2013 optional supplemental benefits - health net€¦ · it’s just another way that health net...

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Optional benefits enhance your health care coverage! For an additional monthly premium, Health Net gives you two options to enhance your basic medical coverage with routine benefits including dental, vision, acupuncture and chiropractic care. It’s just another way that Health Net offers more health care choices that are right for you.

Gold Option 1 includes coverage for acupuncture, chiropractic care, preventive/comprehensive dental, and routine vision exams and eyewear for an additional monthly premium of $49.

Gold Option 2 includes coverage for preventive/comprehensive dental and routine vision exams and eyewear for an additional monthly premium of $25.

Both options are available to members of the Health Net Ruby 1, Health Net Ruby 4, Health Net Ruby Select (HMO), Health Net Jade and Health Net Green plans. The premium for optional supplemental benefits is paid in addition to the monthly plan premium and the Medicare Part B premium.

We’ve made access to these benefits easy. Each Gold Benefit is self-referral, so you don’t need a referral from your primary care physician to access these benefits. In addition, we have contracted with well-established companies whose network providers are conveniently located.

This booklet provides you with an overview of acupuncture, chiropractic, dental and vision benefits along with the care and treatment they cover and is designed to answer your questions quickly and conveniently.

If not all of your questions are answered in this booklet, please feel free to call our Customer Contact Center at 1-800-977-7522 (TTY/TDD 1-800-977-6757 for the hearing and speech impaired), 8:00 a.m. to 8:00 p.m., 7 days a week.

Optional Supplemental Benefits – Gold Benefits

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The following companies are our plan providers:

•Acupunctureandchiropracticcare–AmericanSpecialtyHealth Networks, Inc.(ASHNetworks) Member Services: 1-800-678-9133 (TTY/TDD 1-877-710-2746 for the hearing and speech impaired), Monday through Friday from 5:00 a.m. to 6:00 p.m. Pacific time (PT).

•Dental–Health NetDental(administered through Dental Benefit Providers, Inc.) Member Services: 1-866-249-4435 (TTY/TDD 1-800-855-2880 for the hearing and speech impaired), Monday through Friday from 8:00 a.m. to 11:00 p.m. Eastern time.

•Vision–Health NetVision(offeredthroughEyeMedVisionCare,LLC) Member Services: 1-866-392-6058 (TTY/TDD 1-866-308-5375 for the hearing and speech impaired), Monday through Saturday from 5:00 a.m. to 8:00 p.m., and Sunday from 8:00 a.m. to 5:00 p.m. PT.

Getting started with your Gold BenefitsTo use your benefits, follow these simple steps:

• readthrougheachsectionof this document to understand each benefit;

• selecttheplanprovideryouwishto visit from your Health Net MedicareAdvantageHMOPlanProvider Directory (HMO Plan Provider Directory) or the Dental PPO Plan Provider Directory (Dental PPO Directory);

• callandscheduleanappointment;

• identifyyourselfasaHealth Netmember; then

• showyourHealth NetmemberIDcard when you visit the provider.

Please note: The open enrollment period for optional supplemental plans for current Health Net medical members is October 15, 2012, through January 31, 2013. New members must enroll no later than 30daysaftertheirinitialeffectivedate of medical coverage. Members may disenroll at any time from this option by providing written notice to Health Net. The disenrollment date will be the first day of the month following Health Net’s receipt of the disenrollment request. Once disenrolled, members must wait until the next open enrollment period to enroll for aJanuary1effectivedate. Please see the Evidence of Coverage for complete details.

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1 Subject to medical necessity determination and contract limitations and/ or exclusions.

For more information about the acupuncture and chiropractic benefits, pleasecontactASHNetworksatthenumberlistedinthisbooklet.

Gold Option 1Gold Option 1 provides coverage for acupuncture, chiropractic care, preventive/comprehensive dental, and routine vision care for an additional monthly premium of $49 (premium for optional supplemental benefits is paid in addition to the monthly plan premium and the Medicare Part B premium).

Acupuncture and chiropractic careHealth Netoffersquality,affordableacupuncture and chiropractic care through an arrangement withAmericanSpecialtyHealth Networks, Inc.(ASHNetworks). You may self-refer to any participating acupuncturist or chiropractor through this plan – without consulting your primary care physician.

TheASHNetworks-contractedchiropractor or acupuncturist you select will provide the initial examinationandwillcontactASHNetworks for authorization of the treatment plan he or she develops for you based on medical necessity and your list of covered services. Allcoveredservicesmustbemedically necessary and may require verification of medical necessity by

ASHNetworks.Pleasereferto the Health Net HMO Plan Provider Directory.

