January 1 – December 31, 2018 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Health Net Gold Select (HMO) This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2018. It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, Health Net Gold Select (HMO), is offered by Health Net of California, Inc. (When this Evidence of Coverage says “we,” “us,” or “our,” it means Health Net of California, Inc. When it says “plan” or “our plan,” it means Health Net Gold Select (HMO).) Health Net of California, Inc. has a contract with Medicare to offer HMO plans. Enrollment in a Health Net Medicare Advantage plan depends on the renewal of these contracts. This document is available for free in Spanish. Please contact our Member Services number at 1-800-275-4737 for additional information. (TTY users should call 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. This information is also available in a different format, including large print and audio. Please call Member Services at the number listed on the back cover of this booklet if you need plan information in another format. Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2019. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. H0562_18_101_001ANOCEOC Accepted 09052017 539710 EOC017448EO00 H0562_101-001 Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Expires: May 31, 2020) (Approved 05/2017) 2018 Evidence of Coverage for Health Net Gold Select (HMO) 1 Table of Contents 2018 Evidence of Coverage Table of Contents This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member .................................................................. 4 Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, the Part D late enrollment penalty, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources ........................................... 23 Tells you how to get in touch with our plan (Health Net Gold Select (HMO)) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Chapter 3. Using the plan’s coverage for your medical services ........................ 42 Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan’s network and how to get care when you have an emergency. Chapter 4. Medical Benefits Chart (what is covered and what you pay) ............. 59 Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care. Chapter 5. Using the plan’s coverage for your Part D prescription drugs ........ 161 Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan’s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan’s programs for drug safety and managing medications. 539710 EOC017448EO00 H0562_101-001 2018 Evidence of Coverage for Health Net Gold Select (HMO) 2 Table of Contents Chapter 6. What you pay for your Part D prescription drugs ............................. 183 Tells about the three stages of drug coverage (Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the six cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost- sharing tier. Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs ................................................................... 203 Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Chapter 8. Your rights and responsibilities ......................................................... 211 Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ....................................... 224 Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. • Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. • Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan ................................................. 280 Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices ........................................................................................ 289 Includes notices about governing law and about non-discrimination. Chapter 12. Definitions of important words ........................................................... 303 Explains key terms used in this booklet. CHAPTER 1 Getting started as a member 2018 Evidence of Coverage for Health Net Gold Select (HMO) 4 Chapter 1. Getting started as a member Chapter 1. Getting started as a member SECTION 1 Introduction ........................................................................................ 6 Section 1.1 You are enrolled in Health Net Gold Select (HMO), which is a Medicare HMO ................................................................................................................ 6 Section 1.2 What is the Evidence of Coverage booklet about? .......................................... 6 Section 1.3 Legal information about the Evidence of Coverage ........................................ 6 SECTION 2 What makes you eligible to be a plan member? .............................. 7 Section 2.1 Your eligibility requirements .......................................................................... 7 Section 2.2 What are Medicare Part A and Medicare Part B? ........................................... 7 Section 2.3 Here is the plan service area for Health Net Gold Select (HMO) ................... 7 Section 2.4 U.S. Citizen or Lawful Presence ..................................................................... 8 SECTION 3 What other materials will you get from us? ..................................... 8 Section 3.1 Your plan membership card – Use it to get all covered care and prescription drugs ............................................................................................ 8 Section 3.2 The Provider Directory: Your guide to all providers in the plan’s network ... 9 Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network ........... 10 Section 3.4 The plan’s List of Covered Drugs (Formulary) ............................................ 11 Section 3.5 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs .................. 11 SECTION 4 Your monthly premium for Health Net Gold Select (HMO) ........... 11 Section 4.1 How much is your plan premium? ................................................................ 11 SECTION 5 Do you have to pay the Part D “late enrollment penalty”? ........... 12 Section 5.1 What is the Part D “late enrollment penalty”? .............................................. 12 Section 5.2 How much is the Part D late enrollment penalty? ......................................... 13 Section 5.3 In some situations, you can enroll late and not have to pay the penalty ....... 13 Section 5.4 What can you do if you disagree about your Part D late enrollment penalty? ......................................................................................................... 14 SECTION 6 Do you have to pay an extra Part D amount because of your income? ............................................................................................. 