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Swp plansummary_ppo vbasic500 022004 ifp20031024.pdf

Effective February 1, 2004
HEALTH NET LIFE INSURANCE COMPANY
Individual & Family Plan PPO Value BASIC Plans


PPO EXCLUSIONS & LIMITATIONS

No payment will be made under the Health Net Life Individual & Family PPO Plans for expenses incurred for or
which are follow-up care to any of the items below. The following are selective listings only. For comprehensive
listings, see the Health Net Life Individual & Family PPO Policy for the PPO coverages.
o Services and Supplies which Health Net Life determines are not medically necessary, except as set out
under "Does Health Net cover the cost of participation in clinical trials?" and "What if I have a disagreement with Health Net" in Common Questions. o Custodial Care. Custodial Care is not rehabilitative care and is primarily provided to assist a patient in meeting the activities of daily living such as: help in walking, getting in and out of bed, bathing, dressing, feeding and preparation of special diets, and supervision of medications which are ordinarily self-administered, but not care that requires skilled nursing services on a continuing basis. o Procedures that Health Net Life determines to be experimental or investigational, except as set out under "Does Health Net cover the cost of participation in clinical trials?" and "What if I have a disagreement with Health Net" in Common Questions. o Services or supplies provided before the effective date of coverage; services or supplies provided after coverage through this plan has ended are not covered. o Services for which the Member is not legally obligated to pay or for which no charge is made to the o Any service or supplies not specifically listed as covered expenses o Services or supplies that are intended to impregnate a woman are not covered. o Oral contraceptives are covered. Vaginal contraceptives are limited to diaphragms and cervical caps and IUDs, are limited to one prescription per year, and are only covered when a Member Physician performs a fitting examination and prescribes the device. o Injectable contraceptives are covered when administered by a physician. Norplant and Norplant kits are not o Cosmetic surgery that is performed to alter or reshape normal structures of the body in order to improve o Dental care o Treatment and services for a Temporomandibular Joint Disorders are covered when determined to be medically necessary, excluding crowns, inlays, bridgework and appliances o Any services or supplies furnished by a non-eligible institution that is other than a legally operated hospital or Medicare-approved skilled nursing facility, or that is primarily a place for the aged, a nursing home or any similar institution, regardless of how designated o Surgery and related services for the purpose of correcting the malposition or improper development of the bones of the upper or lower jaw, except when such surgery is required due to recent trauma or the existence of tumors or neoplasms, or when otherwise medically necessary o Hearing aids o Treatment for mental disorders as a condition of parole or probation and court ordered testing o Private duty nursing o Any eye surgery for the purpose of correcting refractive defects of the eye o Contact or corrective lenses (except an implanted lens that replaces the organic eye lens), vision therapy o Rehabilitation therapy services are not covered when such services are the result of the following conditions: (a) psychosocial speech delay, (b) mental retardation or dyslexia, (c) attention deficit disorder and associated behavior problems (d) developmental articulation and language disorders. o Services to reverse voluntary surgically induced infertility o Sex change procedures or treatment Effective February 1, 2004
HEALTH NET LIFE INSURANCE COMPANY
Individual & Family Plan PPO Value BASIC Plans

o Physical exams for insurance, licensing, employment, school or camp. Any physical, vision or hearing
exams that are not related to diagnosis or treatment of illness or injury, except as specifically stated in the Health Net Life Policy o Any outpatient drugs, medications or other substances dispensed or administered in any setting, except as specifically stated in the Health Net Life Policy o Services for conditions of pregnancy that result under a surrogate parenting agreement when compensation is obtained for the surrogacy o Conditions covered by Workers' Compensation or similar laws o Any expenses related to the following items, whether authorized by a physician or not: (a) disposable supplies for home use; (b) exercise equipment; (c) hygienic equipment, jacuzzis and spas; (d) surgical dressings; (e) support appliances and supplies such as stockings; arch supports; and (f) Personal or comfort items o Conditions caused by acts of war, whether or not declared o Conditions caused by the Member's commission (or attempted commission) of a felony o Conditions caused by release of nuclear energy, when government funds are available o Amounts charged by Out-of-Network providers for covered medical services and treatment that Health Net Life determines to be in excess of the covered expense o Optometric services, eye exercises including orthoptics, except as specifically stated in the Policy o Services or supplies received for the treatment of a pre-existing condition during the first six consecutive months during which the Member is covered o Immunizations or inoculations for adults or children, except as described in the Policy o Any services not related to the diagnosis or treatment of a covered illness or injury o Inpatient room and board charges incurred in connection with an admission to a hospital or other inpatient treatment facility primarily for diagnostic tests that could have been performed safely on an outpatient basis o Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain o Expenses in excess of a hospital's (or other inpatient facility's) most common semiprivate room rate o Treatment of chronic alcoholism, drug addiction and other chemical dependency problems, including detoxification services, except as specifically stated in the Policy o Any expenses related to the following items, whether authorized by a physician or not: (a) alteration of the Member's residence to accommodate the Member's physical or medical condition, including the installation of elevators; (b) corrective appliances, except prosthetics, casts and splints; (c) air purifiers, air conditioners and humidifiers; and (d) educational services or nutritional counseling, except as specifically provided in the Policy o Treatment or surgery for obesity, weight reduction or weight control, except when provided for morbid obesity, as determined by Health Net Life o All benefits provided under the Policy shall be reduced by any amounts to which a Member is entitled under the program commonly referred to as Medicare when federal law permits Medicare to pay before an individual health plan. o Services performed by a person who lives in the Member's home or who is related to the Member by blood o Physician self-treatment o Any services provided by, or for which payment is made by, a local, state or federal government agency. This limitation does not apply to Medi-Cal, Medicaid or Medicare. o If the Member receives services or obtains supplies in a foreign country, benefits will be payable for o Hyperkinetic syndromes, learning disabilities, behavior problems or mental retardation regardless of the type of service. Certain conditions are covered if their level of severity meets the criteria of Serious Emotional Disturbances of a Child or Severe Mental Illness o Services to diagnose, evaluate or treat infertility IFP20031024 Effective February 1, 2004
HEALTH NET LIFE INSURANCE COMPANY
Individual & Family Plan PPO Value BASIC Plans