You can receive a maximum of 24 combined1 visits annually to a contracted provider for acupuncture and/or chiropractic care services. You will pay a $15 copayment for each visit.

AcupunctureAcupunctureisatreatmentthatcanrelieve symptoms of pain, nausea and some neuromusculoskeletal conditions.Acupuncturestimulatesthe nerves in the skin and muscle, andcanproduceavarietyofeffects.Itincreases the body’s release of natural painkillers in the pain pathways of both the spinal cord and the brain. This modifies the way pain signals are received. But acupuncture does much more than reduce pain, and has abeneficialeffectonhealth.Patientsoften notice an improved sense of well-being after treatment.

Modern research shows that acupuncturecanaffectmostofthebody’s systems – the nervous system, muscle tone, hormone outputs, circulation, antibody production and allergic responses, as well as the respiratory, digestive, urinary and reproductive systems.

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Acupuncture and chiropractic benefit Gold Option 1Acupunctureand/orchiropracticcareoffice visit

$15 copay per visit

Annualvisitlimit 24 visits per year (acupuncture and chiropractic visits combined)

Benefits of acupuncture include but are not limited to the relief of:1

•Painsyndromes.•Musculoskeletalconditions.•Nauseaassociatedwithpregnancy

or chemotherapy.

(Please refer to the Gold Benefits ExclusionsandLimitationssectionsof your Evidence of Coverage (EOC) or other plan documents to see if these conditions are covered by your plan.)

Chiropractic careChiropractic physicians give special attention to physiological and biochemical aspects, including structural, spinal, vascular, nutritional, emotional and environmental relationships.

Procedures specifically include the adjustment and manipulation of the spinal column. Chiropractic is a drug-free, non-surgical science. Many people find chiropractic careveryeffective,particularlyforlow back pain. Now you can have convenient,affordablechiropracticcare with Gold Option 1.

Your chiropractic benefits include, but are not limited to:

•Chiropracticmanipulationandadjustments (see note below).

•Treatmentfortheaggravationofanillness or injury.

•Treatmentfortheexacerbationofan illness or injury.

Note: Manual manipulation of the spine to correct subluxation is a Medicare-covered service and is covered under your Health Net MedicareAdvantageplanbenefit. If you choose to use your Gold Option 1 benefits first, and additional chiropractic care is needed, you may elect to continue coverage under your Health Net Medicare Advantageplanbenefits.You will pay a higher copayment for each visit, but these visits will not count toward your Gold Option 1 annual visit limit. Please refer to your Evidence of Coverage (EOC) document for further information.

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Limitations and exclusionsAcupuncture 1. Services or treatments not

approvedbyASHNetworksasmedically necessary, except for a new patient examination and urgent services.

2. Services or treatments not delivered by contracted acupuncturists for the delivery of acupuncture care to members, except for urgent services.

3. Services for examinations and/or treatments for conditions other than those related to neuromusculoskeletal disorders, nausea or pain syndromes from contracted acupuncturists.

4. Hypnotherapy, behavior training, sleep therapy and weight programs.

5. Thermography, magnets used for diagnostic or therapeutic use, ion cord devices, manipulation or adjustments of the joints, physical therapy services, iridology, hormone replacement products, acupuncture point or trigger-point injections (including injectable substances), laser/laser biostim, colorpuncture,NAETdiagnosisand/or treatment, and direct moxibustion.

6. Services and other treatments that are classified as experimental or investigational.

7. Radiological X-rays (plain film studies), magnetic resonance imaging,CATscans,bonescans,nuclear radiology, diagnostic radiology and laboratory services.

8. Transportation costs including local ambulance charges.

9. Education programs, non-medical lifestyle or self-help or any self-help physical exercise training or related diagnostic testing.

10. Services or treatments for pre-employment physicals or vocational rehabilitation.

11. Services or treatments caused by or arising out of the course of employment or covered under public liability insurance.

12.Anyservicesortreatmentsforconditions caused by or arising out of the course of employment or covered under workers’ compensation or similar laws.

13.Airconditioners,airpurifiers,therapeutic mattresses, supplies, durable medical equipment or appliances.

14. Prescription drugs or medicines, including non-legend or proprietary medicine or medication not requiring a prescription order.

15. Services provided by an acupuncturist practicing outside the service area, except for urgent services.

16. Hospitalization, surgical procedures, anesthesia, manipulation under anesthesia, proctology, colonic irrigation, injections and injection services or other related services.

17.Auxiliaryaidsandservices,including, but not limited to, interpreters, transcription services, written materials, telecommunications devices, telephone handset amplifiers, television decoders and telephones compatible with hearing aids.

