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HEALTH NET A Better Decision

Member Connections 2008 In This Edition: GET INFORMED – find personal support that fits you, your health and your life. 1 Decision Power: Newly expanded program 2 Case Management: Real help for serious illness 3 Quality of Care: How we strive to improve it 3 When you need answers: Here’s how to reach us SEEK CARE – know how to access the network for care. 3 Selecting a PCP: Why it’s important 4 Emergency Care: What to do 4 Using Participating Providers: The Benefits 5 Network News: Hospital for Special Surgery joins our network TAKE CONTROL – understand your benefits and know your rights. 5 Member Basics: Get Health Net basic training in your in-box 6 Appeals: Know your rights MANAGE YOUR ACCOUNT – take care of important details anytime. 6 Health Plan Details: Online 24/7 6 See what’s new 6 Claim Status: Three ways to check ALSO IN THIS ISSUE 7 Deciphering the lingo 8 Free Week of Fitness 8 Wanted: Your Feedback

This newsletter was designed to help you be confident in your choice of health plan and your understanding of how it works. If you have any questions, please contact one of our Member Advocates at the number on the back of your Health Net ID card. We value you as a member and are here to help in any way we can.

Newly Expanded Decision Power Program! sm

Promoting health in balance for every stage of your life Information, Resources and Support that Span the Full Spectrum of Health

What does “health in balance” mean? For every person, there is a different definition. That’s why Health Net created Decision Power. Newly expanded, Decision Power now brings together under one roof the information, resources and personal support that fit you, your health and your life. Whether you … • have a question • want help with a specific health goal • need treatment but want to understand all your options • are living with illness (see articles on page 2) … you can use Decision Power online. Or you can call a Health Coach. 24 hours-a-day, seven days-a-week, Decision Power is here for you.

Log on to for tools you need:

Try a step-by-step plan for losing weight, stopping smoking or boosting nutrition. You can use both our online coaching and self-help tools. Phone coaching support is included, so it’s easier to make lasting health changes. Track your health progress and build a complete medical snapshot to have whenever you need it with a Personal Health Record (PHR). Be sure to select to have your claims populated into your PHR for the most accurate picture. Assess your health and get tips to maintain or improve your health after you complete our Health Risk Questionnaire. Find support for any kind of mental health concern such as depression, excessive alcohol use, eating disorders, etc. (continued on page 2)

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Newly Expanded Decision Power Program (continued from page 1)

Be informed with our trusted, easy to understand materials, audio and streaming video resources that help weigh the pros and cons of various treatments through real-life stories. Know your numbers with our health trackers (cholesterol, diet, fitness), treatment cost estimator and hospital comparison reports. Get healthy discounts — Take advantage of deep discounts on fitness, safety and wellness programs, including fitness clubs, weight loss programs, massage therapy, eye exams and more.

Talk to a Health Coach to get:

1-to-1 health coaching for any and every health question, goal or situation. You can request to talk to the same Health Coach every time you call. 24-hour answers to health and symptom questions. Techniques to help you feel comfortable talking with your doctor and expressing your preferences. Pointers for setting achievable health goals; guidance on evaluating treatment options. Guidance and support for living with an ongoing illness such as asthma, diabetes, heart disease, etc. Specialized consultation from nurse case managers to help both patients and family members deal with the complexity of end-stage illnesses. You can use Decision Power whenever you want and as often as you like. Because when it comes to your health, there’s more than one right answer. * Health Net stores all Personal Identifiable Information (PII) and Protected Health Information (PHI) on a secure server, and it is treated in accordance with stringent HIPAA regulations. Some data will be used for statistical analysis that will in no way identify individual members.

Case Management: Real Help for Serious Illness Our Decision Power program can be a valuable resource tool to anyone who is faced with serious illness. You or a loved one might benefit from case management if you: • Have a long term illness • Have been hospitalized frequently • Need high-tech or extensive home care • Have sustained a traumatic injury • Have a terminal illness

How Decision Power case management works.

Health Net has a team of nurses and health care professionals who can work with you and your doctors to develop a plan that helps you manage your illness and regain your health. The case manager can help you find community resources; promote communication and coordination with all professionals involved in your care; use your health care benefits wisely; and help you fully understand your health condition, treatment options, and what actions you can take to improve your health. Participation in case management is voluntary; your choice about participation will not affect your health care benefits. If you would like to request an evaluation to determine whether case management can help you, call a Health Coach at 1-800-893-5597 or the number on the back of your Health Net ID card.

