Fillable Application for Group Service Agreement/Group Policy (Dickerson Insurance Services)

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Application for Group Service Agreement/Group Policy (Dickerson Insurance Services)

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Small Business
Application for Group Service
Agreement/Group Policy
Medical and Life/AD&D plans are provided by Health Net of California, Inc. and/or Health Net Life Insurance Company (together,
“Health Net”). Dental HMO plans, other than pediatric dental, are offered and administered by Dental Benefit Providers of
California, Inc., and dental PPO and indemnity insurance plans, other than pediatric dental, are underwritten by Unimerica Life
Insurance Company and administered by Dental Benefit Administrative Services (together, “DBP”). Vision plans, other than
pediatric vision, are underwritten by Health Net Life Insurance Company and serviced by EyeMed Vision Care, LLC (“EyeMed”)
and Envolve Vision, Inc.
Pediatric dental HMO plans are provided by Health Net of California, Inc. Pediatric dental PPO and indemnity plans are provided
by Health Net Life Insurance Company.
Neither DBP nor EyeMed are affiliated with Health Net. Obligations under dental plans, other than pediatric dental, are not
obligations of, and are not guaranteed by, Health Net.
Application is hereby made for a Group Service Agreement/Group Policy provided by Health Net and/or DBP, the provisions of
which are to be made available to all eligible employees, as defined, and their eligible dependents desiring or requiring coverage
hereunder. The following information regarding employee and/or dependent data is being submitted to allow Health Net and/or
DBP to determine the eligibility of employees and/or dependents seeking enrollment.
Welcome to HealthNet
SIMPLE STEPS FOR COMPLETING THE FORM:
1. Carefully review and select the plan option(s) that is/are best for your business.
2. Make a copy of the completed application for your records.
If a correction is needed, cross out and initial each correction. Please do not use a white-out product.
HealthNet Medical:
1-800-522-0088 (English)
1-800-331-1777 (Spanish)
1-877-891-9053 (Mandarin)
HealthNet Life: 1-800-865-6288
HealthNet Dental: 1-866-249-2382
HealthNet Vision: 1-866-392-6058
PRETAX SOLUTIONS E.G., IRS CODE SECTION 125 PREMIUMONLY PLANS AND FLEX PLANS
If you are interested in learning about the tax savings potential for your employees and company, please contact Total
Administrative Services Corporation (TASC) at 1-800-422-4661.
FOR ADMINISTRATIVE USE ONLY:
Existing Business/Group
PO Box 9103
Van Nuys, CA 91409-9103
www.healthnet.com
New Business/Group
Please send all completed paperwork to your
designated account executive or broker.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
1
Small Business
Application for Group Service
Agreement/Group Policy
Important: If adding Dental or Vision to your existing coverage, please complete sections 1 (ancillary options), 2, 3, 4, 5, 6, 7,
and 8; for all other changes to existing coverage, please complete only sections 2, 3, 4, and 7.
1. Health plan information
SELECT A PACKAGE, THEN SELECT YOUR PLANS:
■■ Enhanced Choice A ■■ Enhanced Choice B ■■ O t h er__________________________________________________________________________________________
FULL HMO NETWORK
1
Platinum
■■ $0 ■■ $10 ■■ $20 ■■ $30
Gold
■■$30 ■■ $35 ■■ $40 ■■$50
Silver
■■ $50
SMARTCARE HMO NETWORK
2
Platinum
■■ $0 ■■ $10 ■■ $20 ■■ $30
Gold
■■$30 ■■ $35 ■■ $40 ■■$50
Silver
■■ $50
WHOLECARE HMO NETWORK
1
Platinum
■■ $0 ■■ $10 ■■ $20 ■■ $30
Gold
■■$30 ■■ $35 ■■ $40 ■■$50
Silver
■■ $50
SALUD HMO Y MÁS NETWORK
3
Platinum
■■ $0 ■■ $10 ■■ $20 ■■ $30
Gold
■■$30 ■■ $35 ■■ $40 ■■$50
Silver
■■ $50
COMMUNITYCARE HMO NETWORK
4
Silver
■■ $1750/$50 Bronze
■■ CommunityCare Bronze 60 HMO 6300/65 + Child Dental
PURECARE HSP NETWORK
1
■■ PureCare Platinum 90 HSP 0/15 + Child Dental
■■ PureCare Gold 80 HSP 350/25 + Child Dental
■■ PureCare Silver 70 HSP 2250/50 + Child Dental
■■ PureCare Bronze 60 HSP 6300/65 + Child Dental
FULL PPO NETWORK
■■ Platinum 90 PPO 0/15 + Child Dental
■■ Platinum 90 PPO 350/15 + Child Dental Alt
■■ Gold 80 PPO 0/30 + Child Dental Alt
■■ Gold 80 PPO 250/25 + Child Dental
■■ Gold 80 PPO 500/20 + Child Dental Alt
■■ Gold 80 PPO 1000/30 + Child Dental Alt
■■ Gold 80 PPO 1500/0 + Child Dental Alt
■■ Gold 80 Value PPO 750/15 + Child Dental Alt
■■ Silver 70 PPO 2250/50 + Child Dental
■■ Silver 70 PPO 2250/55 + Child Dental Alt
■■ Silver 70 HDHP PPO 1400/40% + Child Dental Alt
■■ Silver 70 Value PPO 1700/50 + Child Dental Alt
■■ Bronze 60 PPO 6300/65 + Child Dental
ENHANCEDCARE PPO NETWORK
5
■■ EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt
■■ EnhancedCare Gold 80 PPO 0/30 + Child Dental Alt
■■ EnhancedCare Gold 80 PPO 500/20 + Child Dental Alt
■■ EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt
■■ EnhancedCare Gold 80 PPO 1500/0 + Child Dental Alt
■■ EnhancedCare Gold 80 Value PPO 750/15 + Child Dental Alt
■■ EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt
■■ EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt
■■ EnhancedCare Silver 70 Value PPO 1700/50 + Child Dental Alt
OTHER PLANS:
___________________________________________________________________________________________________________________________________________________
ANCILLARY OPTIONS
Note: All medical plans include pediatric dental and pediatric vision coverage. Individuals will receive pediatric dental and vision
coverage under the medical plan until the last day of the month in which the individual turns 19. For off-cycle dental/vision plan
additions, your renewal date will be coordinated with your medical plan renewal date.
Dental (DHMO)
■■ HN Plus 150
■■ HN Plus 225
Dental (DPPO)
■■ Classic 5 1500 (w/ortho)
■■ Essential 6 1500
■■ Essential 5 1500 (w/ortho)
■■ Essential 2 1000
■■ Classic 4 1500
Vision (PPO)
■■ Elite 1010-1
■■ Preferred 1025-3
■■ Exam Only
■■ Supreme 010-2
■■ Preferred Value 10-3
■■ Preferred 1025-2
■■ Plus 20-1
Optional Rider
