| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
Small Group Business Submission Checklist |
01/01/2021 | Download |
|
Employer Application 1.22 |
01/01/2022 | Download |
|
Employer Application 1.23 |
01/01/2023 | Download |
|
Electronic Check Form |
05/01/2022 | Download |
|
Group Size Attestation Form |
07/01/2022 | Download |
|
Proof of Eligibility Statement for Sole Proprietor, Partner or Corporate Officer |
01/01/2022 | Download |
|
Religious Organization Exemption Form |
07/01/2022 | Download |
|
In Force Group Forms |
||
|
Employer Group Size Attestation Form |
07/01/2022 | Download |
|
Renewal Plan Election & Open Enrollment Change Form 1.22 |
01/01/2022 | Download |
|
Renewal Plan Election & Open Enrollment Change Form 1.23 |
01/01/2023 | Download |
|
Ancillary Add-On or Change Form |
07/01/2022 | Download |
|
Administration |
||
|
Welcome To Health Net Employer Guide |
07/01/2022 | Download |
|
EFT Online Set Up Instructions |
07/01/2022 | Download |
|
Registering as a Client Administrator Flyer |
07/01/2022 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment/Change Form 1.22 |
01/01/2022 | Download |
|
Employee Enrollment/Change Form 1.23 |
01/01/2023 | Download |
|
Understanding the Continuity of Care Assistance Policy |
07/01/2022 | Download |
|
Continuity of Care Assistance Form |
07/01/2022 | Download |
|
Prescription Transition Form |
07/01/2022 | Download |
|
Life Insurance Employee Enrollment/Change Form |
07/01/2022 | Download |
|
Evidence of Insurability Form |
07/01/2022 | Download |
|
Claim Forms |
||
|
Authorization to Use and Disclose Health Information |
07/01/2022 | Download |
|
Medical Claim Form |
07/01/2022 | Download |
|
Prescription Drug Claim Form |
07/01/2022 | Download |
|
Dental Claim Form |
07/01/2022 | Download |
|
Vision Claim Form |
07/01/2022 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2023 Medical HMO |
|||
|
Full Network HMO |
|||
|
Full Network HMO Platinum $0 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Platinum $0 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Platinum $10 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Platinum $10 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Platinum $20 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Platinum $20 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Platinum $30 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Platinum $30 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Gold $30 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Gold $30 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Gold $35 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Gold $35 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Gold $40 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Gold $40 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Gold $50 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Gold $50 + Infertility |
01/01/2023 | SBC | |
|
Full Network HMO Silver $55 |
01/01/2023 | Summary | SBC |
|
Full Network HMO Silver $55 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Network |
|||
|
WholeCare HMO Platinum $0 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Platinum $0 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Platinum $10 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Platinum $10 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Platinum $20 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Platinum $20 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Platinum $30 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Platinum $30 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Gold $30 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Gold $30 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Gold $35 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Gold $35 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Gold $40 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Gold $40 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Gold $50 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Gold $50 + Infertility |
01/01/2023 | SBC | |
|
WholeCare HMO Silver $55 |
01/01/2023 | Summary | SBC |
|
WholeCare HMO Silver $55 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Network |
|||
|
SmartCare HMO Platinum $0 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Platinum $0 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Platinum $10 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Platinum $10 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Platinum $20 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Platinum $20 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Platinum $30 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Platinum $30 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Gold $30 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Gold $30 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Gold $35 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Gold $35 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Gold $40 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Gold $40 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Gold $50 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Gold $50 + Infertility |
01/01/2023 | SBC | |
|
SmartCare HMO Silver $55 |
01/01/2023 | Summary | SBC |
|
SmartCare HMO Silver $55 + Infertility |
01/01/2023 | SBC | |
|
Salud y Mas HMO Network |
|||
|
Salud HMO y Mas Platinum $0 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Platinum $0 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Platinum $10 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Platinum $10 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Platinum $20 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Platinum $20 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Platinum $30 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Platinum $30 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Gold $30 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Gold $30 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Gold $35 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Gold $35 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Gold $40 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Gold $40 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Gold $50 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Gold $50 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas Silver $55 |
