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Medicare Plans

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

The plan offers several Medicare Advantage (MA) plan options. An MA plan must provide all benefits covered under original Medicare in a manner consistent with professional recognized standards of care.

The plan offers a variety of MA plans for beneficiaries that cover all Medicare benefits, including health care services and/or prescription drug. 

Below are descriptions of MA. Medicare prescription drug plans, and Medicare Supplement plans available in California and, where applicable, their associated plan colors.

The Seniority Plus Green Medicare-Advantage (MA)-only plan offers competitive medical-only benefits at a reasonable cost. Members select a primary care physician (PCP) who provides or coordinates all services. This plan does not include the prescription drug program. This plan is simple, competitive and cost-effective.

The Seniority Plus Ruby and Ruby Select Medicare Advantage with part D HMO plans offer members the convenience of obtaining all their health care through the plan. Members select a primary care physician (PCP) who provides or coordinates all services. Members also have access to the prescription drug program, which includes many of the most commonly prescribed brand-name and generic drugs at affordable prices. The premiums for these plans differ depending on the county. The Ruby Select (HMO) in Alameda, Fresno, San Francisco, and Yolo counties are provider specific plans (PSPs) that limit plan members to a subset of participating providers from the full provider network.

The Medicare Modernization Act (MMA) created a Medicare Advantage (MA) option called "specialized MA plans for special needs individuals," also referred to as Special Needs Plans (SNPs). MA SNPs are categorized as coordinated care plans; however, health plans that offer SNPs may limit enrollment to special needs beneficiaries or a disproportionate percentage of special needs beneficiaries. This ensures that the needs of these special populations are met as effectively as possible. The plan's SNPs are as follows:

  • Seniority Plus Amber I (HMO SNP)
  • Seniority Plus Amber II (HMO SNP)
  • Seniority Plus Amber II Premier (HMO SNP)
  • Jade (HMO SNP)

MMA-authorized SNPs have limited enrollment to three designated subsets of the Medicare population:

  • Institutionalized Medicare beneficiaries - those individuals who reside or are expected to reside continuously for 90 days or longer in a long-term care facility.
  • Dual-eligible Medicare beneficiaries - those individuals who are eligible for both Medicare and Medi-Cal, also known as Medi-Medi.
  • Severely disabled and chronically ill Medicare beneficiaries - these individuals have not been defined by the Centers for Medicare & Medicaid Services (CMS); however, CMS is considering proposals on a case-by-case basis, evaluating the appropriateness of target populations, clinical program and specialty expertise.

The plan offers SNPs to dual-eligible Medicare and Medi-Cal (Medi-Medi) beneficiaries and to severely disabled and chronically ill Medicare beneficiaries in certain counties. Primary care physicians (PCPs) are required to develop a plan of care for the member and coordinate needed care through the Case Management Department.

The Amber I, Amber II, Amber II Premier, and Jade plans offer additional benefits, such as preventive and comprehensive dental, hearing aids, routine vision exams, routine eyewear, transportation services, and membership in a fitness program. 

Amber I

Seniority Plus Amber I (HMO SNP) is the plan's all-benefit dual-eligible (Medicare-Medi-Cal) special needs plan (SNP). All-benefit dual-eligibles include partial and full-benefit dual-eligible members. Members may seek services from highly qualified participating providers. Additionally, this coordinated care plan offers access to prescription drugs through the Medicare Part D Prescription Drug Program with no or reduced premiums and deductibles. It also provides additional core benefits, such as hearing aids, DHMO dental, routine vision exams and eyewear, transportation services, and membership in a fitness program. Medical coverage is offered with reduced coinsurance or copayments, and coordination of benefits (COB) may apply.

Members who meet low-income criteria are eligible for greater prescription drug savings through low-income subsidization (LIS) depending on their income level. Refer to the Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy on the Centers for Medicare & Medicaid (CMS) website at www.cms.gov under "Attachment VI. Final Updated Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy, Annual Percentage Increases" for additional information regarding prescription drug copayments. Beneficiaries must be enrolled in both Medicare Part A and Medicare Part B. In addition, they must be enrolled with Medi-Cal under one of the following categories:

  • Full Medi-Cal (Medicaid) (only);
  • Qualified Medicare beneficiary without other Medi-Cal (Medicaid) (QMB only);
  • QMB Plus;
  • Specified Low-Income Medicare Beneficiary without other Medi-Cal (Medicaid) (SLMB only);
  • SLMB Plus;
  • Qualifying Individual (QI-1);
  • Qualified Disabled and Working Individual (QDWI).