■■ Chiropractic (Optional coverage available on all plans except PPO and EnhancedCare PPO.) ■■ Infertility
LIFE AND AD&D OPTIONS IF HEALTHNET LIFE IS SELECTED, ALL FULLTIME EMPLOYEES ARE ELIGIBLE.
■■ $15,000 (2–100 employees) ■■ $25,000 (15–100 employees) ■■ $50,000 (25–100 employees)
FRM049461EC00_SBG_CA (1/21)
(continued)
SBG GSA 1/21
2
2. Employer group information
Company name: DBA: Group #: SIC code:
Tax ID number (TIN): Type of business:
Is the group subject to ERISA?
■■ Yes ■■ No, government, public plan or church plan
■■ No (please specify reason)__________________________________________________________________________________________________________________________
Type of entity (corporation, sole prop., LLC, partnership): Date of business inception: Effective date (renewal date):
Company contact: Telephone: Fax:
Physical address: City: State: ZIP: County:
Billing address (if different from physical address): City: State: ZIP: County:
Email address (print clearly):
Company contact for coordination of benefits (COB) (if different from above):
COB address (if different from physical address): City: State: ZIP: County:
3. Empl oyer contribution
NOTE: EMPLOYER CONTRIBUTION FOR HEALTH IS A MINIMUM OF 50% OF THE LOWEST COST PLAN OR $100 PER
EMPLOYEE, AND FOR LIFE IS 100% 29 ENROLLEES AND 50% 10100 ENROLLEES.
Employee Health: ______% or $______ Employee Life: ______%
Dependent Health: % or $
Employee Dental: ______% Employee Vision: ______%
______ ______ Dependent Dental: ______% Dependent Vision: ______%
Note: Dental and Vision can be either voluntary or employer-paid. If employer-paid, you must complete the employer contribution.
If you select Dental and/or Vision with no contribution, indicate “0.”
4. Eligibility information
1. Will there be eligibility conditions that will apply prior to the probationary period
(e.g., being in an eligible job classification, achieving job-related licensure
requirements, or satisfying a “reasonable and bona fide employment-based
orientation period”)?
■■ Yes ■■ No
2. Employer’s probationary period for new hires/r
ehires – first of the month
following:
■■ Date of hire ■■ 1 mo. ■■ 30 days ■■ 60 days*
*He althNet will adjust the effective date for new enrollees if needed to ensure
that the waiting period doe
s not exceed 90 days.
3. Do you want to waive the probationary period for all enrollees at initial
enrollment?
■■ Yes ■■ No
4. Average number of hours worked per week required to be eligible for medical
insurance cov
erage:
■■ 20 ■■ 30
5. Average number of employees you employed for the entire pr
evious
calendar year regardless of whether or not they were eligible for coverage: _________
An employee is defined as any person for whom the company issues a W-2, including full-
time, part-time, and seasonal workers, and
regardless of insurance eligibility.
6
To calculate the average number of employees, determine the number of employees for each month, add each month’s number to get
an annual total, and then divide by 12 (or the number of months in business if less than 12 months). Round up or down to the nearest
whole number – example: 24.6 = 25. Do not spell out the number – example: write 3, not three.
6.
Total number of employees worldwide (Count all employees throughout
the U.S. regardless of if they are eligible for coverage, including full-time,
part-time, leased, etc. Do not include 1099 employees or seasonal workers.): _________
(continued)
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
3
4. Eligibility information (continued)
Medical Dental Vision Life
7. Number of eligible employees (including eligible owner(s)):
_________ _________ _________ _________
8. Total number of HealthNet enrollees (excluding COBRA enrollees):
_________ _________ _________ _________
9. Number of HealthNet COBRA enrollees (applying for health coverage):
_________ _________ _________ _________
10. Number of waivers (Please include an enrollment form with Section 7
“Declination of Coverage” indicated.):
_________ _________ _________ _________
11. What type of COBRA
7
are you subject to?
■■ Federal COBRA ■■ Cal-COBRA
If federal COBRA, how would you like your COBRA enrollees to be billed?
■■ Group billed ■■ Member billed
12.
Within the last 12 months, has the employer held a HealthNet contract?
■■ Yes ■■ No
13. Do the eligible enrollees represent a carve-out either by location or union
affiliation?
■■ Yes ■■ No
14. Does the group file a DE-9C?
■■ Yes ■■ No
8
5. Current carrier (List current carrier if any.)
Is your company currently active with other health insurance? ■■ Yes ■■ No
If so, will you be canceling your other health insurance if approved with HealthNet? ■■ Yes ■■ No
Current health insurance carrier: ___________________________________________________________
Will HealthNet be the only carrier? ■■ Yes ■■ No If “No,” name of other carrier: _____________________________________________________________ _
Plan(s) offered:
Workers’ compensation carrier:
_________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Number of enrollees not covered by workers’ compensation: ___________________________________________________________________________________________
(Employers required to have workers’ compensation must have a policy in effect to be eligible with HealthNet.)
6. Underwriting criteria
General conditions
The issuance of coverage and a Group Service Agreement/Group P
olicy is subject to underwriting review and approval by HealthNet and/
or DBP and receipt of the first month’s premium. The initial quoted rates are subject to HealthNet and/or DBP’s review and revision based
on actual enrollment and any other variations in the group from conditions outlined in the Underwriting Guidelines.
Coverage will be effective on the noted effective date if the application is accepted and approved by HealthNet and/or DBP as appropriate
within specified time requirements.
7. Arbitration agreement and other important terms
Please complete all of the information requested before signing this application. Please initial any changes.