01/01/2023 | Summary | SBC |
|
Salud HMO y Mas Silver $55 + Infertility |
01/01/2023 | SBC | |
|
Salud HMO y Mas SIMNSA |
01/01/2023 | Summary | |
|
CommunityCare HMO Network |
|||
|
CommunityCare HMO Silver $2250/$50 |
01/01/2023 | Summary | SBC |
|
CommunityCare HMO Silver $2250/$50 + Infertility |
01/01/2023 | SBC | |
|
CommunityCare HMO Bronze $6300/$65 |
01/01/2023 | Summary | SBC |
|
CommunityCare HMO Bronze $6300/$65 + Infertility |
01/01/2023 | SBC | |
|
2023 Medical PPO |
|||
|
Full Network |
|||
|
Platinum PPO 0/15 |
01/01/2023 | Summary | SBC |
|
Platinum PPO 0/15 + Infertility |
01/01/2023 | SBC | |
|
Platinum PPO 250/15 |
01/01/2023 | Summary | SBC |
|
Platinum PPO 250/15 + Infertility |
01/01/2023 | SBC | |
|
Gold PPO 0/35 |
01/01/2023 | Summary | SBC |
|
Gold PPO 0/35 + Infertility |
01/01/2023 | SBC | |
|
Gold PPO 350/25 |
01/01/2023 | Summary | SBC |
|
Gold PPO 350/25 + Infertility |
01/01/2023 | SBC | |
|
Gold PPO 500/20 |
01/01/2023 | Summary | SBC |
|
Gold PPO 500/20 + Infertility |
01/01/2023 | SBC | |
|
Gold PPO 750/15 |
01/01/2023 | Summary | SBC |
|
Gold PPO 750/15 + Infertility |
01/01/2023 | SBC | |
|
Gold PPO 1000/35 |
01/01/2023 | Summary | SBC |
|
Gold PPO 1000/35 + Infertility |
01/01/2023 | SBC | |
|
Gold PPO 1600/0 |
01/01/2023 | Summary | SBC |
|
Gold PPO 1600/0 + Infertility |
01/01/2023 | SBC | |
|
Silver PPO 1700/50 |
01/01/2023 | Summary | SBC |
|
Silver PPO 1700/50 + Infertility |
01/01/2023 | SBC | |
|
Silver PPO 2250/60 |
01/01/2023 | Summary | SBC |
|
Silver PPO 2250/60 + Infertility |
01/01/2023 | SBC | |
|
Silver PPO 2500/55 |
01/01/2023 | Summary | SBC |
|
Silver PPO 2500/55 + Infertility |
01/01/2023 | SBC | |
|
Silver HDHP PPO 1500/50% |
01/01/2023 | Summary | SBC |
|
Silver HDHP PPO 1500/50% + Infertility |
01/01/2023 | SBC | |
|
Bronze PPO 6300/65 |
01/01/2023 | Summary | SBC |
|
Bronze PPO 6300/65 + Infertility |
01/01/2023 | SBC | |
|
Bronze HDHP PPO 7000/0% |
01/01/2023 | Summary | SBC |
|
Bronze HDHP PPO 7000/0% + Infertility |
01/01/2023 | SBC | |
|
2022 Medical HMO |
|||
|
Full Network HMO |
|||
|
Full Network HMO Platinum $0 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Platinum $0 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Platinum $10 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Platinum $10 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Platinum $20 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Platinum $20 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Platinum $30 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Platinum $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Gold $30 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Gold $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Gold $35 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Gold $35 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Gold $40 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Gold $40 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Gold $50 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Gold $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
Full Network HMO Silver $50 |
01/01/2022 | Summary | SBC |
|
Full Network HMO Silver $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Network |
|||
|
WholeCare HMO Platinum $0 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Platinum $0 +INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Platinum $10 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Platinum $10 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Platinum $20 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Platinum $20 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Platinum $30 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Platinum $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Gold $30 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Gold $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Gold $35 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Gold $35 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Gold $40 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Gold $40 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Gold $50 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Gold $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
WholeCare HMO Silver $50 |
01/01/2022 | Summary | SBC |
|
WholeCare HMO Silver $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Network |
|||
|
SmartCare HMO Platinum $0 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Platinum $0 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Platinum $10 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Platinum $10 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Platinum $20 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Platinum $20 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Platinum $30 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Platinum $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Gold $30 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Gold $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Gold $35 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Gold $35 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Gold $40 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Gold $40 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Gold $50 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Gold $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
SmartCare HMO Silver $50 |
01/01/2022 | Summary | SBC |
|
SmartCare HMO Silver $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud y Mas HMO Network |
|||
|