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18.Adjunctivetherapynotassociatedwith acupuncture.

19. Dietary and nutritional supplements, including vitamins, minerals, herbs, herbals and herbal products, injectable supplements and injection services, or other similar products.

20. Clinical laboratory services or any other type of diagnostic test or service.

Chiropractic 1. Services or treatments not

approvedbyASHNetworksasmedically necessary, except for a new patient examination and urgent services.

2. Services or treatments not delivered by contracted chiropractors for the delivery of chiropractic care to members, except for urgent services.

3. Services for examinations and/or treatments for conditions other than those related to neuromusculoskeletal disorders from contracted chiropractors.

4. Hypnotherapy, behavior training, sleep therapy and weight programs.

5. Thermography; magnets used for diagnostic or therapeutic use; nerve conduction studies (e.g., EEG, EMG,SEMG,SSEP,andNCV);orelectrocardiogram (EKG) studies.

6. Services, clinical laboratory studies, X-rays, supports and appliances, and other treatments or products that are classified as experimental or investigational.

7. Magnetic resonance imaging, CATscans,bonescans,nuclearradiology, therapeutic radiology and any diagnostic radiology other than covered plain film studies.

8. Transportation costs including local ambulance charges.

9. Education programs, non-medical lifestyle or self-help or any self-help physical exercise training or related diagnostic testing.

10. Services or treatments for pre-employment physicals or vocational rehabilitation.

11.Anyservicesortreatmentsforconditions caused by or arising out of the course of employment or covered under workers’ compensation or similar laws.

12.Airconditioners,airpurifiers,therapeutic mattresses, supplies or any other similar devices or appliances; all chiropractic appliances or durable medical equipment, except as described in the covered services section.

13. Prescription drugs or medicines, including non-legend or proprietary medicine or medication not requiring a prescription order.

14. Services provided by a chiropractor practicing outside the service area, except for urgent services.

15. Hospitalization, surgical procedures, anesthesia, manipulation under anesthesia, proctology, colonic irrigation, injections and injection services or other related services.

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16.Auxiliaryaidsandservices,including, but not limited to, interpreters, transcription services, written materials, telecommunications devices, telephone handset amplifiers, television decoders and telephones compatible with hearing aids.

17.Adjunctivephysiotherapymodalities and procedures unless provided during the same course of treatment and in support of chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissue.

18. Dietary and nutritional supplements, including vitamins, minerals, herbs, herbals and herbal products, injectable supplements and injection services, or other similar products.

Preventive/comprehensive dental careMembers enrolled in Health Net’s Ruby 1, Ruby Select, Ruby 4, Jade and Green plans have two levels of dental benefits and many choices of providers. Members save money when using in-network providers (providers who are listed in the Health Net Dental PPO Directory), or members pay a little more to use providers who are out-of-network (providers who are NOT listed in the Health Net Dental PPO Directory). Prior authorization is not required for covered services under Health Net’s Dental PPO plan.

Reimbursement for dental careIf you see a dentist other than a Health Net Dental PPO provider

Dental care benefit Gold Option 1In-network Out-of-network

Calendar year maximum $1,000, in- and out-of-network combinedCalendar year deductible $50 (applies to all services) $100 (applies to all services)Preventive servicesInitial/routine oral exams, teeth cleaning and routine scaling, flouride treatment, sealant, X-rays as part of a general exam, emergency exam, space maintainers

Covered at 100% (deductible applies)


General servicesFillings, general anesthetics



Major servicesCrowns, removable and fixed bridges, complete and partial dentures, oral surgery, periodontics, endodontics



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for covered dental care services, you should ask the dentist to bill Health Net Dental directly. However, if the dentist insists on payment at the time service is provided, you should send a copy of the paid bill to:

Health Net Dental Attn:ClaimsUnit PO Box 30567 SaltLakeCity,UT84130-0567

Please include either the dentist’s completed claim form, or a separate sheet of paper if a claim form is unavailable, that includes the following information:

•name,address,IDnumberand group number from your Health Net identification card;

•nameandaddressofthedentistwho provided the service (unless stated on the bill); and

• anitemizedreceiptthatspecifiesthe covered services provided.

If additional information is needed, the member will be advised in writing. If all or part of the claim is denied, you will receive written notice of the decision within 30 days, including:

• thereasonfordenial,and

•noticeoftherighttorequestreconsideration of the denial and an explanation of the grievance and appeals process.

AllsuchclaimsshouldbesenttoHealth Net Dental within 60 calendar days from the date of service to be considered for payment.