Amber II and Amber II Premier

Health Net Seniority Plus Amber II and Amber II Premier (HMO SNP) plans are Health Net's (Medicare-Medi-Cal) SNP designed for full-benefit dual-eligible beneficiaries. These coordinated care plans offer access to prescription drugs through the Medicare Part D Prescription Drug Program. They also provide additional core benefits, such as hearing aids, DHMO dental, routine vision and eyewear, transportation services, and membership in a fitness program. Full-benefit dual-eligible members have no out-of-pocket expenses for medical coverage due to their full-benefit dual-eligibility status and receive prescription drug savings through LIS. Actual cost-sharing is based upon the member's income level. Refer to the Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy on the CMS website at www.cms.gov under "Attachment VI. Final Updated Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy, Annual Percentage Increases" for additional information regarding prescription drug copayments. Refer to the Coordination of Benefits for Amber I and Amber II section below for additional information.

To apply for this plan, beneficiaries must:

  • be enrolled in both Medicare Parts A and B,
  • be enrolled with Medi-Cal under either Full Medicaid, QMB Plus or SLMB Plus,
  • continue to maintain Medi-Cal eligibility,
  • reside in the service area, and
  • use participating providers for all routine care.

Cost-Share

Cost-share amounts for medical benefits mirror original Medicare. Providers can contact the SNP Provider Services Center. Any cost-share amounts indicated in the Schedule of Benefits are not the member's responsibility due to their full-benefit dual-eligibility status and should be handled through the COB process.

Coordination of Benefits

Members are instructed to present both their Medicare and Medi-Cal (beneficiary identification card (BIC)) or Medi-Cal managed-care plan (or both) identification (ID) cards to their participating provider when accessing medical services and to their pharmacy when accessing prescription medication services.

Note: Physicians should use the Medi-Cal eligibility verification system to identify a patient's Medi-Cal plan. Learn more about this system at www.Medi-Cal.ca.gov/Services.asp.

The plan's COB process for dual-eligible SNP members includes notifying providers when member claims have been denied or there is a balance owed. For members enrolled in the Medi-Cal managed care plan, the plan informs providers that the claim has been forwarded to the Medi-Cal managed care plan for further payment review. For members enrolled in fee-for-service (FFS) Medi-Cal through the state, providers are instructed to bill the state for any denied services or balance owed. Providers cannot hold a Medicare member responsible for any cost-sharing for covered services when a state entity is responsible for paying such amount. Where the state is responsible for paying the cost-share amount, providers must either accept the contracting rate as payment in full or bill the appropriate state source for the cost-share amount. Seniority Plus Amber I, Amber II and Amber II Premier (HMO SNP) participating providers who are not contracting with Medi-Cal FFS cannot refuse to provide covered services to dual-eligible members.

Chronic Special Needs Plan - Health Net Jade (HMO SNP)

Health Net Jade (HMO SNP) is the chronic care SNP for individuals who have been diagnosed with one or more of the following conditions:

  • chronic heart failure (CHF)
  • diabetes mellitus
  • cardiovascular disorders (cardiac arrhythmias, coronary artery disease, peripheral vascular disease, chronic venous thromboembolic disorder)

Members select a PCP who provides or coordinates all services. This coordinated care plan offers access to prescription drugs through the Medicare Part D prescription drug program with no or reduced premiums and deductibles, and reduced coinsurance or copayments. It also provides additional core benefits, such as hearing aids, routine vision exams and eyewear, transportation services, and membership in a fitness program. DHMO dental is also covered as a core benefit for members residing in Kern, Los Angeles and Orange counties. This plan is only available to individuals enrolled in Medicare Parts A and B, who have been diagnosed with one or more of the conditions listed above, and who reside in the service area.

Plan enrollment is contingent upon confirmation of a qualifying condition by the provider. The beneficiary must submit either a completed Pre-qualification Assessment Tool (PDF), which requires verification after the beneficiary's enrollment, or a Chronic Condition Verification Form (PDF) already completed by the member's provider. If the beneficiary submits only a Pre-qualification Assessment Tool, the plan works with the applicable provider once the beneficiary is enrolled to obtain the provider's attestation on the Chronic Condition Verification Form, as required by CMS. If the member does not qualify within the first two months of the enrollment date, the member is disenrolled from the Jade plan based on Medicare guidelines, and the member receives a Special Election Period (SEP) to enroll in an alternate Medicare plan.

Only individuals who are eligible for enrollment in the plan's dual-eligible special needs plans (SNP) and who are also excluded from enrollment into Cal MediConnect can be enrolled in the plan's dual-eligible SNP plans in the following Cal MediConnect counties: Los Angeles, Orange, Riverside, San Bernardino, and San Diego. Excluded Cal MediConnect individuals include:

  • individuals under age 21,
  • individuals with other private or public health insurance,
  • developmentally disabled (DD) beneficiaries receiving services through a Department of Developmental Services 1915© waiver; regional center; state developmental center; or intermediate care facilities for the developmentally disabled (ICF/DD);
  • individuals with a share of cost - in community and not continuously certified,
  • individuals residing in one of the Veterans' Homes of California,
  • individuals living in 20 designated rural ZIP codes in San Bernardino, Los Angeles and Riverside counties, and
  • individuals with a diagnosis of end-stage renal disease (ESRD) at the time of enrollment unless they are already in a separate line of business operated by the health plan.