*When a Medically Necessary mastectomy has been performed, breast reconstruction surgery and surgery
performed on either breast to restore or achieve symmetry (balanced proportions) in the breast are covered. In
addition when surgery is performed to correct or repair abnormal structures of the body caused by, congenital
defects, developmental abnormalities, trauma, Infection, tumors, or disease, to do either of the following:
improve function or create a normal appearance to the extent possible, unless the surgery offers a minimal
improvement in the appearance of the member.
Additional exclusions and limitations for:
Value PPO 25, Value PPO 400, Value PPO 750, Value
Basic 500, and NetSaver 1500
o Care for conditions of pregnancy, including hospital and professional services. This includes prenatal and

Value Basic 500, Value Basic 1000 and NetSaver 1500
o Immunizations or inoculations for foreign travel or occupational purposes.
o Allergy serum

Value Basic 500, Value Basic 1000, Value Basic 2500, Value Basic 4000 and
NetSaver 1500
o Acupuncture
o Chiropractic Services
o Routine physical examinations

Value Basic 500
o Rehabilitative services
NetSaver 1500
o Outpatient Prescription Drugs

EFFECTIVE FEBRUARY 1, 2004
HEALTH NET OF CALIFORNIA, INC.
Individual & Family HMO and EOA Plans

HMO EXCLUSIONS & LIMITATIONS

No payment will be made under the Health Net Individual & Family HMO or EOA Plans for
expenses incurred for or which are follow-up care to any of the items below. The following are
selective listings only. For comprehensive listings, see the Health Net Individual & Family Plan
Contract and Evidence of Coverages (EOC) for the HMO or the EOA plans.
o Services and Supplies which Health Net determines are not medically necessary, except as set
out under "Does Health Net cover the cost of participation in clinical trials? or "What if I have a disagreement with Health Net" in Common Questions. o Custodial Care. Custodial Care is not rehabilitative care and is primarily provided to assist a patient in meeting the activities of daily living such as: help in walking, getting in and out of bed, bathing, dressing, feeding and preparation of special diets, and supervision of medications which are ordinarily self-administered, but not care that requires skilled nursing services on a continuing basis. o Procedures that Health Net determines to be experimental or investigational, except as set out under "Does Health Net cover the cost of participation in clinical trials? or "What if I have a disagreement with Health Net" in Common Questions. o Services or supplies provided before the effective date of coverage; services or supplies provided after coverage through this plan has ended are not covered o Services for which the Member is not legally obligated to pay or for which no charge is made to o Any service or supplies not specifically listed as covered expenses o Services or supplies that are intended to impregnate a woman are not covered o Oral contraceptives are covered. Vaginal contraceptives are limited to diaphragms, cervical caps and IUDs, and are only covered when a Member Physician performs a fitting examination and, in the case of diaphragms and cervical caps, prescribes the device. IUDs are only available through the member Physician’s office, are covered as a medical benefit, and are limited to one fitting and device per year, unless additional fittings or devices are medically necessary. Diaphragms and cervical caps are only available through a prescription from a pharmacy and are limited to one prescription per year unless additional fittings or devices are medically necessary. Injectable contraceptives are covered as a medical benefit when administered by a physician. o Cosmetic surgery that is performed to alter or reshape normal structures of the body in order to o Dental care** o Treatment and services for a Temporomandibular Joint Disorder are covered when determined to be medically necessary, excluding crowns, inlays, bridgework and appliances o Any services or supplies furnished by a non-eligible institution that is other than a legally operated hospital or Medicare-approved skilled nursing facility, or that is primarily a place for the aged, a nursing home or any similar institution, regardless of how designated. o Surgery and related services for the purpose of correcting the malposition or improper development of the bones of the upper or lower jaw, except when such surgery is required due to trauma or the existence of tumors or neoplasms, or when otherwise medically necessary o Hearing aids o Treatment for mental disorders as a condition of parole or probation and court ordered testing IFP20031024 EFFECTIVE FEBRUARY 1, 2004
HEALTH NET OF CALIFORNIA, INC.
Individual & Family HMO and EOA Plans