Salud HMO y Mas Platinum $0 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Platinum $0 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Platinum $10 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Platinum $10 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Platinum $20 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Platinum $20 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Platinum $30 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Platinum $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Gold $30 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Gold $30 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Gold $35 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Gold $35 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Gold $40 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Gold $40 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Gold $50 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Gold $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
Salud HMO y Mas Silver $50 |
01/01/2022 | Summary | SBC |
|
Salud HMO y Mas Silver $50 INF (with Infertility) |
01/01/2022 | SBC | |
|
CommunityCare HMO Network |
|||
|
CommunityCare HMO Silver $1750/$50 |
01/01/2022 | Summary | SBC |
|
CommunityCare HMO Silver $1750/$50 INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net CommunityCare Bronze 60 HMO 6300/65 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net CommunityCare Bronze 60 HMO 6300/65 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
2022 Medical HSP |
|||
|
Health Net PureCare Platinum 90 HSP 0/15 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net PureCare Platinum 90 HSP 0/15 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net PureCare Gold 80 HSP 350/25 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net PureCare Gold 80 HSP 350/25 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net PureCare Silver 70 HSP 2250/50 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net PureCare Silver 70 HSP 2250/50 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net PureCare Bronze 60 HSP 6300/65 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net PureCare Bronze 60 HSP 6300/65 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
2022 Medical PPO |
|||
|
Full Network |
|||
|
Health Net Platinum 90 PPO 0/15 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net Platinum 90 PPO 0/15 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Platinum 90 PPO 250/15 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Platinum 90 PPO 250/15 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Gold 80 PPO 0/30 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Gold 80 PPO 0/30 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Gold 80 PPO 350/25 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net Gold 80 PPO 350/25 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Gold 80 PPO 500/20 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Gold 80 PPO 500/20 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Gold 80 Value PPO 750/15 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Gold 80 Value PPO 750/15 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Gold 80 PPO 1000/30 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Gold 80 PPO 1000/30 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Gold 80 PPO 1500/0 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Gold 80 PPO 1500/0 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Silver 70 PPO 2250/50 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net Silver 70 PPO 2250/50 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Silver 70 PPO 2250/55 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Silver 70 PPO 2250/55 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Bronze 60 PPO 6300/65 + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental |
01/01/2022 | Summary | SBC |
|
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental INF (with Infertility) |
01/01/2022 | SBC | |
|
EnhancedCare PPO Network |
|||
|
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 0/30 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 0/30 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 500/20 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 500/20 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Gold 80 Value PPO 750/15 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 Value PPO 750/15 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 1500/0 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 1500/0 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Silver 70 Value PPO 1700/50 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Silver 70 Value PPO 1700/50 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt |
01/01/2022 | Summary | SBC |
|
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility) |
01/01/2022 | SBC | |
|
2021 Medical HMO |
|||
|
Full HMO Network |
|||
|
Full Network HMO Platinum $0 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Platinum $0 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Platinum $10 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Platinum $10 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Platinum $20 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Platinum $20 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Platinum $30 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Platinum $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Gold $30 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Gold $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Gold $35 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Gold $35 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Gold $40 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Gold $40 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Gold $50 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Gold $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
Full Network HMO Silver $50 |
01/01/2021 | Summary | SBC |
|
Full Network HMO Silver $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Network |
|||
|