This dental plan does not cover services and supplies provided by non-physician/dentist health care practitioners.Additionally,nopayment will be made for services received that are not a covered benefit under the Health Net Dental PPO plan. Please refer to this booklet for information on covered services.

You save when using a PPO dentist: Our PPO dentists have agreed to reduce their treatment fees, which will lower your out-of-pocket expenses.

Your costs: Payment is based on the “usual and customary” charge that is pre-set for each procedure. This charge is determined by the complexity of the treatment and the fee most commonly charged for that procedure in a particular geographic area. This is the “maximum allowable” for any procedure and the benefit will be calculated based on the dentist’s submitted fee or the usual and customary amount – whichever is lower.

Balance billing: If your dentist charges more than the usual and customary amount for a procedure, youareresponsibleforthedifferencebetween what is charged and the usual and customary amount. This is called “balance billing.” If you receive treatment from a PPO dentist, you will not be “balance billed” – our PPO dentists have agreed to accept the pre-set usual and customary fees, plus your coinsurance payment, if any, as payment in full.

Our contracted

dentists have

agreed to

reduce their

treatment

fees, which

will lower your

out-of-pocket

expenses.

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General dental limitations 1. Periodic oral examinations.

Limitedtotwo(2)timespercalendar year.

2. Complete series or panorex radiographs.Limitedto1timeper consecutive 36 months.2 Exception to this limit will be made for panorex radiographs if taken for diagnosis of third molars, cysts or neoplasms.

3.Bitewingradiographs.Limitedto2 series of films per calendar year.

4.Extraoralradiographs.Limitedto2 films per calendar year.

5.Dentalprophylaxis.Limitedto 2 times per calendar year.

6.Fluoridetreatments.Limitedtocovered persons under the age of 17 years, and limited to 1 time per calendar year.

7.Spacemaintainers.Limitedtocovered persons under the age of 16 years, limited to 1 per consecutive 60 months.2 Benefit includes all adjustments within 6 months of installation

8.Sealants.Limitedtocoveredpersons under the age of 17 years, and once per permanent molar every consecutive 36 months.2

9. Restorations. Multiple restorations on one surface will be treated as a single filling.

10.Pinretention.Limitedto2pinsper tooth; not covered in addition to cast restoration.

11.Inlaysandonlays.Limitedto1time per tooth per consecutive 60 months.2 Covered only when a filling cannot restore the tooth.

12.Crowns.Limitedto1timeper tooth per consecutive 60 months.2 Covered only when a filling cannot restore the tooth.

13. Post and cores. Covered only for teeth that have had root canal therapy.

14. Sedative fillings. Covered as a separate benefit only if no other service, other than X-rays and exam, were performed on the same tooth during the visit.

15 . Scaling and root planing. Limitedto1timeperquadrantper consecutive 24 months.2

16.Periodontalmaintenance.Limitedto 2 times per calendar year following active and adjunctive periodontal therapy, exclusive of gross debridement.

17.Fulldentures.Limitedto1timeevery consecutive 60 months.2 No additional allowances for precision or semi-precision attachments.

18.Partialdentures.Limitedto 1 time every consecutive 60 months.2 No additional allowances for precision or semi-precision attachments.

19. Relining and rebasing dentures. Limitedtorelining/rebasingperformed more than 6 months aftertheinitialinsertion.Limitedto1 time per consecutive 12 months.

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20. Repairs to full dentures, partial denturesandbridges.Limitedtorepairs or adjustments performed more than 12 months after the initialinsertion.Limitedto1perconsecutive 6 months.

21. Palliative treatment. Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit.

22.Occlusalguards.Limitedto1 guard every consecutive 36 months2 and only if prescribed to control habitual grinding.

23.Full-mouthdebridement.Limitedto 1 time every consecutive 36 months.2

24. General anesthesia. Covered only where clinically necessary.

25.Osseousgrafts.Limitedto1perquadrant or site per consecutive 36 months.2

26. Periodontal surgery. Hard tissue and soft tissue periodontal surgery are limited to 1 per quadrant or site per consecutive 36 months2 per surgical area.

27. Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays. Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental

placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances..

General dental exclusions 1. Dental services that are not

medically necessary.

2. Hospitalization or other facility charges.

3.Anydentalprocedureperformedsolely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance).

4. Reconstructive surgery regardless of whether or not the surgery which is incidental to a dental disease, injury or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.

5.Anydentalprocedurenotdirectly associated with dental disease.

6.Anyprocedurenotperformedina dental setting.

