13-14 csunorthridgedom sbc

8/13/2019 13-14 CSUNorthridgeDom SBC

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Health Net Life Ins. Co.: PPO 9GHCSU Northridge Coverage Period: 09/01/2013-08/31/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:All Covered Persons |Plan Type: PPO

3 of 8NG/9GH/STB/MD/C0

Common

Medical Event

Services You May Need

Your Cost IfYou Use an

In-networkPPO Provider


Out-of-networkProvider

Limitations & Exceptions

www.healthnet.com

Specialty drugs $25/order 40% co-ins

Supply/order: 30 day supply fromspecialty pharmacy except wherequantity limits apply. PriorAuthorization is required for selectdrugs. Out of network provider mayrequire up front payment from you.

If you haveoutpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% co-ins 40% co-ins May require prior authorization.Physician/surgeon fees 20% co-ins 40% co-ins none

If you needimmediate medicalattention

Emergency room services 20% co-ins 20% co-ins$100 deductible applies if patient is notadmitted as inpatient.

Emergency medical transportation 20% co-ins 20% co-ins Air ambulance requires prior auth.

Urgent care 20% co-ins 20% co-ins$100 deductible applies if patient is notadmitted as inpatient.

If you have ahospital stay

Facility fee (e.g., hospital room) 20% co-ins $500/stay+40% co-ins Requires prior authorization.

Physician/surgeon fee 20% co-ins 40% co-ins none

If you have mentalhealth, behavioralhealth, or substance

abuse needs

Mental/Behavioral health outpatient services$25/visit-severe20% co-ins- non

severe40% co-ins May require prior authorization.

Mental/Behavioral health inpatient services 20% co-ins$500/stay

+40% co-insRequires prior authorization.

Substance use disorder outpatient services 20% co-ins 40% co-ins May require prior authorization.

Substance use disorder inpatient services 20% co-ins$500/stay


If you are pregnant

Prenatal and postnatal care 20% co-ins 40% co-ins none

Delivery and all inpatient services 20% co-ins$500/stay



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Common

Medical Event

Services You May Need


In-networkPPO Provider


Out-of-networkProvider

Limitations & Exceptions

If you need helprecovering or have

other special healthneeds

Home health care 20% co-ins 40% co-insEach day of care is limited to a maxpayment of $110. May require priorauthorization.

Rehabilitation services 20% co-ins 40% co-insThrough OON, the max payable is $25for each visit. May require prior auth.

Habilitation services Not covered Not covered none

Skilled nursing care 20% co-ins $500/stay+40% co-ins

Combined limit of 100 days each planyear. Requires prior authorization.

Durable medical equipment 20% co-ins 40% co-insLimited to $5,000 each plan yearcombined with hearing aids. May requireprior authorization.

Hospice service 20% co-ins 20% co-ins May require prior authorization.

If your child needs

dental or eye care

Eye exam $25/visit 50% co-ins Covered only through age 16.

Glasses Not covered Not covered noneDental check-up Not covered Not covered none

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)

Bariatric surgery

Cosmetic surgery

Dental care (Child & Adult)

Glasses

Infertility treatment Long-term care

Non-emergency care when traveling outsidethe U.S.

Private-duty nursing

Routine eye care (Adult)

Routine foot care

Weight loss programs


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Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)

Acupuncture

Chiropractic care

Hearing aids (limited to $5,000 each plan yearcombined with DME)

Your Rights to Continue Coverage:

If you lose coverage under this plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keephealth coverage. Any such rights may be limited in duration and will require you to pay apremium,which may be significantly higher than the premiumyou pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-866-801-1446. You may also contact your state insurance department, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 orwww.dol.gov/ebsa, or the U.S. Department of Health and

Human Services at 1-877-267-2323 x61565 orwww.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappealor file a grievance. Forquestions about your rights, this notice, or assistance, you can contact: Health Nets Customer Contact Center at 1-866-801-1446, submit a grievance form

through www.healthnet.com, or file your complaint in writing to, Health Net Appeals and Grievance Department, P.O. Box 10348, Van Nuys, CA 91410-0348. If you have a grievance against Health Net, you can also contact the California Department of Insurance, at 1-800-927-HELP (4357) or via theConsumers portal of www.insurance.ca.gov. For information about group health care coverage subject to ERISA, contact the U.S. Department of LaborsEmployee Benefits Security Administration at 1-866-444 (EBSA (3272) or www.dol.gov/ebsa/healthreform.


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Language Access Services:Spanish (Espaol): Para obtener asistencia en Espaol, llame al 1-866-801-1446.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-801-1446.

Chinese ():1-866-801-1446.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-801-1446.

To see examples of how this plan might cover costs for a sample medical situation, see the next page.


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Health Net Life Ins. Co.: PPO 9GHCSU Northridge Coverage Period: 09/01/2013-08/31/2014Coverage Examples Coverage for:All Covered Persons |Plan Type: PPO


Having a baby

(normal delivery)

Managing type 2 diabetes

(routine maintenance ofa well-controlled condition)

About these Coverage

Examples:

These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.

Amount owed to providers:$7,540Plan pays$5,730Patient pays$1,810

Sample care costs:

Hospital charges (mother) $2,700Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40Total $7,540

Patient pays:

Deductibles $250

Copays $0

Coinsurance $1,410

Limits or exclusions $150Total $1,810

Amount owed to providers:$5,400Plan pays$2,870Patient pays$2,530

Sample care costs:

Prescriptions $2,900Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $200

Copays $280

Coinsurance $1,930

Limits or exclusions $120

Total $2,530

This isnot a costestimator.

Dont use these examples to

estimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.

See the next page forimportant information aboutthese examples.


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