This is an application only. Coverage and the issuance of a Group Service Agreement/Group Policy is subject to review and approval by
HealthNet and/or DBP and receipt of the first month’s premium.
The undersigned hereby acknowledge to the best of their knowledge or belief that the preceding information constitutes true and complete
representations to HealthNet and/or DBP. Should it be determined at the time of enrollment or during the 24-month period after the Group
Agreement/Group Policy is issued that there has been an intentional misrepresentation of material fact, as prohibited by the terms of this
Group Agreement/Group Policy, the Group Agreement/Group Policy may be canceled with 30 days advance notice of such cancellation.
Upon policy anniversary date, submission of renewal premium will confirm acceptance of that renewal and subsequent premium year.
Applicant, in the event this application is accepted, agrees to make authorized payroll dues deductions for such eligible employees who
enroll under the Group Service Agreement/Group Policy and to forward such amounts in advance of the due date to HealthNet and/or DBP
together with the reports necessary to maintain accurate and complete membership records. Furthermore, applicant agrees to comply
with the applicable regulations pertaining to membership requirements, additions to the group, and deletions from the group. Please return
this application to your HealthNet account executive or broker as specified.
Applicant, in the event this application is accepted, agrees to cooperate with HealthNet in complying fully with the requirements of section 2715
of the Public Health Service Act to disclose summary plan and benefit information to eligible and renewing plan participants and beneficiaries.
Applicant acknowledges that it has received information provided by the HealthNet “Summary of Benefits and Coverage to Eligible and Covered
Persons – Instructions for Reproduction and Distribution” and agrees to assume the responsibilities assigned to the “Group” thereunder. The
undersigned hereby acknowledge responsibility for obtaining and for sending an electronic or printed copy of the Summary of Benefits and
Coverage document (SBC) to plan participants and beneficiaries. To retrieve your group’s SBCs, go to www.healthnet.com/sbc.
(continued)
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
4
7. Arbitration agreement and other important terms (continued)
The following standard minimum participation and contribution requirements apply unless modified in quote or renewal underwriting
guidelines.
Minimum contribution is defined as: The employer contribution toward HealthNet’s premium that must be equal to or greater than 50% or $100
of employee single premium.
Minimum participation is defined as: For groups of 1–5 eligible employees, a minimum of 70% participation is required. For groups of 6–100
eligible employees, a minimum of 25% participation or 5 active subscribers, whichever is greater, is required.
Failure to maintain these minimum contribution and minimum participation requirements may result in termination or non-renewal.
This Application for Group Service Agreement/Group Policy and any attached Addendum, together with the HealthNet and/or DBP Plan Contract
or Insurance Policy (as referenced herein), and the employee enrollment forms form the entire agreement between the parties.
California law prohibits an HIV test from being required or used by health care services, plans or insurance companies as a
condition of obtaining coverage.
BINDING ARBITRATION AGREEMENT: On behalf of Group Applicant, and subject to
certain restrictions prohibiting application of mandatory arbitration to members of
employer groups subject to ERISA, 29 U.S.C. SECTION 1001, et seq., I understand and
agree that any and all disputes, except adverse benefit determinations, as defined at
45 CFR 147.136, or disagreements between Group and HealthNet and/or DBP regarding
the construction, interpretation, performance or breach of the HealthNet and/or DBP
Plan Contract or Insurance Policy, or regarding other matters relating to or arising out
of the HealthNet and/or DBP Plan Contract or Insurance Policy, whether stated in tort,
contract or otherwise, must be submitted to final and binding arbitration in lieu of a
jury or court trial. I understand that, by agreeing to submit all disputes, except disputes
concerning adverse benefit determinations, to individual, final and binding arbitration,
all parties, including HealthNet and/or DBP are giving up their constitutional rights
to the extent permitted by law to have their dispute decided in a court of law before
a jury. I also hereby waive all rights to participate in any class arbitration. I also
understand that disputes with HealthNet and/or DBP involving claims for medical
services malpractice (that is, whether any medical services rendered were unnecessary
or unauthorized or were improperly, negligently or incompetently rendered) are also
subject to final and binding arbitration. In the event that the total amount of damages
claimed is $50,000 or less with respect to disputes involving alleged professional
liability or medical malpractice, the parties shall, within 30 days of submission of the
demand for arbitration, appoint a mutually acceptable single neutral arbitrator who
shall hear and decide the case and have no jurisdiction to award more than $50,000.
If the parties fail to reach an agreement during this time frame, then either party may
apply to a court of competent jurisdiction for appointment of the arbitrator(s) to hear
and decide the matter, in accordance with California Code of Civil Procedure 1281.6.
A more detailed arbitration provision is included in the HealthNet and/or DBP Plan
Contract or Insurance Policy.
Officer of the company signature: Officer of the company e-signature:
Officer title: Date:
Applicant’s signature above confirms to the best of their knowledge or belief:
1) Applicant’s agreement to all the terms and conditions set out in this Application,
