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M53401 (CA 1/18)
Group Medicare Supplement plan
Janis E. CarterHealth Net
2018 Outline of Coverage
M53401 (CA 1/18)
Health Net LifeOutline of Group Medicare Supplement Plan Coverage –
Bene�t Plans A, B, C, D, F, High Deductible Plan F, G, K, L, and M are o�ered by Health Net Life Insurance Company (HNL)
Medicare supplement insurance can only be sold in standard plans. This chart shows the benefits included in each plan that can be sold on or after June 1, 2010. Every insurance company must offer Plan A. Some plans may not be available.
�e basic bene�ts included in all plans are:Hospitalization: Medicare Part A coinsurance plus coverage for 365 additional days a�er Medicare bene�ts end.
Medical expenses: Medicare Part B coinsurance (usually 20 percent of the Medicare-approved amount) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments.
Blood: First three pints of blood each year.
Hospice: Part A coinsurance.
M53401 (CA 1/18)
A B C D F/High Deductible Plan F*
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance*
Skilled nursing facility coinsurance
Skilled nursing facility coinsurance
Skilled nursing facility coinsurance
Part A deductible Part A deductible Part A deductible Part A deductiblePart B deductible Part B deductible
Part B excess (100%)
Foreign travel emergency
Foreign travel emergency
Foreign travel emergency
* Plan F also has an option called a High Deductible Plan F. �is high deductible plan pays the same bene�ts as Plan F a�er a member has paid a calendar year $2,240 deductible. Bene�ts from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by this certi�cate. �ese expenses include Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.
G K L M NBasic, including 100% Part B coinsurance
Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%
Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance, except up to $20 copay for office visit, and up to $50 copay for ER
Skilled nursing facility coinsurance
50% skilled nursing facility coinsurance
75% skilled nursing facility coinsurance
Skilled nursing facility coinsurance
Skilled nursing facility coinsurance
Part A deductible 50% Part A deductible
75% Part A deductible
50% Part A deductible
Part A deductible
Part B excess (100%)Foreign travel emergency
Foreign travel emergency
Foreign travel emergency
Out-of-pocket limit $5,240; paid at 100% after limit reached
Out-of-pocket limit $2,620; paid at 100% after limit reached
M53401 (CA 1/18)
Read your Medicare Supplement plan certi�cate very carefully�is is only an outline describing your Medicare Supplement plan certi�cate’s most important features. �e Certi�cate is your insurance contract. You must read the Medicare Supplement plan certi�cate itself to understand all of the rights and duties of both you and HNL.
�irty-day right to return the Medicare Supplement plan certi�cateIf you �nd you are not satis�ed with your Medicare Supplement plan certi�cate, prior to making any health care coverage changes, please contact your employer to determine the impact these changes may have on your eligibility with your group-sponsored coverage. If you decide to terminate your enrollment under the Group Medicare Supplement plan certi�cate, you may return it to your employer. If you send the certi�cate back to your employer within 30 days a�er you receive it, we will treat the coverage as if it had never been issued and refund any applicable premium paid to your employer.
Medicare Supplement plan certi�cate replacementIf you are replacing another health insurance Policy, do NOT cancel it until you have actually received your new Medicare Supplement plan certi�cate and are sure you want to keep it.
Disclosures�e Certi�cate of Insurance may not fully cover all your medical costs. Neither HNL nor any of its agents are connected with Medicare. �is Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security o�ce or consult �e Medicare Handbook for more details. For additional information concerning Policy bene�ts, contact the Health Insurance Counseling and Advocacy Program (HICAP) or your agent. Call the HICAP toll-free telephone number, 1-800-434-0222, for a referral to your local HICAP o�ce. HICAP is a service provided free of charge by the State of California.
Complete answers are very importantWhen you �ll out the enrollment form for the HNL Group Medicare Supplement plan, be sure to answer truthfully and completely. Review the enrollment form carefully before you sign it. Be certain that all information has been properly recorded.
M53401 (CA 1/18)
If your physician accepts assignment of Medicare bene�ts, the di�erence between your physician’s charge, ($2,000) and the Part B Charges Approved for Payment by Medicare ($1,850) is absorbed by your physician and you pay no coinsurance. If your physician does not accept assignment of Medicare bene�ts, you pay the Part B Excess Charges.
Unlike Plans A, B, C, D, K, L, and M, Plans F and G pay Part B Excess Charges. Part B Excess Charges are the di�erence between physician charges and the Charges Approved for Payment by Medicare. If you enroll in Plans F or G, you pay no Part B coinsurance.
