Transcription
CA Seniority Plus (Employer HMO) PlanEvidence of Coverage and Plan DocumentEffective January 1, 2014Contracted by the CalPERS Board of AdministrationUnder the Public Employees’ Medical & Hospital Care Act (PEMHCA)
EOC ID: 429567
Evidence of Coverage:Your Medicare Health Benefits and Services and Prescription Drug Coverageas a Member of Health Net Seniority Plus (Employer HMO)This booklet gives you the details about your Medicare health care and prescription drugcoverage for your 2014 benefit period. It explains how to get coverage for the health careservices and prescription drugs you need. This is an important legal document. Please keep itin a safe place.This plan, Health Net Seniority Plus (Employer HMO), is offered by Health Net of California,Inc. (When this Evidence of Coverage says “we,” “us,” or “our,” it means Health Net ofCalifornia, Inc. When it says “plan” or “our plan,” it means Health Net Seniority Plus (EmployerHMO).)Health Net of California, Inc. is a Medicare Advantage organization with a Medicare contract tooffer this HMO plan.Member Services has free language interpreter services available for non-English speakers(phone numbers are printed on the back cover of this booklet).This information is also available in a different format, including large print, audio and in nonEnglish formats. Please call Member Services at the number printed on the back cover of thisbooklet if you need plan information in another format.Benefits, formulary, pharmacy network, premium, deductible, and/or copayments/coinsurancemay change for the 2015 plan year.EOC ID: 429567
Table of ContentsGETTING STARTED AS A MEMBER . 1IMPORTANT PHONE NUMBERS AND RESOURCES . 14USING THE PLAN’S COVERAGE FOR YOUR MEDICAL SERVICES . 31MEDICAL BENEFITS CHART (WHAT IS COVERED AND WHAT YOU PAY) . 44USING THE PLAN’S COVERAGE FOR YOUR PRESCRIPTION DRUGS. 103WHAT YOU PAY FOR YOUR PRESCRIPTION DRUGS . 120ASKING US TO PAY OUR SHARE OF A BILL YOU HAVE RECEIVED FORCOVERED MEDICAL SERVICES OR DRUGS . 142YOUR RIGHTS AND RESPONSIBILITIES . 148WHAT TO DO IF YOU HAVE A PROBLEM OR COMPLAINT (COVERAGEDECISIONS, APPEALS, COMPLAINTS) . 160ENDING YOUR MEMBERSHIP IN THE PLAN . 219LEGAL NOTICES . 229DEFINITIONS OF IMPORTANT WORDS. 240
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member1GETTING STARTED AS A MEMBERIntroductionYou are enrolled in Health Net Seniority Plus (Employer HMO), which is aMedicare HMOYou are covered by Medicare, and you have chosen to get your Medicare health care and yourprescription drug coverage through our plan, Health Net Seniority Plus (Employer HMO).There are different types of Medicare health plans. Health Net Seniority Plus (EmployerHMO) is a Medicare Advantage HMO Plan (HMO stands for Health MaintenanceOrganization). Like all Medicare health plans, this Medicare HMO is approved by Medicareand run by a private company.What is the Evidence of Coverage booklet about?This Evidence of Coverage booklet tells you how to get your Medicare medical care andprescription drugs covered through our plan. This booklet explains your rights andresponsibilities, what is covered, and what you pay as a member of the plan.This plan, Health Net Seniority Plus (Employer HMO), is offered by Health Net of California,Inc. (When this Evidence of Coverage says “we,” “us,” or “our,” it means Health Net ofCalifornia, Inc. When it says “plan” or “our plan,” it means Health Net Seniority Plus (EmployerHMO).)The words “coverage” and “covered services” refer to the medical care and services and theprescription drugs available to you as a member of Health Net Seniority Plus (EmployerHMO).What does this section tell you?Look through this section of your Evidence of Coverage to learn: What makes you eligible to be a plan member? What is your plan’s service area? What materials will you get from us? What is your plan premium and how can you pay it? How do you keep the information in your membership record up to date?