including the conditions of enrollment and Underwriting Guidelines; and 2) the accuracy
and completeness of the information that the Applicant has entered in this Application.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
5
8. Broker information
Broker name: HealthNet broker ID #: Broker lic. #: Date submitted:
Agency name: Telephone #: Fax #: Email address:
Address: City: State: ZIP:
Broker/Consultant signature: Broker/Consultant e-signature: Date:
Account executive name: Date:
General agent/ID #: Date:
9. Agent/Broker certification
I , _______________________________________ ( n a m e o f a g e n t / b ro k e r ) ,
(NOTE: You must select the appropriate box. You may only select one box.)
■■ did not assist the applicant(s) in an y way in completing or submitting this application. All information was completed by the
applicant(s) with no assistance or advice of any kind from me.
OR
■■ assist ed the applicant(s) in submitting this application. I advised the applicant(s) that the applicant(s) should answer all
questions completely and truthfully and that no information requested on the application should be withheld. I explained that
withholding information could result in rescission or cancellation of coverage in the future. The applicant(s) indicated to me
that they understood these instructions and warnings. To the best of my knowledge, the information on the application is complete
and accurate. I explained to the applicant, in easy to understand language, the risk to the applicant of providing inaccurate
information, and the applicant understood the explanation.
If I willfully state as true any material fact I know to be false, I shall, in addition to any applicable penalties or remedies available under
current law, be subject to a civil penalty of up to ten thousand dollars ($10,000).
Please answer all questions 1 through 3:
1. Who filled out and completed the application form? __________________________________________________________________________________________
2. Did you personally witness the applicant(s) sign the application? ■■ Yes ■■ No
3. Did you review the application after the applicant(s) signed it? ■■ Yes ■■ No
10. For HealthNet use only
Underwriter signature: Date: Approved:
■■ Medical ■■ Dental ■■ Vision
Declined:
■■ Medical ■■ Dental ■■ Vision
Billing #: Effective date:
SBG representative signature: Date: Group # (Health): Policyholder # (Life): Medical plan:
HealthNet of California, Inc. offers the following products: HMO, Salud con HealthNet HMO y Más and HSP. HealthNet Life Insurance Company offers the following products: PPO and Life and AD&D
insurance. Unimerica Life Insurance Company offers the following products: Dental PPO. Dental Benefit Providers of California, Inc. offers the following product: Dental HMO. HealthNet Life Insurance
Company offers the following product serviced by EyeMed Vision Care, LLC: (“EyeMed”) and Envolve Vision, Inc.: Vision PPO.
“Plan Contract” refers to the HealthNet of California, Inc. and/or Dental Benefit Providers of California, Inc. Group Service Agreement and Evidence of Coverage; “Insurance Policy” refers to HealthNet
Life Insurance Company, Unimerica Life Insurance Company Group Policy and Certificate of Insurance.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
6
□
□
□
□
Small Business Group submission checklist
To ensure prompt processing, please make sure to include
the following documents.
Groups applying for a 1st-of-the-month effective date
must be submitted to HealthNet by the 5th of the month.
Paperwork must be completed by the 20th of the month;
otherwise, the group will be rolled to the following month.
A signed original application for Group Service
Agreement (GSA)/Group Policy
A compl
ete employee application for each eligible
employee enrolling/waiving cov
erage
A check or an Electronic Check form for the first month’s
premium drawn from the group account
The late
st quarter DE-9C, reconciled:
• If the group has not been in business long enough
to have a DE-9C, six week
s of payroll, including
withholdings, may be submitted.
• 2-week payroll is required for all employees that don’t
appear on the current DE-9C.
• For wages exceeding part-time and wages below
full-time status, payroll will be required.
• To reconcile the DE-9C, please indicate next to each
employee’s name one of the following:
T – Terminated (including termination date)
E – Eligible and enrolling
W – Eligible and waiving coverage
S – Seasonal
WP – Waiting period (include date of hire for
those in waiting period)
TEMP – Temporary employees
PT – Part-time
Covered by another carrier – add carrier name.
□ Ownership paperwork (required if owner/partners’
names do not appear on the DE-9C or payroll records).
Must list each person’s first and last name. Paperwork
must be filed with the state or county. Documentation
may include:
• For sole proprietor:
– California B
usiness License
– Fictitious Business Name Statement
– Schedule C Tax Form
• For partnership:
– California Business License (showing both names)
– Fictitious Business Name Statement (showing
both names)
– Schedule K Tax Form (for all eligible owners)
– Tax certificate (showing both names)
• For corporation:
– Articles of Incorporation
– Statement of Information
– Tax Form 1120
Note: Please consult your sales representative for
acceptable ownership documentation for other
business structures.
FOR PPO AND ENHANCEDCARE PPO PLANS:
□ Copies of EOBs for employees requesting Deductible
Credit from prior carrier
SEND ALL COMPLETED PAPERWORK TO YOUR DESIGNATED ACCOUNT EXECUTIVE OR BROKER.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
7
1
Available in all or parts of Alameda, Contra Costa, El Dorado, Fresno, Kern, Kings, Los Angeles, Madera, Marin, Merced, Napa, Nevada, Orange, Placer, Riverside, Sacramento,
San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Ventura, and Yolo counties.
2
Available in all or parts of Los Angeles, Orange, Riverside, San Diego, San Bernardino, Santa Clara, and Santa Cruz counties.
3