An example showing a physician’s charges �e following are examples of how the plans pay bene�ts for Part B charges, assuming a physician bill of $2,000 and the annual Medicare Part B deductible of $183 has been met.
Physician accepts assignment
Physician does not accept assignment
Charges approved for payment by Medicare
$1,850 $1,850
Medicare pays 80% of approved charges
$1,480 $1,480
�is policy pays $370 $370
You pay coinsurance $0 $150
Plan: A, B, C, D, K, L, and M
Physician accepts assignment
Physician does not accept assignment
Charges approved for payment by Medicare
$1,850 $1,850
Medicare pays 80% of approved charges
$1,480 $1,480
�is policy pays $370 $520
You pay coinsurance $0 $0
Plan: F and G
M53401 (CA 1/18)
Plan A Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day
91st day and after:
• While using 60 lifetime reserve days
• Once lifetime reserve days are used:
– Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0
$0
$0
$335 a day
$670 a day
100% of Medicare-eligible expenses
$0
$1,340 (Part A deductible)$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.
First 20 days
21st through 100th day
101st day and after
All approved amounts
All but $167.50 a day
$0
$0
$0
$0
$0
Up to $167.50 a day
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
Plan A Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$0
Generally 20%
$0
$183 (Part B deductible)
$0
All costs
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$0
20%
$0
$183 (Part B deductible)
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment – First $183 of Medicare-
approved amounts* – Remainder of Medicare-
approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B deductible)
$0
Parts A and B
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Plan B Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day
91st day and after:
• While using 60 lifetime reserve days
• Once lifetime reserve days are used:
– Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0 $0
$1,340 (Part A deductible)
$335 a day
$670 a day
100% of Medicare-eligible expenses
$0
$0
$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital.
First 20 days
21st through 100th day
101st day and after
All approved amounts
All but $167.50 a day
$0
$0
$0
$0
$0
Up to $167.50 a day
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
Plan B Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$0
Generally 20%
$0
$183 (Part B deductible)
$0
All costs
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$0
20%
$0
$183 (Part B deductible)
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment – First $183 of Medicare-
approved amounts* – Remainder of Medicare-
approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B deductible)
$0
Parts A and B
M53401 (CA 1/18)
Plan C Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve days• Once lifetime reserve days
are used: – Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0 $0
$1,340 (Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses$0
$0
$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $167.50 a day
$0
$0
$0
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Plan C Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$183 (Part B deductible)
Generally 20%
$0
$0
$0
All costs
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$183 (Part B deductible)
20%
$0
$0
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment – First $183 of Medicare-
approved amounts* – Remainder of Medicare-
approved amounts
100%
$0
80%
$0
$183 (Part B deductible)
20%
$0
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Other benefits – not covered by Medicare
Services Medicare pays Plan pays You payForeign travel – not covered by MedicareMedically necessary emergency care services beginning during the �rst 60 days of each trip outside the USAFirst $250 each calendar yearRemainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum
Parts A and B
M53401 (CA 1/18)
Plan D Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve days• Once lifetime reserve days
are used: – Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0 $0
$1,340 (Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses$0
$0
$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $167.50 a day
$0
$0
$0
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Plan D Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$0
Generally 20%
$0
$183 (Part B deductible)
$0
All costs
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$0
20%
$0
$183 (Part B deductible)
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment – First $183 of Medicare-
approved amounts* – Remainder of Medicare-
approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B deductible)
0%
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Other benefits – not covered by Medicare
Services Medicare pays Plan pays You payForeign travel – not covered by MedicareMedically necessary emergency care services beginning during the �rst 60 days of each trip outside the USAFirst $250 each calendar yearRemainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum
Parts A and B
M53401 (CA 1/18)
Plan F Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve days• Once lifetime reserve days
are used: – Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0
$0
$1,340 (Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses
$0
$0
$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $167.50 a day
$0
$0
$0
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Plan F Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$183 (Part B deductible)
Generally 20%
100%
$0
$0
$0
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$183 (Part B deductible)
20%
$0
$0
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment – First $183 of Medicare-
approved amounts* – Remainder of Medicare-
approved amounts
100%
$0
80%
$0
$183 (Part B deductible)
20%
$0
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Other benefits – not covered by Medicare
Services Medicare pays Plan pays You payForeign travel – not covered by MedicareMedically necessary emergency care services beginning during the �rst 60 days of each trip outside the USAFirst $250 each calendar yearRemainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum
Parts A and B
M53401 (CA 1/18)
High Deductible Plan F Medicare (Part A)Hospital services – per benefit period
�is high deductible plan pays the same bene�ts as Plan F a�er a member has paid a $2,240 calendar year deductible. Bene�ts from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. �is includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Services Medicare paysA�er you pay $2,240 deductible, plan pays
In addition to $2,240 deductible, you pay
Hospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve days• Once lifetime reserve days
are used: – Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day $0 $0
$1,340 (Part A deductible)$335 a day
$670 a day 100% of Medicare-eligible expenses$0
$0
$0
$0 $02
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare paysA�er you pay $2,240 deductible, plan pays
In addition to $2,240 deductible, you pay
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $167.50 a day
$0
$0
$0
All costsBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
M53401 (CA 1/18)
High Deductible Plan F Medicare (Part B)Medical services – per calendar year
�is high deductible plan pays the same bene�ts as Plan F a�er a member has paid a $2,240 calendar year deductible. Bene�ts from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,240. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. �is includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Services Medicare paysA�er you pay $2,240 deductible, plan pays
In addition to $2,240 deductible, you pay
Medical expenses – In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$183 (Part B deductible)
Generally 20%
100%
$0
$0
$0
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$183 (Part B deductible)
20%
$0
$0
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare paysA�er you pay $2,240 deductible, plan pays
In addition to $2,240 deductible, you pay
Home health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment – First $183 of Medicare-
approved amounts* – Remainder of Medicare-
approved amounts
100%
$0
80%
$0
$183 (Part B deductible)
20%
$0
$0
$0
Other benefits – not covered by Medicare
Services Medicare pays Plan pays You payForeign travel – not covered by MedicareMedically necessary emergency care services beginning during the �rst 60 days of each trip outside the USAFirst $250 each calendar yearRemainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Parts A and B
M53401 (CA 1/18)
Plan G Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve days• Once lifetime reserve days
are used: – Additional 365 days
– Beyond the additional 365 days
All but $1,340 All but $335 a day
All but $670 a day
$0
$0
$1,340 (Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses
$0
$0
$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $167.50 a day
$0
$0
$0
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0
100%
3 pints
$0
$0
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
Plan G Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$0
Generally 20%
100%
$183 (Part B deductible)
$0
$0
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$0
20%
$0
$183 (Part B deductible)
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment
– First $183 of Medicare-approved amounts*
– Remainder of Medicare-approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B deductible)
$0
Other benefits – not covered by Medicare
Services Medicare pays Plan pays You payForeign travel – not covered by MedicareMedically necessary emergency care services beginning during the �rst 60 days of each trip outside the USAFirst $250 each calendar yearRemainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Parts A and B
M53401 (CA 1/18)
Plan K Medicare (Part A)1
Hospital services – per benefit period
Services Medicare pays Plan pays You pay1Hospitalization2Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve daysOnce lifetime reserve days are used:• Additional 365 days
• Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0
$0
$670 (50% of Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses
$0
$670 (50% of Part A deductible)◆
$0
$0
$03
All costs
1 You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5,240 each calendar year. �e amounts that count toward your annual limit are noted with diamonds (◆) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”), and you will be responsible for paying this di�erence in the amount charged by your provider and the amount paid by Medicare for the item or service.
2 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
3 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare pays Plan pays You pay1Skilled nursing facility care2You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $83.75 a day
$0
$0
Up to $83.75 a day◆
All costsBloodFirst 3 pintsAdditional amounts
$0100%
50%$0
50%◆
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
50% of Medicare copay/coinsurance
50% of Medicare copayment/coinsurance◆
2 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
M53401 (CA 1/18)
Plan K Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You pay**Medical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Preventive bene�ts for Medicare-covered services
Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 75% or more of Medicare-approved amounts
Generally 80%
$0
$0
Remainder of Medicare-approved amounts
Generally 10%
$0
$183 (Part B deductible)◆
All costs above Medicare-approved amounts
Generally 10%◆
All costs (and they do not count toward out-of-pocket limit of $5,240)**
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*
Remainder of Medicare-approved amounts
$0
$0
Generally 80%
50%
$0
Generally 10%
50%◆
$183 (Part B deductible)◆
Generally 10%◆
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
** �is plan limits your annual out-of-pocket payments for Medicare-approved amounts to $5,240 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”), and you will be responsible for paying this di�erence in the amount charged by your provider and the amount paid by Medicare for the item or service.
M53401 (CA 1/18)
Services Medicare pays Plan pays You pay**Home health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment
– First $183 of Medicare-approved amounts*
– Remainder of Medicare-approved amounts
100%
$0
80%
$0
$0
10%
$0
$183 (Part B deductible)◆
10%◆
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Parts A and B
M53401 (CA 1/18)
Plan L Medicare (Part A)1
Hospital services – per benefit period
Services Medicare pays Plan pays You pay1Hospitalization2Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve daysOnce lifetime reserve days are used:• Additional 365 days
• Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0 $0
$1,005 (75% of Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses$0
$335 (25% of Part A deductible)◆ $0
$0
$03
All costs
1 You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,620 each calendar year. �e amounts that count toward your annual limit are noted with diamonds (◆) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”), and you will be responsible for paying this di�erence in the amount charged by your provider and the amount paid by Medicare for the item or service.