Living with a Chronic Disease? If you or a loved one has a chronic disease, we have a number of Decision Power programs to help you take care of your condition and prevent complications. These voluntary programs may be available to individuals who have asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), heart failure and diabetes. Program staff can provide you with detailed information and personal support. If you would like to participate, call a Health Coach at 1-800-893-5597 or the number on the back of your Health Net ID card.

Try it today! Log on to or call Decision Power at 1-800-893-5597 (TDD/TTY: 1-800-276-3821)

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How to reach us DO I NEED PRIOR AUTHORIZATION FOR THIS PROCEDURE? WHAT’S MY COPAYMENT TO SEE MY DOCTOR? IS THERE A LOWER COST GENERIC FOR MY PRESCRIPTION? We know you have many questions, and sometimes you need someone in your corner who can advocate for your health care service needs. This is why we created our Member Advocate team, which is comprised of local, hand-chosen Health Net associates who have received extensive classroom and on-thejob training, along with continued coaching and call monitoring. Our goal is to ensure prompt, accurate, and friendly service with onecall resolution, whenever possible. And since we realize your time is precious, we also strive to answer each call in 30 seconds or less.

How We Strive to Improve the Quality of Your Care Health Net maintains a quality improvement program that continuously monitors and evaluates member care and services. Activities include coordination of wellness interventions and preventive health initiatives (see information below), disease management and case management, behavioral health, patient safety, practitioner and provider credentialing (to ensure you receive access to providers who have met certain quality standards), member rights and responsibilities and other monitoring activities. Outreach programs include: pregnancy, asthma, breast cancer screening, diabetes, education (preventive health guidelines), coordinated support (coordination of medical and behavioral health—mental health and substance abuse) and a host of safety and efficiency initiatives. We also have a first-in-the-region program that offers incentives for physicians who demonstrate improvements in quality care, such as those related to preventive care and wellness. For more information about our quality improvement program and our progress on improving the care and service you receive, call the number on the back of your Health Net ID card.

The Health Net Member Advocate team can be reached by calling 1-800-441-5741, Monday – Friday, 8:00 a.m. – 6:00 p.m., EST. 24-hour self-service member support is also available: • For your convenience, we offer a 24/7 Interactive Voice Response (IVR) unit, which allows callers to do a number of things: • Check eligibility/plan information • Check copayment information • Order ID cards • Order an Evidence of Coverage (EOC) (your plan contract) • Request materials, Primary Care Physician changes, or name/address changes • Check claims status information • — For 24/7 access to a variety of topics, including how to find a doctor, wellness program discounts, and how to save money on your prescriptions — simply log on to

Selecting a PCP – Why it’s important Selecting a Health Net Primary Care Physician (PCP) is a critical part of ensuring you get the best care. We work with your PCP to identify “gaps in care.” Some examples would be if your child has not received certain immunizations or if you have not had wellness screenings, such as a mammogram or prostate exam. You do not need to receive services from a PCP; however, we strongly encourage you to update us with your PCP information. This is an important step to ensure you always get the most out of your health plan.

How to Find and Select a PCP: 1 Online: a) To find a PCP (or any type of provider), select “Find a Doctor or Hospital” at b) To change your PCP, simply create or log into your existing account at Go to “Get Things Done” and select “Change Primary Physician” 2 Phone: Call the number on the back of your ID card to speak with a Member Advocate. You can request a printed directory; however, the most current listing is available online or by phone.

Note: If you are a PPO member, you do not need to select or update your PCP.

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Emergency and Urgent Care: What to Do As a Health Net member, you’re covered for emergency and urgent care when illness or injury strikes you or your covered family members. However, it’s important to know the difference between emergency and urgent care, both to ensure you obtain the best level of care and to maximize your health care benefits. If you use the emergency room when the situation is not an emergency, you may be responsible for the costs of the visit.*

What to do in an urgent or emergency situation

Before going to an emergency room, you should determine if the situation is a true emergency. If the problem is an emergency, you should not hesitate to go to the hospital. However, if it’s not a critical situation, you should follow these steps:

1 Call your PCP or treating physician. Your doctor may give you advice on where you should go to obtain care.** 2 If your doctor does not return your call within a reasonable amount of time, and you believe your health is at risk, seek care in an urgent care center or skip to step 3 or 4. 3 Take appropriate over-the-counter medication. 4 Call Decision Power, toll-free, at 1-800-893-5597. A nurse is available to respond to your health-related questions 24 hours a day, seven days a week, and can assist you in determining the appropriate level of care.

Emergency: Generally a sudden, serious and unexpected illness, injury or condition, including severe pain, which a reasonable person with an average knowledge of health and medicine would believe requires immediate medical attention. Urgent care: A situation that is urgent, but not life threatening, such as an extremely high fever. Please refer to your Evidence of Coverage document for benefit and coverage information pertaining to urgent care and emergency services.