7. Procedures that are considered to be Experimental, Investigational orUnproven.Thisincludespharmacological regimens not acceptedbytheAmericanDentalAssociation(ADA)CouncilonDental Therapeutics. The fact that an Experimental, Investigational orUnprovenservice,treatment,device or pharmacological regimen is the only available treatment for

2Multi-year benefit may not be available in subsequent years.

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a particular condition will not result in coverage if the procedure is considered to be Experimental, InvestigationalorUnproveninthe treatment of that particular condition.

8. Services for injuries or conditions covered by workers’ compensation or employer liability laws, and services that are provided without cost to the covered person by any municipality, county or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

9. Expenses for dental procedures begun prior to the covered person becoming enrolled under the Policy.

10. Dental services otherwise covered under the policy, but rendered after the date individual coverage under the Policy terminates, including dental services for dental conditions arising prior to the date individual coverage under the Policy terminates.

11. Services rendered by a provider with the same legal residence as a covered person or who is a member of a covered person’s family, including spouse, brother, sister, parent or child.

12. Foreign services are not covered unless required as an emergency.

13. Replacement of crowns, bridges, and fixed and removable prosthetic appliances inserted

prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12-month period, the plan is responsible only for the procedures associated with the addition.

14. Replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been covered under the Policy for 12 continuous months.

15. Replacement of complete dentures, fixed and removable partial dentures, or crowns, if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.

16. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

17.Attachmentstoconventionalremovable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

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18. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion(VDO).

19. Placement of dental implants, implant-supported abutments and prostheses.

20. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

21. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or congenital anomalies of hard or soft tissue, including excision.

22. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

23. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upperandlowerjawbonesurgery (including that related to the temporomandibular joint). No coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

24.Acupuncture,acupressureand other forms of alternative treatment, whether or not used as anesthesia.

25. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

26. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

27. Occlusal guards used as safety itemsortoaffectperformanceprimarily in sports-related activities.

28. Dental services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

29. Orthodontic services.

For more information about these dental benefits, please contact Health Net Dental at the number listed in this booklet.

DentalbenefitsareunderwrittenbyHealth NetofArizona, Inc.andadministered through Dental Benefit Providers, Inc.

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Vision careYour Gold Option 1 package includes vision care services from a nationwide network of vision care professionals. Your plan is easy to use and includes an annual routine eye exam. Health Net carefully screens the vision care professionals in its provider organization to help assure quality of care.

With this plan, you can choose to receive your vision care from many

officesthroughoutArizona.Mostarefull-service providers, so you can get your examination, lenses and frame or contact lenses all at the same location.

Your vision benefits include:Exam There is a $10 copayment in-network, or a $45 copayment out-of-network, for an annual visit to your vision provider. In- or out-of-network, you are covered for a vision exam once every 12 months.

Vision care benefit Gold Option 1In-network Out-of-network allowance

Eye exam – refractive (available once every 12 months)

$10 copay $45

Contact lens fit and follow up (contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed) Standard

Premium

$0 copay, paid in full / Fit and two follow-up visits

$0 copay, 10% off retail price, plus $55 allowance

$40

$40

Frames, lens and options package (available once every 24 months)2

$250 allowance / member receives 20% off balance over $250

Up to $250 allowance / Member pays 100% of balance

Contacts – (available once every 24 months)2 Conventional

Disposables

Medically necessary

$0 copay, $250 allowance / Member receives 15% off balance over $250

$0 copay, $250 allowance / Member pays 100% of balance

$0 copay, paid in full





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Frames, lens and options packageFrames, lenses and lens options are covered up to a $250 maximum retail benefit allowance in-network, or up to a $250 maximum retail benefit allowance out-of-network. In-network, members will receive 20% offanybalanceovertheallowanceamount. Out-of-network, you areresponsibleforthedifferencebetween the retail amount and the $250 allowance.

In- or out-of-network, you are covered for materials once every 24 months.2 You can choose from any of the frames available at the plan provider’s office and apply your material allowance.

Contact lenses Should you choose contact lenses for elective reasons, your vision plan will cover a maximum allowance of $250 toward the cost in-network, or a maximum of $250 toward the cost out-of-network. For medically necessary contacts, your vision plan will pay in full for in-network, or a maximum of $250 toward the cost out-of-network.

Memberswillreceive15%offthebalance over allowance amount for conventional contact lenses, or a maximum of $250 toward the cost out-of-network. In- or out-of-network, you are covered for one pair of contact lenses once every 24 months.2

The contact lenses allowance is in place of the frames and lenses option. Covered services are available once every 24 months.2

Note: Coverage of one pair of glasses (or medically necessary contact lenses) following cataract surgery is not covered under Gold Option 1, but it is a Medicare-covered benefit under your Health Net Medicare Advantageplan.PleaserefertoyourEvidence of Coverage (EOC) for further information.