Available in Orange County and select ZIP codes of Kern, Los Angeles, Riverside, San Diego, and San Bernardino counties.
4
Available in Los Angeles, Orange and San Diego counties.
5
Available in Los Angeles County.
6
This information is for rating purposes and not to determine group size. The determination of how to count employees of related corporate entities when calculating group size
for medical loss ratio (MLR) purposes is based on whether the entities are considered a single employer under Section 414 of the Internal Revenue Code (subsection (b), (c),
(m), or (o)) and is not based on the multiple tax identification status of the related entities.
7
Note: Generally, employers who normally employed 20 or more employees during the previous calendar year are subject to federal COBRA. Employers who
employed 2–19 employees on at least 50% of its working days the previous calendar year are subject to Cal-COBRA. Please consult your legal counsel if you need
help determining which law applies to you.
8
If a DE-9C is not available, please provide a letter of explanation and supporting documentation, subject to underwriting approval, with this group service agreement
application.
HealthNet of California, Inc. and HealthNet Life Insurance Company are subsidiaries of HealthNet, LLC. HealthNet and Salud con HealthNet are registered service marks of HealthNet, LLC. All other
identified trademarks/service marks remain the property of their respective companies. All rights reserved.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
8
Health Net of California, Inc. and
Health Net Life Insurance Company (Health Net)
Ensure Your Employees
Understand Their Health Care Coverage
SUMMARY OF BENEFITS AND COVERAGE TO ELIGIBLE AND COVERED PERSONS
Affordable Care Act (ACA)
requirement for employers
that sponsor group health
plans
As required by the ACA, health plans
and employer groups must provide
the Summary of Benefits and Coverage
(SBC)
1
to eligible employees and family
members, who are:
1
26 C.F.R. § 54.9815-2715; 29 C.F.R. § 2590.715-2715; and 45 C.F.R. § 147.200.
• currently enrolled in the group
health plan, or
• eligible to enroll in the plan, but not
yet enrolled, or
• covered under COBRA Continuation
coverage.
Health Net is committed to ensuring
compliance with all timing and content
requirements with regard to the
distribution of the SBC. To meet this
goal, you are required to provide the
SBC in the exact and unmodified
form, including appearance and
content, as provided to you by
HealthNet.
Please follow the instructions
below so you will know how to
distribute the SBC.
SBC form and manner
You may provide the SBC to eligible
or covered individuals in paper or
electronic form (i.e., email or
Internet posting).
PAPER SBC
• If you provide a paper copy, the
SBC must be in the exact format and
font provided by Health Net, and,
as required under the ACA, must be
copied on four double-sided pages.
• If you mail a paper copy, you
may provide a single SBC to the
employee’s last known address,
unless you know that a family
member resides at a different
address. In that case, you must
provide a separate SBC to that family
member at the last known address.
ELECTRONIC SBC
For covered individuals, you may
provide the SBC electronically if
certain requirements from the U.S.
Department of Labor are met.
2
2
Such requirements can be found at 29 C.F.R. § 2520.104b-1(c).
• If you email the SBC, you must
send the SBC in the exact electronic
PDF forma
t provided to you by
HealthNet.
• If you post the SBC on the
Internet, you must advise your
employees by email or paper that
the SBC is available on the
Internet and provide the Internet
address. You must also inform your
employees that the SBC is available
in paper form, free of charge, upon
request. You may use the Model
Language below for an e-card
or postcard in connection with a
website posting of the SBC:
(continued)
This document is provided to you as a customer courtesy and is not intended to be legal advice. Please consult with your own legal counsel to determine your responsibilities under the SBC regulations
of the Affordable Care Act.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
9
Availability of Summary
Health Information
As an employee, the health
benefits available to you represent
a significant component of your
compensation package. They also
provide important protection for
you and your family in case of
illness or injury.
Your plan offers a series of health
coverage options. Choosing a
health coverage option is an
important decision. To help you
make an informed choice, your
plan makes available a Summary
of Benefits and Coverage (SBC).
The SBC summarizes important
information about any health
coverage option in a standard
format to help you compare across
options.
The SBC is available online at:
<[group’s website.com]>. A paper
copy is also available, free of
charge, by calling the toll-free
number on your ID card.
Timing of SBC distribution
• Upon application. If you distribute
written application materials, you
must include the SBC with those
materials. If you do not distribute
written application materials for
enrollment, you must provide the
SBC by the first day the employee
is eligible to enroll in the plan.
• Special enrollees. For special
enrollees,
3
you must provide the
SBCs within 90 days following
enrollment.
3
Special enrollees are individuals who request coverage through special enrollment. Regulations regarding special enrollment are found in the U.S. Code of Federal Regulations,
at 45 C.F.R. 146.117 and 26 C.F.R. 54.9801-6, and 29 C.F.R. 2590.701-6.
• Upon renewal. If open enrollment
materials are required for renewal,
you must provide the SBC no later
than the date on which the open
enrollment materials are distributed.
If renewal is automatic, you must
provide the SBC no later than
30 days prior to the first day of the
new plan year.
If your group health plan is renewed
less than 30 days prior to the
effective date, you must provide
the SBC as soon as practicable, but
no later than 7 business days after