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member2What if you are new to our plan?If you are a new member, then it’s important for you to learn what the plan's rules are and whatservices are available to you. We encourage you to set aside some time to look through thisEvidence of Coverage booklet.If you are confused or concerned or just have a question, please contact our plan’s MemberServices (phone numbers are printed is on the back cover of this booklet).Legal information about the Evidence of CoverageIt’s part of our contract with youThis Evidence of Coverage is part of our contract with your employer or retiree group about howwe cover your care. Other parts of this contract include your enrollment form, the List ofCovered Drugs (Formulary), and any notices you receive from us about changes to yourcoverage or conditions that affect your coverage. These notices are sometimes called “riders” or“amendments.”The contract is in effect for months in which you are enrolled in Health Net Seniority Plus(Employer HMO).Each plan year, Medicare allows us to make changes to the plans that we offer. This means wecan change the costs and benefits of Health Net Seniority Plus (Employer HMO) at the end ofeach plan year. We can also choose to stop offering the plan, or to offer it in a different servicearea at the end of each plan year.Medicare must approve our plan each yearMedicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. Youcan continue to get Medicare coverage as a member of our plan as long as we choose to continueto offer the plan and Medicare renews its approval of the plan.What makes you eligible to be a plan member?Your eligibility requirementsYou are eligible for membership in our plan as long as: You live in our geographic service area (see the “Here is the plan service area for ourplan” portion below for the description of our service area) -- and -- you have both Medicare Part A -- and -- Medicare Part B
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member3 -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions,such as if you develop ESRD when you are already a member of a plan that we offer, oryou were a member of a different plan that was terminated -- and –you meet any additional eligibility requirements of your employer's or union'sbenefit administrator.Eligibility and EnrollmentInformation pertaining to eligibility, enrollment, termination of coverage, and conversion rightscan be obtained through the CalPERS website at www.calpers.ca.gov, or by calling CalPERS.Also, please refer to the CalPERS Health Program Guide for additional information abouteligibility. Your coverage begins on the date established by CalPERS.It is your responsibility to stay informed about your coverage. For an explanation of specificenrollment and eligibility criteria, please consult your Health Benefits Officer or, if you areretired, the CalPERS Health Account Services Section at:CalPERSHealth Account Services SectionP.O. Box 942714Sacramento, CA 94229-2714Or call:888 CalPERS (or 888-225-7377)(916) 795-3240 (TDD)Live/WorkIf you are an active employee or a working CalPERS retiree, you may enroll in a plan usingeither your residential or work ZIP Code. When you retire from a CalPERS employer and are nolonger working for any employer, you must select a health plan using your residential ZIP Code.If you use your residential ZIP Code, all enrolled dependents must reside in the health plan’sservice area. When you use your work ZIP Code, all enrolled dependents must receive allcovered services (except emergency and urgent care) within the health plan’s service area, evenif they do not reside in that area.If you currently pay a premium for Medicare Part A and/or Medicare Part B, you mustcontinue to pay your premium in order to keep your Medicare Part A and/or MedicarePart B and to remain a member of this plan.What are Medicare Part A and Medicare Part B?When you first signed up for Medicare, you received information about what services arecovered under Medicare Part A and Medicare Part B. Remember:
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member4 Medicare Part A generally helps cover services furnished by institutional providers suchas hospitals (for inpatient services), skilled nursing facilities or home health agencies. Medicare Part B is for most other medical services (such as physician’s services andother outpatient services) and certain items (such as durable medical equipment andsupplies).Here is the plan service area for our planAlthough Medicare is a Federal program, our plan is available only to individuals who live in ourplan service area. To remain a member of our plan, you must keep living in this service area. Theservice area is described below.Our service area includes these counties in California:Alameda CountyContra Costa CountyFresno CountyKern CountyLos Angeles CountyOrange CountyPlacer County, the following ZIP codes only: 95602, 95603, 95604, 95631, 95648, 95650,95658, 95661, 95663, 95677, 95678, 95681, 95701, 95703, 95713, 95714, 95715, 95717, 95722,95736, 95746, 95747, 95765Riverside CountySacramento CountySan Bernardino CountySan Diego CountySan Francisco CountySan Joaquin CountySan Mateo CountySanta Barbara, the following ZIP codes only: 93013, 93014, 93067, 93101, 93102, 93103,93105, 93106, 93107, 93108, 93109, 93110, 93111, 93116, 93117, 93118, 93120, 93121, 93130,93140, 93150, 93160, 93190, 93199, 93252, 93427, 93436, 93437, 93438, 93440, 93441, 93460,93463, 93464.