For more information about these vision benefits, please contact Health Net Visionatthenumberlistedinthisbooklet.

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Gold Option 2Gold Option 2 provides coverage for preventive/comprehensive dental and routine vision care for an additional monthly premium of $25 (premium for optional supplemental benefits is paid in addition to the monthly plan premium and the Medicare Part B premium).

Preventive/comprehensive dental careYou can see any licensed dentist to receive covered preventive and general comprehensive dental services; however, your cost-sharing will be lower if you use plan providers.

Reimbursement for dental careIf you see a dentist other than a Health Net Dental PPO provider for covered dental care services, you should ask the dentist to bill Health Net Dental directly. However,

if the dentist insists on payment at the time service is provided, you should send a copy of the paid bill to:

Health Net Dental Attn:ClaimsUnit PO Box 30567 SaltLakeCity,UT84130-0567

Please include either the dentist’s completed claim form, or a separate sheet of paper if a claim form is unavailable, that includes the following information:

•name,address,IDnumberand group number from your Health Net identification card;

•nameandaddressofthedentistwho provided the service (unless stated on the bill); and

• anitemizedreceiptthatspecifiesthe covered services provided.

If additional information is needed, the member will be advised in writing. If all or part of the claim is denied, you will receive written notice of the decision within 30 days, including:

Dental care benefit Gold Option 2In-network Out-of-network

Calendar year maximum $1,000, in- and out-of-network combinedCalendar year deductible $50, in-network and out-of-network combined

(applies to all services)Preventive servicesInitial/routine oral exams, teeth cleaning and routine scaling, X-rays as part of a general exam



General servicesFillings



Major servicesPeriodontal scaling and root planing, full-mouth debridement, periodontal maintenance



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• thereasonfordenial,and•noticeoftherighttorequest

reconsideration of the denial and an explanation of the grievance and appeals process.

AllsuchclaimsshouldbesenttoHealth Net Dental within 60 calendar days from the date of service to be considered for payment.

This dental plan does not cover services and supplies provided by non-physician/dentist health care practitioners.Additionally,nopayment will be made for services received that are not a covered benefit under the Health Net Dental PPO plan. Please refer to this booklet for information on covered services.

You save when using a PPO dentist: Our PPO dentists have agreed to reduce their treatment fees, which will lower your out-of-pocket expenses.

Your costs: Payment is based on the “usual and customary” charge that is pre-set for each procedure. This charge is determined by the complexity of the treatment and the fee most commonly charged for that procedure in a particular geographic area. This is the “maximum allowable” for any procedure and the benefit will be calculated based on the dentist’s submitted fee or the usual and customary amount – whichever is lower.

Balance billing: If your dentist charges more than the usual and customary amount for a procedure, youareresponsibleforthedifferencebetween what is charged and the usual and customary amount. This is called “balance billing.” If you receive

treatment from a PPO dentist, you will not be “balance billed” – our PPO dentists have agreed to accept the pre-set usual and customary fees, plus your coinsurance payment, if any, as payment in full.

General dental limitations 1.Periodicoralevaluation.Limited

to 2 per calendar year. 2. Complete series or panorex

radiographs.Limitedto1timeper consecutive 36 months.2 Exception to this limit will be made for panorex radiographs if taken for diagnosis of third molars, cysts or neoplasms.

3.Bitewingradiographs.Limitedto1 series of films per calendar year.

4.Extraoralradiographs.Limitedto2 films per calendar year.

5.Dentalprophylaxis.Limitedto 2 times per calendar year.

6. Restorations. Multiple restorations on one surface will be treated as a single filling.

7.Scalingandrootplaning.Limitedto 1 time per quadrant per consecutive 24 months.2

8. Periodontal maintenance. Limitedto2timespercalendaryear following active and adjunctive periodontal therapy, exclusive of gross debridement.

9.Full-mouthdebridement.Limitedto 1 time every consecutive 36 months.2

General dental exclusions 1. Dental services that are not

medically necessary.

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2. Hospitalization or other facility charges.

3.Anydentalprocedureperformedsolely for cosmetic/aesthetic reasons (cosmetic procedures are those procedures that improve physical appearance).

4. Reconstructive surgery regardless of whether or not the surgery which is incidental to a dental disease, injury or congenital anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.

5.Anydentalprocedurenotdirectlyassociated with dental disease.

6.Anyprocedurenotperformedina dental setting.