WholeCare HMO Platinum $0 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Platinum $0 +INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Platinum $10 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Platinum $10 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Platinum $20 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Platinum $20 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Platinum $30 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Platinum $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Gold $30 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Gold $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Gold $35 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Gold $35 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Gold $40 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Gold $40 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Gold $50 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Gold $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
WholeCare HMO Silver $50 |
01/01/2021 | Summary | SBC |
|
WholeCare HMO Silver $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Network |
|||
|
SmartCare HMO Platinum $0 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Platinum $0 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Platinum $10 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Platinum $10 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Platinum $20 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Platinum $20 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Platinum $30 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Platinum $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Gold $30 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Gold $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Gold $35 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Gold $35 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Gold $40 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Gold $40 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Gold $50 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Gold $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
SmartCare HMO Silver $50 |
01/01/2021 | Summary | SBC |
|
SmartCare HMO Silver $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
CommunityCare HMO Network |
|||
|
CommunityCare HMO Silver $1750/$50 |
01/01/2021 | Summary | SBC |
|
CommunityCare HMO Silver $1750/$50 INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net CommunityCare Bronze 60 HMO 6300/65 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net CommunityCare Bronze 60 HMO 6300/65 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud y Mas HMO Network |
|||
|
Salud HMO y Mas Platinum $0 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Platinum $0 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Platinum $10 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Platinum $10 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Platinum $20 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Platinum $20 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Platinum $30 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Platinum $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Gold $30 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Gold $30 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Gold $35 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Gold $35 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Gold $40 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Gold $40 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Gold $50 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Gold $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
Salud HMO y Mas Silver $50 |
01/01/2021 | Summary | SBC |
|
Salud HMO y Mas Silver $50 INF (with Infertility) |
01/01/2021 | SBC | |
|
2021 Medical HSP |
|||
|
Health Net PureCare Platinum 90 HSP 0/15 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net PureCare Platinum 90 HSP 0/15 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net PureCare Gold 80 HSP 350/25 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net PureCare Gold 80 HSP 350/25 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net PureCare Silver 70 HSP 2250/50 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net PureCare Silver 70 HSP 2250/50 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net PureCare Bronze 60 HSP 6300/65 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net PureCare Bronze 60 HSP 6300/65 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
2021 Medical PPO |
|||
|
Full PPO Network |
|||
|
Health Net Platinum 90 PPO 0/15 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net Platinum 90 PPO 0/15 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Platinum 90 PPO 250/15 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Platinum 90 PPO 250/15 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Gold 80 PPO 0/30 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Gold 80 PPO 0/30 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Gold 80 PPO 350/25 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net Gold 80 PPO 350/25 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Gold 80 PPO 500/20 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Gold 80 PPO 500/20 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Gold 80 Value PPO 750/15 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Gold 80 Value PPO 750/15 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Gold 80 PPO 1000/30 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Gold 80 PPO 1000/30 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Gold 80 PPO 1500/0 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Gold 80 PPO 1500/0 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Silver 70 PPO 2250/50 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net Silver 70 PPO 2250/50 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Silver 70 PPO 2250/55 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Silver 70 PPO 2250/55 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Bronze 60 PPO 6300/65 + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental |
01/01/2021 | Summary | SBC |
|