* See your Evidence of Coverage for more details. ** Health Net Passport plan members should contact their physician group prior to or within 48 hours of first seeking care, or as soon as possible.

benefits of using participating providers Except in the case of an emergency, it is to your advantage to use in-network/participating physicians, hospitals and facilities for health care services. By doing so, you have lower out-of-pocket costs and better coordination of your health care. If however, you have a Point of Service (POS) plan and choose to seek services from an out-of-network physician, hospital or facility, you are responsible for a greater portion of the charges Situation

and will have higher out-of-pocket costs. (HMO members do not have out-of-network coverage.) To help you better understand what potentially signifies an in-network visit verses an out-of-network visit, we’ve listed some examples. For specifics, please contact a Member Advocate at the number on the back of your ID card.


You receive care from an out-of-network physician for an outpatient hospital-based procedure.

Out-of-network: All hospital and related hospital-based services will be paid at your out-of-network benefit (coinsurance and deductible will be applied).

You receive care from an outof-network physician who admits you to an out-of-network hospital.

Out-of-network: All hospital and related hospital-based services will be paid at your out-of-network benefit (coinsurance and deductible will be applied).

For a current list of participating providers, quickly search online at Or simply give us a call.

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Our Provider Network Is Growing

Renowned Hospital for Special Surgery Joins Our Network We have added over 10,000 provider locations in the tri-state area since 2007, and are not stopping there. We know that quality care begins with those who care for you. This is why our efforts continue to focus on recruiting reputable physicians, facilities and hospitals.* We are pleased to announce that we recently signed a multi-year agreement with the Hospital for Special Surgery (HSS) in New York, the nation’s top hospital for orthopedics and rheumatology. This allows our commercial members (non-Medicare Advantage) in-network access to this hospital for all covered inpatient and outpatient services. HSS has physician office locations in Uniondale, New York; Princeton, New Jersey; and Old Greenwich, Connecticut. Additional areas of expertise at HSS include spine surgery, sports medicine, orthopedic trauma, hand surgery and

foot and ankle surgery. HSS physicians with a subspecialty training in the field of spine surgery focus on patients who suffer from congenital or acute spinal disorders as well as from chronic back pain. In March of this year, The Hospital Quality Alliance released a patient survey of hospitals nationwide on different aspects of care. Patients ranked HSS well above the national average in both overall satisfaction and willingness to recommend the hospital to others. HSS also was ranked as the top hospital in orthopedics by U.S. News & World Report in its 2007 “America’s Best Hospitals” survey. HSS physicians from its Sports Medicine and Shoulder Service are associated with the New York Mets, New York Football Giants, New York Knicks, Nets Basketball and the New York Red Bulls Soccer, among many other leading sports organizations. In addition, HSS sports medicine specialists serve on the U.S. Olympic Committee medical staff team that covered the 2008 Games in Beijing.

Up-to-date Provider Listing Always Available

With a physician network consisting of more than 150,000 physician and provider office locations, Health Net is one of the largest health plans in the Northeast. For the most current list of participating physicians and providers (updated every day), please visit our website,, and select “Find a Doctor or Hospital.” If you don’t have online access or would prefer to receive a copy of the September ‘08 provider directory, please call the number on the back of your ID card. * Health Net contracts with a network of carefully chosen Physicians and Hospitals to provide covered services to our members. As a Health Net member, you receive the lowest out-of-network expense when you obtain your care from these providers. If you have an Advantage Platinum HMO plan, when you receive care from a contracted provider, you are only responsible for the copayments outlined in the Schedule of Benefits listed in your Evidence of Coverage. You must obtain all covered services from contracted physicians and hospitals or covered services will be denied (unless it is an Emergency). If you have a Point of Service (POS) plan and elect to receive services from a non-participating provider, you are responsible for payment of deductibles and/or coinsurance as outlined in your Evidence of Coverage. ** U.S. News & World Report in its 2007 “America’s Best Hospitals” survey.

Get Health Net basic training in your in-box Health Net Member Basics is a monthly online newsletter that provides important information to help you better understand and make the most of your health plan. Each month, we explain a topic that you may find confusing, or let you know about important tools and resources that can help you manage your health. Recent topics have included: • Understanding Prior Authorization • What Your Claims Information Really Means • How to Print Temporary ID Cards • Health and Wellness Tools & Resources to Take Advantage of • Understanding Your Provider Network To receive Health Net Member Basics and take advantage of the many resources available to you on the Health Net website, go to, click Register Now, and make sure you opt in to receive email communications from Health Net. Already registered on but not getting Health Net Member Basics? Simply log on to, click Get Things Done, and click Change Email Address. You will be able to confirm that your email address is correct and change it if necessary. Make sure the “I would like to receive email communications from Health Net” box is checked. Then click Submit, and you should receive the next issue of Health Net Member Basics.