o Private duty nursing o Any eye surgery for the purpose of correcting refractive defects of the eye, unless medically necessary, recommended by the Member’s treating physician and authorized by Health Net o Contact or corrective lenses (except an implanted lens that replaces the organic eye lens), o Services to reverse voluntary surgically induced infertility o Sex change procedures or treatment o Physical exams for insurance, licensing, employment, school or camp. Any physical, vision or hearing exams that are not related to diagnosis or treatment of illness or injury, except as specifically stated in the Health Net HMO or EOA Plan Contract and EOC o Any outpatient drugs, medications or other substances dispensed or administered in any setting, except as specifically stated in the Health Net HMO or EOA Plan Contract and EOC o Services for a surrogate pregnancy are covered. However, when compensation is obtained for a surrogacy, Health Net shall have a lien on such compensation to recover its medical expense o Although this plan covers Durable Medical Equipment, it does not cover the following items: (a) exercise equipment; (b) hygienic equipment, jacuzzis and spas; (c) surgical dressings other than primary dressings that are applied by your Physician Group or a Hospital to lesions of the skin or surgical incisions; and (d) stockings, corrective shoes and arch supports. o Personal or comfort items o Disposable supplies for home use o Home birth, unless the criteria for emergency care have been met o Physician self-treatment o Physicians treating immediate family members o Chiropractic services o Home health care (limited to 100 combined visits per calendar year; maximum three visits per o Medical services or supplies that are not authorized by Health Net or the physician group o Treatment for alcoholism or drug addiction, except detoxification o Services and supplies rendered by a nonparticipating physician without authorization from o Diagnostic procedures or testing for genetic disorders, except for prenatal diagnosis of fetal genetic disorders in cases of high risk pregnancy o Nonprescription drug, medical equipment or supply that can be purchased without a prescription (except when prescribed by a physician for management and treatment of diabetes). If a drug that was previously available by prescription becomes available in an over-the-counter (OTC) form in the same prescription strength, then any prescription drugs that are similar agents and have comparable clinical effect(s), will only be covered when Prior Authorization is obtained from Health Net. o Routine foot care, unless medically necessary for a diabetic condition o Treatment of obesity when obtained through group programs or organized clinics o Acupuncture o Services to diagnose, evaluate or treat infertility are not covered o Services related to educational and professional purposes EFFECTIVE FEBRUARY 1, 2004
HEALTH NET OF CALIFORNIA, INC.
Individual & Family HMO and EOA Plans
o Treatment, testing or screening of learning disabilities, except for some conditions when the level of severity meets the criteria of severe mental illness or serious emotional disturbances of a child * When a Medically Necessary mastectomy has been performed, breast reconstruction surgery and surgery performed on either breast to restore or achieve symmetry (balanced proportions) in the breast are covered. In addition when surgery is performed to correct or repair abnormal structures of the body caused by, congenital defects, developmental abnormalities, trauma, Infection, tumors, or disease, to do either of the following: improve function or create a normal appearance to the extent possible, unless the surgery offers a minimal improvement in the appearance of the member. ** The HMO 15 Plus, HMO 40 Plus and EOA 15 Plus plans includes certain dental and vision services. ADDITIONAL EXCLUSIONS AND LIMITATIONS FOR ELECT OPEN ACCESS PLANS, OPEN ACCESS BENEFIT
ONLY

o Blood transfusions, including blood processing, the cost of blood, unreplaced blood and blood o Any expenses for sterilization
o Visits by a physician to a member's home
o Ground or air ambulance or other medical transportation services
o Renal dialysis
o Home health care visits
o Hospice care
o All services and supplies related to pregnancy
o Any expenses related to inpatient hospital or skilled nursing care
o Outpatient hospital services, including outpatient surgery
o Durable medical equipment
o Wellness and other patient educational programs

Additional HMO and EOA Product Information
Mental Health and chemical dependency services

Health Net has contracted exclusively with Managed Health Network (the Administrator), specializing in mental health and chemical dependency services. Members can call 1-888-426-0030 without need for an authorization from their Health Net contracting physician group. The direct access to confidential assessment ensures that any enrolled Member who calls will receive timely care specific to their individual needs. o When Health Net Members need mental health or chemical dependency care, simply call the toll-free line. For a referral, intake specialists and clinicians are on duty to take calls 24 hours a day, seven days a week. This 24-hour availability enhances your access, and reduces the possibility of going to a nonparticipating provider for care. o Members who call for non-emergency care will always be referred for an initial evaluation. You will be given the name of a qualified mental health professional from a comprehensive specialty network. There are no additional requirements, and all evaluations are scheduled

Source: http://www.quickquote.com/vf/brochures/HealthNet/HN-Exclusions.pdf

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