14 Section 6.1 Who pays an extra Part D amount because of income? ................................ 14 Section 6.2 How much is the extra Part D amount? ......................................................... 15 Section 6.3 What can you do if you disagree about paying an extra Part D amount? ..... 16 Section 6.4 What happens if you do not pay the extra Part D amount? ........................... 16 2018 Evidence of Coverage for Health Net Gold Select (HMO) 5 Chapter 1. Getting started as a member SECTION 7 More information about your monthly premium ............................ 16 Section 7.1 If you pay a Part D late enrollment penalty, there are several ways you can pay your penalty ...................................................................................... 17 Section 7.2 Can we change your monthly plan premium during the year? ...................... 18 SECTION 8 Please keep your plan membership record up to date ................. 19 Section 8.1 How to help make sure that we have accurate information about you .......... 19 SECTION 9 We protect the privacy of your personal health information ........ 20 Section 9.1 We make sure that your health information is protected ............................... 20 SECTION 10 How other insurance works with our plan ..................................... 20 Section 10.1 Which plan pays first when you have other insurance? ................................ 20 2018 Evidence of Coverage for Health Net Gold Select (HMO) 6 Chapter 1. Getting started as a member SECTION 1 Introduction Section 1.1 You are enrolled in Health Net Gold Select (HMO), which is a Medicare HMO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, Health Net Gold Select (HMO). There are different types of Medicare health plans. Health Net Gold Select (HMO) is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization) approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. The word “coverage” and “covered services” refers to the medical care and services and the prescription drugs available to you as a member of Health Net Gold Select (HMO). It’s important for you to learn what the plan’s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan’s Member Services (phone numbers are printed on the back cover of this booklet). Section 1.3 Legal information about the Evidence of Coverage It’s part of our contract with you This Evidence of Coverage is part of our contract with you about how our plan covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called “riders” or “amendments.” The contract is in effect for months in which you are enrolled in our plan between January 1, 2018 and December 31, 2018. Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of our plan after December 31, 2018. We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2018. 2018 Evidence of Coverage for Health Net Gold Select (HMO) 7 Chapter 1. Getting started as a member Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan. SECTION 2 What makes you eligible to be a plan member? Section 2.1 Your eligibility requirements You are eligible for membership in our plan as long as: • You have both Medicare Part A and Medicare Part B (Section 2.2 tells you about Medicare Part A and Medicare Part B) • -- and -- you live in our geographic service area (Section 2.3 below describes our service area). • -- and -- you are a United States citizen or are lawfully present in the United States • -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: • Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies). • Medicare Part B is for most other medical services (such as physician’s services and other outpatient services) and certain items (such as durable medical equipment (DME) and supplies). Section 2.3 Here is the plan service area for Health Net Gold Select (HMO) Although Medicare is a Federal program, our plan is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below. Our service area includes these counties in California: Los Angeles and Orange. NOTE: Health Net Gold Select (HMO)'s service area is "segmented" (“segmented” means that the counties that make up the plan's overall service area are divided into smaller service area 2018 Evidence of Coverage for Health Net Gold Select (HMO) 8 Chapter 1. Getting started as a member groups). The following counties are part of Health Net Gold Select (HMO)'s overall service area but are part of a different segment: Riverside and San Bernardino, California. If you move from your current location to Riverside or San Bernardino counties, you will continue to be a member of Health Net Gold Select (HMO) and will not be disenrolled from Health Net. You will, however, receive a new identification card and Evidence of Coverage (EOC), as applicable. The premium, benefits, and cost-sharing may be different. You are required to contact Health Net Member Services in order to keep your membership record up to date. Please see Chapter 8, “Your rights and responsibilities,” Section 2.1 for more information about reporting changes to your address of residence. If you have any questions about your plan's service area, please call Member Services. Phone numbers are printed on the back cover of this booklet. If you plan to move out of the service area, please contact Member Services (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location. It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. Section 2.4 U.S. Citizen or Lawful Presence A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify Health Net Gold Select (HMO) if you are not eligible to remain a member on this basis. Health Net Gold Select (HMO) must disenroll you if you do not meet this requirement. SECTION 3 What other materials will you get from us? Section 3.1 Your plan membership card – Use it to get all covered care and prescription drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. You should also show the provider your Medicaid card, if applicable. Here’s a sample membership card to show you what yours will look like: 2018 Evidence of Coverage for Health Net Gold Select (HMO) 9 Chapter 1. Getting started as a member As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here’s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your plan membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. (Phone numbers for Member Services are printed on the back cover of this booklet.) Section 3.2 The Provider Directory: Your guide to all providers in the plan’s network The Provider Directory lists our network providers. What are “network providers”? Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The most recent list of providers is available on our website at https://ca.healthnetadvantage.com. Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and