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Health Plan Details: online 24/7 Need information about how your plan works? We want you to get your answers when it’s convenient for you. Health Net’s website,, is available 24 hours a day, 7 days a week. Simply register, log in and select from one of many topics. If you don’t have online access, you can refer to your Evidence of Coverage plan document. If you need another copy, call the number on the back of your Health Net ID card. What’s new on Find a doctor or hospital – For the most current and complete directory of participating physicians, facilities and hospitals, select “Find a Doctor or Hospital.” You also have the option to print a customized listing of physicians and providers. Note: The online doctor search tool will be significantly enhanced later this year. Be one of the first to test it out! View your Evidence of Coverage and Explanation of Benefits – Choose to view your EOC and EOB online vs. receiving via mail. Go paperless today! View plan details – Get plan details, like who’s covered, what’s covered and more. Take care of business – Update and manage your account information, check claims, print and order ID cards, download useful forms and brochures. View prescription coverage – View your pharmacy benefits, manage your prescriptions, get pharmacy forms and drug lists, and check drug costs. Access Decision PowerSM Health and Wellness tools and resources – Get the one-on-one support and tools you need to make informed health care decisions. See the Decision Power article for more details or log onto and select “Decision Power: Health and Wellness.”

Other information you can find online:

• Which health benefits are included in your plan and which are excluded from coverage • Your copayments and other out-of-pocket responsibilities for medical and drug benefits (if applicable) • Out-of-area coverage — the type of coverage available and how to obtain coverage for out-of-area services received • How to submit a claim if your provider did not submit it to Health Net • Provider qualifications, languages spoken, education • The importance of a primary care physician and how he/she can help you manage your health care • Going to a specialist, mental health/substance abuse provider, or the hospital • Obtaining emergency coverage, urgent care and after-hour care • Providing feedback to Health Net — a compliment, concern, complaint, or request for Health Net to reconsider a denied claim or health care service • Health Net’s evaluation of and coverage for new medical technology/advances • Your Member Rights and Responsibilities

Just as we are committed to our customers’ well-being, we are equally committed to our environment. Throughout this brochure you will see the Health Net go green logo representing yet another way we have eliminated a paper process and created the same function, if not better, online.


Unde r s tand Y o u r r ight s

You have the right to request that Health Net reconsider denied claims or health care services. If Health Net upholds the denial decision, you may have the right under state law to submit an appeal to an external independent review organization. State law defines the types of denial decisions that are eligible for external independent review and the process used to evaluate these requests. You can find out more information about the appeal process and the external review process in your Health Net Evidence of Coverage/contract. If you need a copy, or have any questions, please call the number on the back of your Health Net ID card to speak with a Member Advocate.

Has your claim been paid? Need to know the status of a claim? There are three easy ways to find out: 1 Online – anytime: Simply log on to Go to “Get Things Done,” and select “Check Medical Claims.” To view your claims, enter your search criteria, such as date of service or a date range. 2 Phone – anytime: Call the number on the back of your Health Net ID card and follow the voice prompts. 3 Member Advocates (8:00 am – 6:00 pm): Call the number on the back of your Health Net ID card to speak with a Member Advocate.

COMING SOON… A redesign of our website to make it more robust and member-friendly than ever before! Be the first to test out the new site later this fall!

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Deciphering the Lingo Ever wonder what all those “insurance terms” mean? Here we try to put some of them in language you can understand. It’s one thing to have benefits; it’s another to understand them. What is a “deductible”?

This is the amount you pay for covered services before Health Net begins to pay. If you have a deductible, it’s listed in your Evidence of Coverage. Routine care services, such as annual checkups, screenings and immunizations, are usually covered right away without having to meet the deductible amount first.

What is a “copayment”?

This is a fixed dollar amount that you pay for some services when you receive care. For example, if you have a $20 office visit copyament, you pay $20 when you see your doctor. Copayments are listed in your Evidence of Coverage.

What is “coinsurance”?

This is a percentage of medical costs that you may be required to pay for covered services. If you have coinsurance, it’s listed on your Evidence of Coverage.