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental INF (with Infertility) |
01/01/2021 | SBC | |
|
EnhancedCare PPO Network |
|||
|
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 0/30 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 0/30 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 500/20 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 500/20 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Gold 80 Value PPO 750/15 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 Value PPO 750/15 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Gold 80 PPO 1500/0 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Gold 80 PPO 1500/0 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Silver 70 Value PPO 1700/50 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Silver 70 Value PPO 1700/50 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC | |
|
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt |
01/01/2021 | Summary | SBC |
|
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility) |
01/01/2021 | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
2023 Small Group Broker Portfolio Guide |
01/01/2023 | Download |
|
2023 Small Group Portfolio Desktopper |
01/01/2023 | Download |
|
2023 Small Group Ancillary Products Guide |
01/01/2023 | Download |
|
Ancillary Product Sell Sheet 1.23 |
01/01/2023 | Download |
|
2022 Small Group Broker Portfolio Guide |
01/01/2022 | Download |
|
2022 Small Group Portfolio Desktopper |
01/01/2022 | Download |
|
2022 Small Group Ancillary Products Guide |
01/01/2022 | Download |
|
Ancillary Product Sell Sheet 1.22 |
01/01/2022 | Download |
|
Small Group Renewal Guide Q1 2023 |
01/01/2023 | Download |
|
Small Group Renewal Guide Q4 2022 |
10/01/2022 | Download |
|
HealthNet.com Flyer |
08/01/2022 | Download |
|
Helpful Information & Resources Flyer |
01/01/2022 | Download |
|
The HSA for Life Employer Flyer |
07/01/2022 | Download |
|
Minute Clinic Listing |
07/01/2022 | Download |
|
Online Provider Search Instructions |
07/01/2022 | Download |
|
Underwriting Simplified Flyer through June 2023 |
04/01/2023 | Download |
|
Underwriting Simplified Flyer through March 2023 |
01/01/2023 | Download |
|
Enhanced Choice Underwriting Guidelines 1.23 |
01/01/2023 | Download |
|
Dental & Vision Underwriting Guidelines 1.23 |
01/01/2023 | Download |
|
Life Underwriting Guidelines 1.23 |
01/01/2023 | Download |
|
SBG Infertility Benefits GA-Broker Talking Points |
02/01/2020 | Download |
|
Small Business Savings Brochure - Southern California |
01/01/2022 | Download |
|
Small Business Savings Brochure - Northern California |
01/01/2022 | Download |
|
Top 10 Reasons to Sell Health Net |
04/01/2022 | Download |
|
Top 10 Reasons for Employee Enrollment Delays |
01/01/2021 | Download |
|
2022 Free Wellness Webinars Flyer |
07/01/2022 | Download |
|
Medical |
||
|
Active & Fit Member Flyer |
01/01/2022 | Download |
|
Babylon Health Flyer |
01/01/2022 | Download |
|
Behavior Health Benefits with MHN Services Flyer |
04/01/2022 | Download |
|
Beginnings Open Enrollment Flyer |
07/01/2022 | Download |
|
California MinuteClinic Health Reference Guide |
01/01/2022 | Download |
|
Decision Power Healthy Discounts Guide |
01/01/2022 | Download |
|
Decision Power Health & Wellness Member Guide |
01/01/2022 | Download |
|
Employee Guide to Health Net Benefits |
01/01/2020 | Download |
|
ER vs Urgent Care Flyer |
07/01/2022 | Download |
|
First Health Network Out of State FAQ for Brokers |
07/01/2022 | Download |
|
First Health Network Out of State FAQ for Members |
07/01/2022 | Download |
|
Generic vs Brand-Name Drugs Information |
07/01/2022 | Download |
|
Getting Started with Mail Order Pharmacy Kit |
07/01/2022 | Download |
|
Maintenance Choice Pharmacy Program |
09/01/2022 | Download |
|
Advanced Choice Pharmacy Network [used for CommunityCare, Salud y Mas, SmartCare HMO plans and EnhancedCare PPO plans] |
01/01/2020 | Download |
|
Standard Pharmacy Network |
01/01/2020 | Download |
|
Health Coaching Program |
07/01/2022 | Download |
|
CommunityCare Network Brochure |
01/01/2023 | Download |
|
Small Group HMO Network Guide – Central California |
09/01/2022 | Download |
|
Small Group HMO Network Guide – Los Angeles County |
09/01/2022 | Download |
|
Small Group HMO Network Guide – Northern California |
09/01/2022 | Download |
|
Small Group HMO Network Guide – Orange County |
09/01/2022 | Download |
|
Small Group HMO Network Guide – Riverside County |
09/01/2022 | Download |
|
Small Group HMO Network Guide – San Bernardino County |
09/01/2022 | Download |
|
Small Group HMO Network Guide – San Diego County |
09/01/2022 | Download |
|
HMO Open Enrollment Flyer |
07/01/2022 | Download |
|
HSA Compatible PPO Plans Brochure |
07/01/2022 | Download |
|
myStrength Program Flyer |
07/01/2022 | Download |
|
Pediatric Dental & Vision (HMO & HSP) Flyer |
09/01/2022 | Download |
|
Pediatric Dental & Vision (PPO) Flyer |
09/01/2022 | Download |
|
PPO Fast Facts |
07/01/2022 | Download |
|
PPO Open Enrollment Flyer |
07/01/2022 | Download |
|
PPO Open Enrollment Brochure |
07/01/2022 | Download |
|
Preventive Care Services Guide |
07/01/2022 | Download |
|
Preventive Screening Guidelines |
07/01/2022 | Download |
|
Prior Carrier Deductible Credit Flyer |
07/01/2022 | Download |
|
Scripps & Salud y Mas Flyer |
11/01/2021 | Download |
|
Salud HMO y Mas Member Brochure-Bilingual |
07/01/2021 | Download |
|
Salud HMO y Mas Service Area |
03/01/2021 | Download |
|
Text4Baby Flyer |
01/01/2020 | Download |
|
Travel Guide - HMO & POS Members |
07/01/2022 | Download |
|
Travel Guide - PPO Members |
07/01/2022 | Download |
|
Uniform Glossary of Health Coverage and Medical Terms |
07/01/2022 | Download |
|
Wellness Rewards Program |
01/01/2022 | Download |
|
Dental |
||
|
Dental Overview Flyer |
01/01/2020 | Download |
|
Dental Member Website Flyer |
01/01/2020 | Download |
|
Dental Provider Search Instructions |
01/01/2020 | Download |
|
Vision |
||
|
Vision Plan Brochure |
01/01/2020 | Download |
|
Vision Member Website Flyer |
01/01/2020 | Download |
|
Life |
||
|
Life and AD&D Product Flyer |
07/01/2022 | Download |