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member5Santa Clara CountySanta Cruz CountySolano CountySonoma CountyStanislaus CountyYolo CountyIf you plan to move out of the service area, please contact Member Services (phone numbers areprinted on the back cover of this booklet). When you move, you will have a Special EnrollmentPeriod that will allow you to switch to Original Medicare or enroll in a Medicare health or drugplan that is available in your new location.It is also important that you call Social Security if you move or change your mailing address.You can find phone numbers and contact information for Social Security in the “Important phonenumbers and resources” section of this booklet.What other materials will you get from us?Your plan membership card – Use it to get all covered care and prescriptiondrugsWhile you are a member of our plan, you must use your membership card for our plan wheneveryou get any services covered by this plan and for prescription drugs you get at networkpharmacies. Here’s a sample membership card to show you what yours will look like:As long as you are a member of our plan, you must not use your red, white, and blueMedicare card to get covered medical services (with the exception of routine clinical research
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member6studies and hospice services). Keep your red, white, and blue Medicare card in a safe place incase you need it later.Here’s why this is so important: If you get covered services using your red, white, and blueMedicare card instead of using your plan membership card while you are a plan member, youmay have to pay the full cost yourself.If your plan membership card is damaged, lost, or stolen, call Member Services right away andwe will send you a new card. (Phone numbers for Member Services are printed on the back coverof this booklet.)The Provider Directory: Your guide to all providers in the plan’s networkThe Provider Directory lists our network providers.What are “network providers”?Network providers are the doctors and other health care professionals, medical groups,hospitals, and other health care facilities that have an agreement with us to accept our paymentand any plan cost-sharing as payment in full. We have arranged for these providers to delivercovered services to members in our plan.Why do you need to know which providers are part of our network?It is important to know which providers are part of our network because, with limited exceptions,while you are a member of our plan, you must use network providers to get your medical careand services. In addition, you may be limited to providers within your Primary Care Provider’s(PCP’s) and/or Medical Group’s network. This means that the PCP and/or Medical Group thatyou choose may determine the specialists and hospitals you can use. See the “Using the plan’scoverage for your medical services” section of this booklet for more information about choosinga PCP. The only exceptions are emergencies, urgently needed care when the network is notavailable (generally, when you are out of the area), out-of-area dialysis services, and cases inwhich our plan authorizes use of out-of-network providers. See the “Using the plan’s coveragefor your medical services” section of this booklet for more specific information aboutemergency, out-of-network, and out-of-area coverage.If you don’t have your copy of the Provider Directory, you can request a copy from MemberServices (phone numbers are printed on the back cover of this booklet). You may ask MemberServices for more information about our network providers, including their qualifications. Youcan also see the Provider Directory at www.healthnet.com, or download it from this Web site.Both Member Services and the Web site can give you the most up-to-date information aboutchanges in our network providers.The Pharmacy Directory: Your guide to pharmacies in our networkWhat are “network pharmacies”?Our Pharmacy Directory gives you a complete list of our network pharmacies – that means all ofthe pharmacies that have agreed to fill covered prescriptions for our plan members.
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member7Why do you need to know about network pharmacies?You can use the Pharmacy Directory to find the network pharmacy you want to use. This isimportant because, with few exceptions, you must get your prescriptions filled at one of ournetwork pharmacies if you want our plan to cover (help you pay for) them.If you don’t have the Pharmacy Directory, you can get a copy from Member Services (phonenumbers are printed on the back cover of this booklet). At any time, you can call MemberServices to get up-to-date information about changes in the pharmacy network. You can also findthis information on our Web site at www.healthnet.com.The plan’s List of Covered Drugs (Formulary)The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tellswhich prescription drugs are covered by our plan. The drugs on this list are selected by the planwith the help of a team of doctors and pharmacists. The list must meet requirements set byMedicare. Medicare has approved the Health Net Seniority Plus (Employer HMO) Drug List.The Drug List also tells you if there are any rules that restrict coverage for your drugs.We will send you a copy of the Drug List each year. To get the most complete and currentinformation about which drugs are covered, you can visit the plan’s Web site(www.healthnet.com) or call Member Services (phone numbers are printed on the back cover ofthis booklet).The Explanation of Benefits (the “EOB”): Reports with a summary of paymentsmade for your Part D prescription drugsWhen you use your Part D prescription drug benefits, we will send you a summary report to helpyou understand and keep track of payments for your Part D prescription drugs. This summaryreport is called the Explanation of Benefits (or the "EOB").The Explanation of Benefits tells you the total amount you have spent on your Part Dprescription drugs and the total amount we have paid for each of your Part D prescription drugsduring the month. See the “What you pay for your prescription drugs” section of this booklet,which gives more information about the Explanation of Benefits and how it can help you keeptrack of your Part D drug coverage.An Explanation of Benefits summary is also available upon request. To get a copy, please contactMember Services (phone numbers are printed on the back cover of this booklet).