2 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
3 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare pays Plan pays You pay1Skilled nursing facility care2You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $125.63 a day
$0
$0
Up to $41.87 a day◆
All costsBloodFirst 3 pintsAdditional amounts
$0
100%
75%
$0
25%◆
$0Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
75% of Medicare copay/coinsurance
25% of Medicare copay/coinsurance◆
2 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
M53401 (CA 1/18)
Plan L Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You pay**Medical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Preventive bene�ts for Medicare-covered services
Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 75% or more of Medicare-approved amounts
Generally 80%
$0
$0
Remainder of Medicare-approved amounts
Generally 15%
$0
$183 (Part B deductible)◆
All costs above Medicare-approved amounts
Generally 5%◆
All costs (and they do not count toward out-of-pocket limit of $2,620)**
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*
Remainder of Medicare-approved amounts
$0
$0
Generally 80%
75%
$0
Generally 15%
25%◆
$183 (Part B deductible)◆
Generally 5%◆
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
** �is plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,620 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”), and you will be responsible for paying this di�erence in the amount charged by your provider and the amount paid by Medicare for the item or service.
M53401 (CA 1/18)
Services Medicare pays Plan pays You pay**Home health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment
– First $183 of Medicare-approved amounts*
– Remainder of Medicare-approved amounts
100%
$0 80%
$0
$0
15%
$0
$183 (Part B deductible)◆
5%◆
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Parts A and B
M53401 (CA 1/18)
Plan M Medicare (Part A)Hospital services – per benefit period
Services Medicare pays Plan pays You payHospitalization1Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days
61st through 90th day91st day and a�er:• While using 60 lifetime
reserve days• Once lifetime reserve days
are used: – Additional 365 days
– Beyond the additional 365 days
All but $1,340
All but $335 a day
All but $670 a day
$0 $0
$670 (50% of Part A deductible)$335 a day
$670 a day
100% of Medicare-eligible expenses
$0
$670 (50% of Part A deductible)
$0
$0
$02
All costs
Skilled nursing facility care1You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days a�er leaving the hospital.First 20 days 21st through 100th day101st day and a�er
All approved amounts
All but $167.50 a day
$0
$0
Up to $167.50 a day
$0
$0
$0
All costs
1 A bene�t period begins on the �rst day you receive service(s) as an inpatient in a hospital and ends a�er you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2 Note: When your Medicare Part A hospital bene�ts are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Bene�ts.” During this time, the hospital is prohibited from billing you for the balance based on any di�erence between its billed charges and the amount Medicare would have paid.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payBloodFirst 3 pintsAdditional amounts
$0100%
3 pints$0
$0$0
Hospice careYou must meet Medicare’s requirements, including a doctor’s certi�cation of terminal illness.
All but very limited copay/coinsurance for outpatient drugs and inpatient respite care
Medicare copay/coinsurance
$0
Plan M Medicare (Part B)Medical services – per calendar year
Services Medicare pays Plan pays You payMedical expenses – in or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipmentFirst $183 of Medicare-approved amounts*Remainder of Medicare-approved amountsPart B Excess Charges (above Medicare-approved amounts)
$0
Generally 80%
$0
$0
Generally 20%
$0
$183 (Part B deductible)
$0
All costs
BloodFirst 3 pintsNext $183 of Medicare-approved amounts*Remainder of Medicare-approved amounts
$0
$0
80%
All costs
$0
20%
$0
$183 (Part B deductible)
$0
Clinical laboratory servicesTests for diagnostic services 100%
$0
$0
* Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
M53401 (CA 1/18)
Services Medicare pays Plan pays You payHome health care – Medicare-approved services• Medically necessary skilled
care services and medical supplies
• Durable medical equipment
– First $183 of Medicare-approved amounts*
– Remainder of Medicare-approved amounts
100%
$0
80%
$0
$0
20%
$0
$183 (Part B deductible)
$0
Other benefits – not covered by Medicare
Services Medicare pays Plan pays You payForeign travel – not covered by MedicareMedically necessary emergency care services beginning during the �rst 60 days of each trip outside the USAFirst $250 each calendar yearRemainder of charges
$0
$0
$0
80% to a lifetime maximum benefit of $50,000
$250
20% and amounts over the $50,000 lifetime maximum
Parts A and B
M53401 (CA 1/18)
Eligibility provisionsYou are eligible for enrollment in one of HNL’s Group Medicare Supplement plans if you are 65 or older or under 65 and entitled to Medicare on the basis of Social Security disability bene�ts, enrolled in Medicare Parts A and B, reside within the State of California, and meet the eligibility requirements established by the Employer Group. Your continued eligibility to participate in this health plan depends on your continued Medicare enrollment. Please call Health Net Medicare Inside Sales for more details at 1-800-944-7287.
