that none of the methods specified as covered by the Plan are medically appropriate, then the Plan will provide coverage for another FDA-approved prescription or contraceptive method as prescribed by Your Physician. Dental Services Dental services are limited to the services stated in “Dental Injury” under the “Plan Benefits” section of the EOC and in the following situation: General anesthesia and associated facility services are covered when the clinical status or underlying medical condition of the Covered Person requires that an ordinarily non-covered dental service which would normally be treated in a dentist’s office and without general anesthesia must instead be treated in a Hospital or Outpatient Surgical Center. The general anesthesia and associated facility services must be Medically Necessary, subject to the other limitations and exclusions of the EOC and will only be covered under the following circumstances (a) Covered Persons who are under seven years of age or (b) Covered Persons who are developmentally disabled or (c) Covered Persons whose health is compromised and general anesthesia is Medically Necessary. Care or treatment of teeth and supporting structures; extraction of teeth; treatment of dental abscess or granuloma; dental examinations and treatment of gingival tissues other than tumors are not covered, except as stated above. Spot grinding, restorative or mechanical devices, orthodontics, inlays or onlays, crowns, bridgework, active splints or orthotics (whether custom fit or not), dental implants (materials implanted into or on bone or soft tissue), or other dental appliances, and related surgeries to treat dental conditions are not covered regardless of reason for such services. Temporomandibular (Jaw) Joint Disorders Temporomandibular Joint Disorder (also known as TMD or TMJ disorder) is a condition of the jaw joint which commonly causes headaches, tenderness of the jaw muscles, tinnitus or dull aching facial pain. These symptoms often result when chewing muscles and jaw joints do not work together correctly. Custom-made oral appliances (intraoral splint or occlusal splint) and surgical procedures to correct a TMD/TMJ disorder are covered when determined to be Medically Necessary. However, spot grinding, restorative or mechanical devices, orthodontics, inlays or onlays, crowns, bridgework, dental splints, dental implants and other dental appliances to treat dental conditions related to TMD/TMJ disorders are not covered. Surgery and Related Services for Disorders of the Jaw (often referred to as “Orthognathic Surgery” or “Maxillary and Mandibular Osteotomy”) Used for the purpose of correcting the malposition or improper development of the bones of the upper or lower jaw, except when such procedures are Medically Necessary. However, spot grinding, restorative or mechanical devices, orthodontics, inlays or onlays, crowns, bridgework, dental splints (whether custom fit or not), dental implants and other dental appliances are not covered under any circumstances. Dietary or Nutritional Supplements Dietary, nutritional supplements and specialized formulas are not covered except when prescribed for the treatment of Phenylketonuria (PKU) (see the “Phenylketonuria (PKU) provision in the “Plan Benefits” section). Refractive Eye Surgery Any eye surgery for the purpose of correcting refractive defects of the eye, such as a near-sightedness (myopia), far-sightedness (hyperopia) and astigmatism, unless Medically Necessary, recommended by the Covered Person’s treating Physician and authorized by Us.  Sex Change Any procedure or treatment designed to alter physical characteristics of the Covered Person to those of the opposite sex, and any other treatment or studies related to sex transformations. Reconstruction of Prior Surgical Sterilization Procedures Services to reverse voluntary surgically induced infertility. Conception by Medical Procedures Services or supplies that are intended to impregnate a woman are not covered. Excluded procedures include but are not limited to: In-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), artificial insemination, zygote intrafallopian transfer (ZIFT) or any other process that involves the harvesting, transplanting or manipulating of a human ovum. Also not covered are services or supplies, (including injections and injectable medications) which prepare the Covered person to receive these services. Experimental or Investigational Procedures Experimental or Investigational drugs, devices, procedures or other therapies are only when: Independent review deems them appropriate as described in the “Independent Medical Review of Investigational or Experimental Therapies” portion of the “General Provisions” section of the EOC, or Clinical trials for cancer patients are deemed appropriate according to the “Medical Benefits” portion of the “Plan Benefits” section. Inpatient Diagnostic Tests Inpatient room and board charges incurred in connection with an admission to a Hospital for diagnostic tests which could have been performed safely on an outpatient basis. Chemical Dependency Treatment of chronic alcoholism, drug addiction and other Chemical Dependency problems, including detoxification services are not covered, except as specifically stated in the “Plan Benefits” section of the EOC. Mental Disorders Care as a condition of parole or probation and court ordered testing is not covered under this EOC.  Noncovered items Any expenses related to the following items, whether authorized by a physician or not.  Air purifiers, air conditioners and humidifiers  Hearing Aids  Food Supplements  Support appliances and supplies such as stockings, arch supports  Disposable supplies for home use  Hygienic equipment , Jacuzzis and spas  Personal or comfort items  Worker Compensation If you require services for which benefits are in whole or in part either payable or required to be provided under any Worker Compensation or Occupational Disease Law, HNL will not provide covered benefits. You are entitled and will pursue recovery from the Worker Compensation carrier liable for the cost of medical treatment related to your illness or injury.  Expenses before Coverage Begins Services received before the covered Person’s effective date.    How to Get in Touch with Health Net PPO  Call Health Net’s Member Services at 1-800-676-6976 or go to the Health Net web site at www.healthnet.com for more information.