The Seniority Plus Sapphire and Sapphire Premier Medicare Advantage with Part D prescription drug HMO plans are designed for full-benefit dual-eligible beneficiaries (receiving the highest level of assistance from Medi-Cal). Full-benefit dual-eligibles are enrolled in both Medicare Parts A and B and Medi-Cal under Full Medicaid, QMB Plus or SLMB Plus. These coordinated care plans offer access to prescription drugs through Medicare Part D and provide additional core benefits, such as acupuncture and chiropractic services, hearing aids, dental, routine vision exams and eyewear, over-the-counter items, transportation services, and membership in a fitness program. The Sapphire and Sapphire Premier plans are designed to work in coordination with a member's Medi-Cal coverage. Full-benefit dual-eligible members have no out-of-pocket expenses for medical coverage and receive prescription medication savings through low-income subsidy (LIS). Actual cost-sharing is based upon the member's income level. Refer to Part D Benefit Parameters for Defined Standard Benefit, Low-Income Subsidy, and Retiree Drug Subsidy on the Centers for Medicare & Medicaid (CMS) website at www.cms.gov under "Attachment VI. Final Updated Part D Benefit Parameters for Defined Standard Benefit, Low Income Subsidy, and Retiree Drug Subsidy, Annual Percentage Increases" for additional information regarding prescription drug copayments.

Cost-Share

Cost-share amounts for medical benefits mirror original Medicare. Providers can contact the Provider Services DepartmentCenter. Any cost-share amounts indicated in the Schedule of Benefits are not the full-benefit dual-eligible members' responsibility due to their dual-eligibility status and should be handled through the coordination of benefits process as follows.

Coordination of Benefits for Dual-Eligible Members

Dual-eligible members are instructed to present both their Medicare and Medi-Cal (Medi-Cal beneficiary identification (ID) card (BIC) or Medi-Cal managed care plan) ID cards to their participating providers when accessing medical services and to their pharmacy when accessing prescription drug services. Note: Physicians should use the Medi-Cal eligibility verification system to identify a patient's Medi-Cal plan. Learn more about this system at www.medi-cal.ca.gov/services.asp. The plan's coordination of benefits process for dual-eligible members includes provider notification when member claims have been denied or there is a balance owed. For members enrolled in the plan's Medi-Cal managed care plan, the plan informs providers that the claim has been forwarded to the Medi-Cal managed care plan for further payment review. In accordance with state and federal regulations, providers cannot hold dual-eligible members responsible for any cost-sharing for covered services when a state entity is responsible for paying such amount. Where the state is responsible for paying the cost-share amount, providers must either accept the contracting rate as payment in full or bill the appropriate state source for the cost-share amount. Participating providers who are not contracting with Medi-Cal fee-for-service (FFS) cannot refuse to provide covered services to dual-eligible members.

The Healthy Heart Medicare Advantage with Part D prescription drug HMO plans provide comprehensive medical and prescription drug benefits with unique offerings. These plans were designed to support a healthy lifestyle. This lifestyle includes avoiding tobacco smoke; managing stress, high blood pressure and high cholesterol; and promoting nutrition, weight management and physical activity. The benefits of Healthy Heart plans include nutrition and weight management programs, support for chronic conditions, smoking cessation telephone and online programs, and more. Members select a primary care physician (PCP) who provides or coordinates all services. The premiums for these plans differ by county. The Healthy Heart plan in San Diego County is a provider-specific plan (PSP) that limits plan members to a subset of participating providers from the full provider network. 

The Gold Select Medicare Advantage (MA) with Part D prescription drug HMO plan provides comprehensive medical coverage with valuable health essentials at low, predictable costs. In addition to medical and prescription drug benefits, this plan also offers transportation to plan-approved locations, complementary coverage for hearing aids, membership in a fitness program, over-the-counter items, preventive and comprehensive dental services, and routine vision exams and eyewear. This is a provider-specific plan (PSP) that limits plan members to a subset of participating providers from the full provider network.

Medicare Supplement plans are identified by the letters A through N. These plans must follow federal and state laws and can only be utilized through a private health plan. The plan offers the following Medicare Supplement plans:

  1. Individual Medicare Supplement Plans - Health Net Life Insurance Company offers individual plans A, C, F, High Deductible F, G, K, L, and M.
  2. Employer Group Retiree Medicare Supplement Plans - Health Net Life Insurance Company offers plans A, B, C, D, F, High Deductible F, G, K, L, and M. Membership in a Health Net employer group is required in order to be eligible for these plans.

Health Net Life Insurance Company Medicare Supplement Optional Supplemental Packages

Health Net Life Insurance Company offers supplemental benefits for an additional monthly premium with individual Medicare Supplement plans.

  1. Optional Package #1 - Hearing care, Standard PPO Dental and PPO Vision
  2. Optional Package #2 - Hearing care, Enhanced PPO Dental and PPO Vision
Last Updated: 10/31/2019