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member8Your monthly premium for your planHow much is your plan premium?Your former employer group/union is responsible for paying any monthly plan premium to theplan. If you are responsible for any contribution to the monthly plan premium, CalPERS will tellyou the amount and how to pay your former employer group/union. You can contact CalPERS at1-888-926-4941 TTY: 1-888-926-5003 8:00 a.m. to 8:00 p.m., Pacific time, seven days a week.In addition, you must continue to pay your Medicare Part B premium (unless your Part Bpremium is paid for by Medicaid or another third party).Cost of the ProgramType of Enrollment Monthly RateEmployee only . 261.24Employee and one dependent . 522.48Employee and two or more dependents. 783.72State Employees and AnnuitantsThe rates shown above are effective January 1, 2014, and will be reduced by the amount theState of California contributes toward the cost of your health benefit plan. These contributionamounts are subject to change as a result of collective bargaining agreements or legislativeaction. Any such change will be accomplished by the State Controller or affected retirementsystem without any action on your part. For current contribution information, contact yourretirement system health benefits officer.Contracting Agency Employees and AnnuitantsThe rates shown above are effective January 1, 2014, and will be reduced by the amount yourcontracting agency contributes toward the cost of your health benefit plan. This amount variesamong public agencies. For assistance on calculating your net contribution, contact your agencyor retirement system health benefits officer.In some situations, your plan premium could be lessThe “Extra Help” program helps people with limited resources pay for their drugs. See the“Important phone numbers and resources” section of this booklet which tells more about thisprogram. If you qualify, enrolling in the program might lower your monthly plan premium.If you are already enrolled and getting help from one of these programs, the information aboutpremiums in this Evidence of Coverage may not apply to you. We send you a separate insert,
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member9called the “Evidence of Coverage Rider for People Who Get “Extra Help” Paying for Part DPrescription Drugs” (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), whichtells you about your drug coverage. If you don’t receive this document, please call MemberServices and ask for the LIS Rider. Phone numbers for Member Services are printed on the backcover of this booklet.In some situations, your plan premium could be moreIn some situations, your plan premium could be more than the amount communicated to you byyour employer or retiree group. This situation is described below. Some members are required to pay a late enrollment penalty because they did not join aMedicare drug plan when they first became eligible or because they had a continuousperiod of 63 days or more when they didn’t have “creditable” prescription drug coverage.(“Creditable” means the drug coverage is expected to pay, on average, at least as much asMedicare’s standard prescription drug coverage.). For these members, the late enrollmentpenalty is billed separately from the plan’s monthly premium.o If you are required to pay the late enrollment penalty, the amount of your penaltydepends on how long you waited before you enrolled in drug coverage or howmany months you were without drug coverage after you became eligible. See the“What you pay for your prescription drugs” section of this booklet which explainsthe late enrollment penalty.Many members are required to pay other Medicare premiumsMany members are required to pay other Medicare premiums. As explained in the “What makesyou eligible to be a plan member?” portion above, in order to be eligible for our plan, you mustmaintain your eligibility for Medicare Parts A and B. For that reason, some plan members (thosewho aren't eligible for premium-free Part A) pay a premium for Medicare Part A. And most planmembers pay a premium for Medicare Part B. You must continue paying your Medicarepremiums to remain a member of the plan.Some people pay an extra amount for Part D because of their yearly income. If your income is 85,000 or above for an individual (or married individuals filing separately) or 170,000 orabove for married couples, you must pay an extra amount directly to the government (not theMedicare plan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you will bedisenrolled from the plan and lose prescription drug coverage. If you have to pay an extra amount, Social Security, not your Medicare plan, willsend you a letter telling you what that extra amount will be. For more information about Part D premiums based on income, go to the “Do youhave to pay an extra Part D amount because of your income?” portion of the “Whatyou pay for your prescription drugs” section in this booklet. You can also visithttp://www.medicare.gov on the web or call 1-800-MEDICARE (1-800-633-4227), 24
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member10hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or you may callSocial Security at 1-800-772-1213. TTY users should call 1-800-325-0778.Your copy of Medicare & You 2014 tells about the Medicare premiums in the section called“2014 Medicare Costs.” This explains how the Medicare Part B and Part D premiums differ forpeople with different incomes. Everyone with Medicare receives a copy of Medicare & You eachyear in the fall. Those new to Medicare receive it within a month after first signing up. You canalso download a copy of Medicare & You 2014 from the Medicare Web site(http://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.Can your monthly plan premium change during the year?In some cases, the part of the premium that you have to pay can change during the year. Thishappens if you become eligible for the “Extra Help” program or if you lose your eligibility forthe “Extra Help” program during the year. If a member qualifies for “Extra Help” with theirprescription drug costs, the “Extra Help” program will pay part of the member’s monthly planpremium. So a member who becomes eligible for “Extra Help” during the year would begin topay less toward their monthly premium. And a member who loses their eligibility during the yearwill need to start paying their full monthly premium. You can find out more about the “ExtraHelp” program in the "Important phone numbers and resources" section under the "Informationabout programs to help people pay for their Part D prescription drugs" portion of this booklet.In addition, in some cases, you may need to start paying or may be able to stop paying a lateenrollment penalty. (The late enrollment penalty may apply if you had a continuous period of 63days or more when you didn’t have “creditable” prescription drug coverage.) This could happenif you become eligible for the “Extra Help” program or if you lose your eligibility for the “ExtraHelp” program during the year: If you currently pay the late enrollment penalty and become eligible for “Extra Help”during the year, you would be able to stop paying your penalty. If the “Extra Help” program is currently paying your late enrollment penalty and you loseyour eligibility during the year, you would need to start paying your penalty.You can find out more about the “Extra Help” program in the “Important phone numbers andresources,” section under “Information about programs to help people pay for their Part Dprescription drugs” portion of this booklet.