Example: How it works, using 20% coinsurance:

The contracted amount (for participating providers) or the maximum amount (for non-participating providers) that Health Net will consider paying for covered benefits: $100 Coinsurance: 20% You pay: $20 | Health Net pays: $80 You are responsible for the coinsurance as well as for amounts over and above the contracted or maximum amount.

Why does Health Net limit the amount that it will consider paying for benefits?

When you use non-participating providers, Health Net has no control over the amount that they will bill. Therefore, Health Net determines how much it will pay for covered benefits based on whichever is less—the maximum amount determined by Health Net or the amount billed by the provider. Your Evidence of Coverage will give you additional information on how this maximum amount is determined.

What is an “Out-of-Pocket Maximum”?

Certain benefits limit the amount you are required to pay. This is called your Outof-Pocket Maximum. Once you reach this limit, you will have no additional out-of-pocket charges for these services for the rest of the plan year.

What is “Utilization Management”?

Utilization management is an important component of health care management, in which services provided to our members, by our providers, are continuously evaluated to maintain the provider commitment to Health Net’s quality and medical management standards.

What’s included in Utilization Management?

• Prior Authorization — Certain services may require authorization first from Health Net. Evidence-based criteria are used to evaluate whether or not the procedure is medically necessary and planned for the appropriate setting (e.g., inpatient, ambulatory surgery, etc.). • Concurrent Review & Discharge Planning — Health Net nurses and doctors follow a member’s progress on a concurrent basis during inpatient hospitalizations. This process includes working with the hospital to plan for a safe discharge in conjunction with the physician’s discharge orders and authorizing post-hospital services when needed. • Care or Case Management — Nurse care managers provide assistance, education and guidance to members (and their families) through major acute and/or chronic long-term health problems. The care managers work closely with members, their doctors, and community resources.

• Retrospective Review — Health Net nurses and doctors may assess the appropriateness of medical services on a case-by-case basis after the services have been provided. Review is usually performed on cases for which authorization was required but not obtained. For more information regarding Health Net’s utilization management process, please call our Member Advocate team at 1-800-441-5741. • The fastest way to get things done. • The easiest way to get more from your health plan. • Second place Gold award for Best eBusiness Site* * The eHealthcare Leadership Awards program was developed in 1999 by eHealthcare Strategy & Trends, a leading Internet resource published by Health Care Communications, Rye, NY.

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Wanted: Your Feedback

Free Week of Fitness! At any health club in the WellQuest Fitness Network Health Net members can enjoy the advantages of health club membership through the WellQuest Fitness Network, including savings, free club transfer, online nutritional support and meal planning. WellQuest’s national network of health clubs includes franchise chains such as Bally’s, Gold’s Gyms, Curves, Lady of America, Jazzercise in addition to many privately owned facilities. To receive a validated pass for the free trial membership and to locate your club of choice, please visit www.WellQuestFitness. com or call 1-800-595-8448. Then present this pass, along with the validated WellQuest pass, to your WellQuest club of choice. Contact the fitness facility in advance to schedule a tour.

At Health Net, our primary goal is to fulfill the needs of our members. If you have specific questions related to your benefits or a claim, please call a Member Advocate at the number listed on the back of your ID card. If you have general comments on how we operate, our policies, or obtaining provider access, there are two ways to provide your feedback: 1 Go to and once you’ve registered, select “Get things done” and “Contact us.” From the dropdown menu (in subject line), select “Operations and Policy feedback” and submit your comments and suggestions. 2 Send your general comments and suggestions to Health Net, One Far Mill Crossing, Shelton, CT 06484, Attention: Process Improvement Team We will respond to all general feedback either by phone or in writing. As appropriate, we will communicate your suggestion or comment to the affected business unit for review and possible implementation. We sincerely value your feedback and hope to hear from you soon!

FREE WEEK OF FITNESS GUEST PASS is entitled to enjoy a free week of fitness at


health club

Valid thru December 15, 2008 (first time users)

(10/08) NE53893 6018136 Coverage is provided by subsidiaries of Health Net of the Northeast, Inc. and Health Net Life Insurance Co. Coverage may be provided by Health Net of New York, Inc. or Health Net Insurance of New York, Inc. in New York; Health Net of New Jersey, Inc. or Health Net Life Insurance Co. in New Jersey; and Health Net of Connecticut, Inc. or Health Net Life Insurance Co. in Connecticut. Health Net® is a registered service mark of Health Net, Inc. All rights reserved. NCQA has awarded an accreditation status of Excellent for service and clinical quality to all three of Health Net of the Northeast’s commercial lines of HMO and POS products (NY, NJ and CT).

Health Net of the Northeast, Inc. One Far Mill Crossing Shelton, CT 06484

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