7. Procedures that are considered to be Experimental, Investigational orUnproven.Thisincludespharmacological regimens not acceptedbytheAmericanDentalAssociation(ADA)CouncilonDental Therapeutics. The fact that an Experimental, Investigational orUnprovenservice,treatment,device or pharmacological regimen is the only available treatment for a particular condition will not result in coverage if the procedure is considered to be Experimental, InvestigationalorUnproveninthe treatment of that particular condition.

8. Services for injuries or conditions covered by workers’ compensation or employer liability laws, and services that are provided without cost to the covered person by any municipality, county or other political subdivision.

This exclusion does not apply to any services covered by Medicaid or Medicare.

9. Expenses for dental procedures begun prior to the covered person becoming enrolled under the Policy.

10. Dental services otherwise covered under the policy, but rendered after the date individual coverage under the Policy terminates, including dental services for dental conditions arising prior to the date individual coverage under the Policy terminates.

11. Services rendered by a provider with the same legal residence as a covered person or who is a member of a covered person’s family, including spouse, brother, sister, parent or child.

12. Foreign services are not covered unless required as an emergency.

13. Replacement of crowns, bridges, and fixed and removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12-month period, the plan is responsible only for the procedures associated with the addition.

14. Replacement of missing natural teeth lost prior to the onset of plan coverage until the patient has been covered under the Policy for 12 continuous months.

15. Replacement of complete dentures, fixed and removable partial dentures, or crowns, if

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damage or breakage was directly related to provider error. This type of replacement is the responsibility of the dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.

16. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

17.Attachmentstoconventionalremovable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

18. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion(VDO).

19. Placement of dental implants, implant-supported abutments, and prostheses.

20. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

21. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or congenital anomalies of hard or soft tissue, including excision.

22. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

23. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upperandlowerjawbonesurgery (including that related to the temporomandibular joint). No coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

24.Acupuncture,acupressureandother forms of alternative treatment, whether or not used as anesthesia.

25. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

26. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

27. Occlusal guards used as safety items ortoaffectperformanceprimarilyin sports-related activities.

2Multi-year benefit, may not be available in subsequent years.For more information about these dental benefits, please contact Health Net Dental at the number listed in this booklet.

DentalbenefitsunderwrittenbyHealth NetofArizona, Inc.andadministeredthrough Dental Benefit Providers, Inc.

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28. Dental services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

29. Orthodontic services.

Vision careYour Gold Option 2 package includes vision care services from a nationwide network of vision care professionals. Your plan is easy to use and includes an annual routine exam. Health Net carefully screens the vision care professionals in its provider organization to help assure quality of care.

With this plan, you can choose to receive your vision care from many officesthroughoutArizona.Mostarefull-service providers, so you can get your examination, lenses and frame or contact lenses all at the same location.

Your vision benefits include:Exam There is a $10 copayment in-network, or a $35 copayment out-of-network, for an annual visit to your vision provider. In- or out-of-network, you are covered for a vision exam once every 12 months.

Frames Frames are covered up to a $100 maximum retail benefit allowance in-network, or up to a $45 maximum retail benefit allowance out-of-

network. In-network, members receive a 20% discount. Out-of-network, members pay balance over the $45 allowance. In- or out-of-network, you are covered for materials once every 24 months.2 You can choose from any of the frames available at the plan provider’s office and apply your frames allowance. If you select frames that exceed your frames allowance, you paythedifferencebetweentheretailprice of the frames you picked and the allowance.

Standard or basic lenses There is a $0 copayment for standard lenses, available once every 24 months.2

In-network• Singlevision–100%coverageonce

every 24 months.2

•Bifocal–100%coverageonceevery24 months.2

•Trifocal–100%coverageonceevery 24 months.2

• Lenticular–100%coverageonceevery 24 months.2

• Standardprogressivelenses–$65copayment, coverage once every 24 months.2

•Premiumprogressivelenses–$65copayment, 80% of charge less $120 allowance once every 24 months.2

Out-of-network• Singlevision–upto$25maximum

retail benefit allowance once every 24 months.2


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•Bifocal–upto$40maximumretailbenefit allowance once every 24 months.2

•Trifocal–upto$55maximumretail benefit allowance once every 24 months.2

• Lenticular–upto$55maximumretail benefit allowance once every 24 months.2

• Standardprogressivelenses–upto $40 maximum retail benefit allowance once every 24 months.2

•Premiumprogressivelenses–upto $40 maximum retail benefit allowance once every 24 months.2

Contact lenses Should you choose contact lenses for elective reasons, your vision plan will cover a maximum allowance of $100 toward the cost in-network after a $0 copay.Memberswillreceive15%offthe balance over allowance amount for conventional contact lenses in-network and a maximum of $80 toward the cost out-of-network. For medically necessary contacts, your vision plan will pay in full for in-network, or $200 out-of-network.