issuance of new policy or the receipt
of written confirmation of intent to
renew your group health plan.
At the time your plan renews, you
are not required to provide the
HealthNet SBC to an employee
who is not currently enrolled in a
HealthNet plan. However, if an
employee requests a Health Net
SBC, you must provide the SBC as
soon as you can, but no later than
7 business days following your
receipt of the request.
Notice of SBC modification
Occasionally, there will be a material
change(s) to the SBCs other than
in connection with a renewal, such
as changes in coverage. You must
provide notice of the material changes
to employees no later than 60 days
prior to the date on which change(s)
become effective. You must provide
this notice in the same number, form
and manner as described above.
When such changes are initiated by
HealthNet, HealthNet will provide you
with modified SBCs for distribution.
Uniform glossary
Employees and family members can
access a glossary of bolded terms
used in the SBC by visiting www.cciio.
cms.gov or by calling HealthNet at the
number on the ID card to request a
copy. HealthNet shall provide a written
copy of the glossary to callers within
7 business days after HealthNet
receives their request.
If you have any questions, please
contact your HealthNet client
manager.
This document is provided to you as a customer courtesy and is not intended to be legal advice. Please consult with your own legal counsel to determine your responsibilities under the SBC regulations
of the Affordable Care Act.
Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC. Health Net and Salud con Health Net are registered service marks of Health Net, LLC. All other
identified trademarks/service marks remain the property of their respective companies. All rights reserved.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21 10
FLY028964EP00 (3/19)
Nondiscrimination Notice
In addition to the State of California nondiscrimination requirements (as described in benefit coverage documents), Health Net
of California, Inc. and Health Net Life Insurance Company (Health Net) comply with applicable federal civil rights laws and do
not discriminate, exclude people or treat them differently on the basis of race, color, national origin, ancestry, religion, marital
status, gender, gender identity, sexual orientation, age, disability, or sex.
HEALTH NET:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language
interpreters and written information in other formats (large print, accessible electronic formats, other formats).
• Provides free language services to people whose primary language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact Health Net’s Customer Contact Center at:
Individual & Family Plan (IFP) Members On Exchange/Covered California 1-888-926-4988 (TTY: 711)
Individual & Family Plan (IFP) Members Off Exchange 1-800-839-2172 (TTY: 711)
Individual & Family Plan (IFP) Applicants 1-877-609-8711 (TTY: 711)
Group Plans through Health Net 1-800-522-0088 (TTY: 711)
If you believe that Health Net has failed to provide these services or discriminated in another way based on one of the
characteristics listed above, you can file a grievance by calling Health Net’s Customer Contact Center at the number above and
telling them you need help filing a grievance. Health Net’s Customer Contact Center is available to help you file a grievance.
You can also file a grievance by mail, fax or email at:
Health Net of California, Inc./Health Net Life Insurance Company Appeals & Grievances
PO Box 10348, Van Nuys, CA 91410-0348
Fax: 1-877-831-6019
Email: Member .Discrimination.Complaints@healthnet.com (Members) or
Non-Member.Discrimination.Complaints@healthnet.com (Applicants)
For HMO, HSP, EOA, and POS plans offered through Health Net of California, Inc.: If your health problem is urgent, if you
already filed a complaint with Health Net of California, Inc. and are not satisfied with the decision or it has been more than
30 days since you filed a complaint with Health Net of California, Inc., you may submit an Independent Medical Review/
Complaint Form with the Department of Managed Health Care (DMHC). You may submit a complaint form by calling the DMHC
Help Desk at 1-888-466-2219 (TDD: 1-877-688-9891) or online at www.dmhc.ca.gov/FileaComplaint.
For PPO and EPO plans underwritten by Health Net Life Insurance Company: You may submit a complaint
by calling the California Department of Insurance at 1-800-927-4357 or online at https://www.insurance.ca.gov/
01-consumers/101-help/index.cfm.
If you believe you have been discriminated against because of race, color, national origin, age, disability, or sex, you can also
file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), electronically
through the OCR Complaint Portal, at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department
of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201,
1-800-368-1019 (TDD: 1-800-537-7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
11
English
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent
to you in your language. For help, if you have an ID card, please call the Customer Contact Center number.
Employer group applicants please call Health Net’s Commercial Contact Center at 1-800-522-0088 (TTY: 711).
Individual & Family Plan (IFP) applicants please call 1-877-609-8711 (TTY: 711).
Arabic
TTY: 711( 1-877-609-8711
Armenian
Անվճար լեզվական ծառայթյններ: Դք կարող եք բանավոր թարգմանիչ ստանալ:
Փաստաթղթերը կարող են կարդալ ձեր լեզվով: Եթե ID քարտ նեք, օգնթյան համար խնդրմ
ենք զանգահարել Հաճախորդների սպասարկման կենտրոնի հեռախոսահամարով: Գործատի
խմբի դիմորդներին խնդրմ ենք զանգահարել Health Net-ի Կորցիոն սպասարկման կենտրոն՝
1-800-522-0088 հեռախոսահամարով (TTY՝ 711): Individual & Family Plan (IFP) դիմորդներին
խնդրմ ենք զանգահարել 1-877-609-8711 հեռախոսահամարով (TTY՝ 711):
Chinese
免費語言服務。您可使用口譯員服務。您可請人將文件唸給您聽並請我們將某些文件翻譯成您的語言
寄給您。如需協助且如果您有會員卡，請撥打客戶聯絡中心電話號碼。雇主團保計畫的申請人請撥打
1-800-522-0088（聽障專線：711）與 Health Net 私人保險聯絡中心聯絡。Individual & Family Plan (IFP)
的申請人請撥打 1-877-609-8711（聽障專線：711）。
Hindi
 