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member11Please keep your plan membership record up to dateHow to help make sure that we have accurate information about youYour membership record has information from your enrollment form, including your address andtelephone number. It shows your specific plan coverage, including your Primary CareProvider/Medical Group.The doctors, hospitals, pharmacies, and other providers in the plan’s network need to havecorrect information about you. These network providers use your membership record toknow what services and drugs are covered and the cost-sharing amounts for you. Becauseof this, it is very important that you help us keep your information up to date.Let us know about these changes: Changes to your name, your address, or your phone number Changes in any other health insurance coverage you have (such as from your employer,your spouse’s employer, workers’ compensation, or Medicaid) If you have any liability claims, such as claims from an automobile accident If you have been admitted to a nursing home If you receive care in an out-of-area or out-of-network hospital or emergency room If you are participating in a clinical research studyIf any of this information changes, please let us know by calling Member Services (phonenumbers are printed on the back cover of this booklet).It is also important to contact Social Security if you move or change your mailing address. Youcan find phone numbers and contact information for Social Security in the “Important phonenumbers and resources” section of this booklet.Read over the information we send you about any other insurance coverage youhaveMedicare requires that we collect information from you about any other medical or druginsurance coverage that you have. That’s because we must coordinate any other coverage youhave with your benefits under our plan. (For more information about how our coverage workswhen you have other insurance, see the “How other insurance works with our plan” portion ofthis section.)Once each year, we will send you a letter that lists any other medical or drug insurance coveragethat we know about. Please read over this information carefully. If it is correct, you don’t need todo anything. If the information is incorrect, or if you have other coverage that is not listed, pleasecall Member Services (phone numbers are printed on the back cover of this booklet).
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member12Here are other ways you can tell us about any other medical or drug insurance coverage that youhave: You can call Member Services to tell us about this other coverage (phone numbers areprinted on the back cover of this booklet). You can indicate this coverage on your enrollment form when you enroll in our plan.Health Net will then send a letter to you to get more detailed information about this othercoverage.We protect the privacy of your personal health informationWe make sure that your health information is protectedFederal and State laws protect the privacy of your medical records and personal healthinformation. We protect your personal health information as required by these laws.For more information about how we protect your personal health information, please go to the“We must protect the privacy of your personal health information” portion in the “Your rightsand responsibilities” section of this booklet.How other insurance works with our planWhich plan pays first when you have other insurance?When you have other insurance (like employer group health coverage), there are rules set byMedicare that decide whether our plan or your other insurance pays first. The insurance that paysfirst is called the “primary payer” and pays up to the limits of its coverage. The one that payssecond, called the “secondary payer,” only pays if there are costs left uncovered by the primarycoverage. The secondary payer may not pay all of the uncovered costs.These rules apply for employer or union group health plan coverage: If you have retiree coverage, Medicare pays first. If your group health plan coverage is based on your or a family member’s currentemployment, who pays first depends on your age, the size of the employer, and whetheryou have Medicare based on age, disability, or End-Stage Renal Disease (ESRD):o If you’re under 65 and disabled and you or your family member is still working,your plan pays first if the employer has 100 or more employees or at least oneemployer in a multiple employer plan has more than 100 employees.
2014 Evidence of Coverage for Health Net Seniority Plus (Employer HMO)Getting started as a member13o If you’re over 65 and you or your spouse is still working, the plan pays first if theemployer has 20 or more employees or at least one employer in a multipleemployer plan has more than 20 employees.o If you have Medicare because of ESRD, your group health plan will pay first forthe first 30 months after you become eligible for Med
You are enrolled in Health Net Seniority Plus (Employer HMO), which is a Medicare HMO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, Health Net Seniority Plus (Employer HMO). There are different types of Medicare health plans. Health Net Seniority Plus .