Claims reimbursement�e Health Net Life Group Medicare Supplement plan features electronic claims processing, a claims payment process between Health Net Life and Medicare. Medicare-certi�ed and Medicare-accepting providers bill Medicare for services provided and, upon processing, Medicare then sends claims electronically to Health Net Life for secondary payment. Electronic claims processing is provided with your membership in the Health Net Medicare Supplement Plan. �ere is no registration necessary.
For claims for services covered by your Health Net Life Group Medicare Supplement Plan, but not by Medicare, such as foreign travel emergency care, you or your medical provider should submit the claims directly to Health Net at:
Health Net Life Insurance Company PO Box 2020 Farmington, MO 63640-9933
You may request a Health Net claim form by contacting the Member Services number provided on your identi�cation card.
How to applyYou may apply by completing the Group Medicare Supplement Enrollment form and returning it to HNL or your Employer, as applicable, within 30 days of your Group Open Enrollment Period. For questions or assistance in enrolling in HNL’s Group Medicare Supplement Plan, please call Health Net Medicare Inside Sales at 1-800-944-7287.
M53401 (CA 1/18)
Termination provisionsHNL can terminate your coverage:
• If the Group’s Policy with HNL is terminated, including termination due to nonpayment of premiums by the group.
• If you no longer meet the eligibility requirements established by HNL and the Group.
Health Net Medicare inside salesOnce you have had a chance to review the information presented here, please feel free to call Health Net Medicare Inside Sales at 1-800-944-7287. We’ll be glad to talk to you about this plan and all the bene�ts it o�ers you.
Grievance and arbitrationIf you have a grievance against HNL, or are ever dissatis�ed with our services and our HNL Medicare Supplement Plan Member Services Department is not able to solve the problem, there is a procedure for appealing the issue. You may write a letter explaining the problem to:
HNL Medicare Supplement Plan Appeals and Grievances Department PO Box 10344 Van Nuys, CA 91410-0344
HNL uses neutral, binding arbitration to settle disputes, which arise out of or relate to coverage under the Policy. When you enroll in an HNL Medicare Supplement Plan, you agree to submit any disputes to arbitration, in lieu of a jury or court trial.
�is binding arbitration provision does not apply to claims, disputes, or controversies relating to alleged professional negligence (medical malpractice) and applies only to matters arising under this Policy.
Medicare has speci�c appeals procedures for the portion of the bill they pay. If you feel a decision made on a claim is incorrect, any Social Security o�ce can help you request a review.
Department of InsuranceIf the Covered Person is unable to resolve a dispute with HNL, the Covered Person may wish to contact:
State of California Department of Insurance 300 S. Spring St. Los Angeles, CA 90013 1-800-927-HELP
M53401 (CA 1/18)
For more information, please contact us at:
Health Net LifeMedicare Supplement Plan PO Box 2020 Farmington, MO 63640-9933
Health Net Medicare Inside Sales:1-800-944-7287
Health Net Member Services:1-800-926-4178
Para los que hablan español:1-800-926-4178
Assistance for the hearing and speech impaired:TTY users call 711.
Underwritten by Health Net Life Insurance Company
BKT017899EK00 (1/18)Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. M53401 (CA 1/18)
Health Net Life Insurance Company (Health Net) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Health Net:• Provides free aids and services to people with disabilities to communicate e�ectively with us,
such as quali�ed 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 quali�ed interpreters and information written in other languages.
If you need these services, contact Health Net’s Customer Contact Center at: Medicare Supplement: 1-800-926-4178 (TTY: 711)
If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can �le a grievance by calling the number above and telling them you need help �ling a grievance; Health Net’s Customer Contact Center is available to help you. You can also �le a grievance by mail, fax or online at:
Health Net Life Insurance Company PO Box 10348 Van Nuys, CA 91410-0348
You can also �le a civil rights complaint with the U.S. Department of Health and Human Services, O�ce for Civil Rights, electronically through the O�ce for Civil Rights Complaint Portal, available 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/o�ce/�le/index.html.
Nondiscrimination Notice
Health Net Life Insurance Company is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.
FLY011615ED00 (11/16)