  
     TTY
TTY

Hmong
Tsis Muaj Tus Nqi Pab Txhais Lus. Koj tuaj yeem tau txais ib tus kws pab txhais lus. Koj tuaj yeem muaj ib
tus neeg nyeem cov ntaub ntawv rau koj ua koj hom lus hais. Txhawm rau pab cuam, yog tias koj muaj daim
npav ID, thov hu rau Neeg Qhua Lub Chaw Tiv Toj tus npawb. Tus tswv ntiav neeg ua haujlwm pab pawg sau
ntawv thov ua haujlwm thov hu rau Health Net Qhov Chaw Tiv Toj Kev Lag Luam ntawm
1-800-522-0088 (TTY: 711). Tus Neeg thiab Tsev Neeg Qhov Kev Npaj (IFP) cov neeg thov ua haujlwm thov
hu rau 1-877-609-8711 (TTY: 711).
Japanese
無料の言語サービスを提供しております。通訳者もご利用いただけます。日本語で文書をお読みす
ることも可能です。ヘルプについては、IDカードをお持ちの場合は顧客連絡センターまでお電話く
ださい。雇用主を通じた団体保険の申込者の方は、Health Netの顧客連絡センター
(1-800-522-0088、TTY: 711) までお電話ください。個人・家族向けプラン (IFP) の申込者の方
は、1-877-609-8711 (TTY: 711) までお電話ください。


Health NetTTY: 711( 1-800-522-0088
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
12
Khmer

      
 
   

Korean
Navajo
1-877-609-8711 (TTY: 711).