Memberswillreceive15%offthebalance over allowance amount for conventional contact lenses. In- or out-of-network, you are covered for one pair of contact lenses once every 24 months.2

The contact lenses allowance is in place of the frames and lenses option. Covered services are available once every 24 months.2

Note: Coverage of one pair of glasses (or medically necessary contact lenses) following cataract surgery is not covered under Gold Option 2, but is a Medicare-covered benefit under your Health Net Medicare Advantageplan.PleaserefertoyourEvidence of Coverage (EOC) for further information.

For more information about these vision benefits, please contact Health NetVisionatthenumberlisted in this booklet.


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Vision care benefit Gold Option 2In-network Out-of-network allowance

Eye exam – refractive (available once every 12 months)

$10 copay $35

Contact lens fit and follow up (contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed) Standard

Premium

$0 copay, paid in full / Fit and two follow-up visits$0 copay, 10% off retail price, plus $55 allowance

$40

$40

Lenses–standardplastic (available once every 24 months)2 Single Bifocal Trifocal Lenticular Standard progressive Premium progressive

$0 copay$0 copay$0 copay$0 copay$65 copay$65, 80% of charge, less $120 allowance

$25$40$55$55$40$40

Lensoptions– UVcoating Tint Standard scratch-resistant Standard polycarbonate Standard anti-reflective coating Other add-ons and services

$15 copay$15 copay$15 copay$40 copay$45 copay

20% off retail price

N/AN/AN/AN/AN/A

N/A

Frames (available once every 24 months)2

$100 allowance / Member receives 20% off balance over $100


Contacts – (available once every 24 months)2

Conventional

Disposables

Medically necessary

$0 copay, $100 allowance / Member receives 15% off balance over $100$0 copay, $100 allowance / Member pays 100% of balance$0 copay, paid in full

$80 allowance / Member pays 100% of balance

$80 allowance / Member pays 100% of balance$200 allowance / Member pays 100% of balance

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Premium for optional supplemental benefits is paid in addition to the monthly plan premium and the Medicare Part B premium. These Optional Supplemental Benefits are not Medicare-covered services; Medicare services are covered under the member’s Medicare Advantage plan. Any unused portion of these benefits cannot be carried over from one year to the next. Health Net Ruby 1 plan members enrolled in Gold Benefits must continue to pay their monthly health plan premium.Health Net of Arizona, Inc. is a Medicare Advantage organization with a Medicare contract. Health Net of Arizona, Inc. is a Coordinated Care plan with a Medicare contract. This contract is renewed annually, and availability of coverage beyond the end of the contract year is not guaranteed. This plan may not be available to Medicare beneficiaries in the following contract year because, by law, plan sponsors, like Health Net, can choose not to renew their contract with CMS, or they can reduce their service area, and CMS may also refuse to renew the contract, thus resulting in a termination or non-renewal. Anyone entitled to Medicare Part A and enrolled in Part B may apply for Health Net’s Medicare Advantage (MA) plans. You must reside in the plan service area in order to apply for Health Net’s MA plans. You can enroll in a Medicare Advantage Plan at any time during the year if you’ve recently become eligible for Medicare Parts A and B, if you’re granted a Special Election Period (such as moving out of your current plan’s service area), or if you meet the eligibility requirements for a Special Needs Plan. Contact Health Net for more information. Medicare beneficiaries must continue to pay their Medicare Part B premiums. Limitations, copayments/coinsurance and restrictions may apply. Plan benefits and cost-sharing may vary by plan, county and region.In-network providers are those providers who contract with Health Net. Out-of-network providers are those who do not have a contract with Health Net and who accept Medicare. Members enrolled in Health Net MA HMO plans must receive all routine care from in-network providers, except in emergent or urgent care situations or for out-of-area renal dialysis. If Health Net MA HMO members obtain routine care from out-of-network providers, neither Medicare nor Health Net will be responsible for the costs. However, members may use in- or out-of-network providers for optional supplemental benefits. Please note that accessing optional supplemental benefits out-of-network may cost more than receiving care from Health Net’s in-network providers.The benefit information provided herein is a brief summary, not a complete description of benefits. For more information, contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year.This information is available for free in other languages. Please contact our customer service number at 1-800-977-7522. TTY/TDD users call 1-800-977-6757.Esta información está disponible en forma gratuita en otros idiomas. Comuníquese con el número de nuestro servicio al cliente al 1-800-977-7522 Los usuarios de TTY/TDD deben llamar al 1-800-977-6757.Health Net of Arizona, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.

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