 
  
 
무료 언어 서비스입니다. 통역 서비스를 받으실 수 있습니다. 문서 낭독 서비스를 받으실 수 있으며
ID일부 서비스는 귀하가 구사하는 언어로 제공됩니다. 도움이 필요하시면 카드에 수록된 번호로
Health Net고객서비스 센터에 연락하십시오. 고용주 그룹 신청인의 경우 의 상업 고객서비스 센터에
1-800-522-0088(TTY: 711) (IFP)번으로 전화해 주십시오. 개인 및 가족 플랜 신청인의 경우
1-877-609-8711(TTY: 711) 번으로 전화해 주십시오.
Doo b33h 7l7n7g00 saad bee h1k1 ada’iiyeed. Ata’ halne’7g77 da [a’ n1 h1d7d0ot’88[. Naaltsoos da t’11
sh7 shizaad k’ehj7 shich9’ y7dooltah n7n7zingo t’11 n1 1k0dooln77[. !k0t’4ego sh7k1 a’doowo[ n7n7zingo
Customer Contact Center hooly4h7j8’ hod77lnih ninaaltsoos nanitingo bee n44ho’dolzin7g77 hodoonihj8’
Health Net’s Commercial
bik11’. Naaltsoos nehilts0osgo naanish b1 dahikah7g77 47 koj8’ hod77lnih
Contact Center 1-800-522-0088 (TTY: 711) (IFP). T’11 h0 d00 ha’1[ch7n7 b1h7g77 47 koj8’ hojilnih
Persian (Farsi)
 
 
 
TTYIFP 
Бесплатная помощь переводчиков. Вы можете получить помощь переводчика. Вам могут прочитать
документы на Вашем родном языке. Если Вам нужна помощь и у Вас при себе есть карточка
участника плана, звоните по телефону Центра помощи клиентам. Участники коллективных планов,
предоставляемых работодателем: звоните в коммерческий центр помощи Health Net по телефону
1‑800‑522‑0088 (TTY: 711). Участники планов для частных лиц и семей (IFP): звоните по телефону
Panjabi (Punjabi)
TTY
Russian
1-877-609-8711 (TTY: 711).


Health NetTTY:711( 1-800-522-0088IFP
TTY:711( 1-877-609-8711
 
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
13
CA Commercial On and Off-Exchange Member Notice of Language Assistance
FLY017550EH00 (12/17)
Spanish
Servicios de idiomas sin costo. Puede solicitar un intérprete, obtener el servicio de lectura de documentos y
recibir algunos en su idioma. Para obtener ayuda, si tiene una tarjeta de identificación, llame al número del
Centro de Comunicación con el Cliente. Los solicitantes del grupo del empleador deben llamar al Centro
de Comunicación Comercial de Health Net, al 1‑800‑522‑0088 (TTY: 711). Los solicitantes de planes
individuales y familiares deben llamar al 1-877-609-8711 (TTY: 711).
Tagalog
Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng interpreter. Makakakuha kayo ng mga
dokumento na babasahin sa inyo sa inyong wika. Para sa tulong, kung mayroon kayong ID card, mangyaring
tumawag sa numero ng Customer Contact Center. Para sa mga grupo ng mga aplikante ng tagapag-empleyo,
mangyaring tumawag sa Commercial Contact Center ng Health Net sa 1-800-522-0088 (TTY: 711).
Para sa mga aplikante ng Planong Pang-indibiduwal at Pampamilya (Individual & Family Plan, IFP),
mangyaring tumawag sa 1-877-609-8711 (TTY: 711).
Thai

 


Vietnamese
Các Dịch Vụ Ngôn Ngữ Miễn Phí. Quý vị có thể có một phiên dịch viên. Quý vị có thể yêu cầu được đọc cho
nghe tài liệu bằng ngôn ngữ của quý vị. Để được giúp đỡ, nếu quý vị có thẻ ID, vui lòng gọi đến số điện thoại
của Trung Tâm Liên Lạc Khách Hàng. Những người nộp đơn xin bảo hiểm nhóm qua hãng sở vui lòng gọi
Trung Tâm Liên Lạc Thương Mại của Health Net theo số 1‑800‑522‑0088 (TTY: 711). Người nộp đơn thuộc
Chương Trình Cá Nhân & Gia Đình (IFP), vui lòng gọi số 1‑877‑609‑8711 (TTY: 711).

 
FRM049461EC00_SBG_CA (1/21)
SBG GSA 1/21
14
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Application for Group Service AgreementGroup Policy (Dickerson Insurance Services)

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Completed 1 June 2021

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