Healthy San Francisco
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1 Part II Section F Introduction 1 Sample Anthem Blue Cross Member ID Card 2 Summary of Benefits and Point of Service Fees 3 CCHCA Physician Handbook (7 th Edition)
2 Program is a program created by the City of San Francisco to provide affordable medical care to uninsured people living in San Francisco. The effective starting date for the program is September 8, While the program provides basic and ongoing medical care to San Franciscans without health insurance, the program is not health insurance. Any services, including emergency care, not obtained through the assigned Medical Group/Medical Home or from the network facilities are not covered. Under the program, eligible participants will pay a quarterly participant fee, which is determined based on family size and household income. Participants will also pay a point of service fee at the time medical services are received. The amount of the point of service fee will depend on the Medical Home the participant chooses, and household income. Participants with household incomes in the % of federal poverty level will generally have a point of service fee; participants with households incomes in the 1-100% of federal poverty level will have no point of service fees, except for emergency care. (See following pages for a schedule of point of service fees under CCHCA). CCHCA and CCHCA and Chinese Hospital are participants as partners in the Program (HSF). Participants enrolled under will make a choice of Medical Home. If CCHCA is chosen as the Medical Home, Participants must choose a Primary Physician under CCHCA and obtain services through CCHCA. CCHCA will pay claims based on the Medi-Cal fee schedule for professional services. Authorizations, and Utilization for members enrolled under the CCHCA Medical Group will continue to be handled in the same manner as the other CCHCA programs. For questions concerning participant application, benefits, or fees associated with the program, please call at or visit their website at: CCHCA Physician Handbook, Part II, Section F - 1 -
3 Sample ID Cards participants who choose CCHCA as the Medical Home will receive two separate ID Cards. One is from, and the other is from CCHCA. Two ID cards are given to the participant because the ID card from does not carry the Primary Physician name and point of service fees. The CCHCA- ID card will carry this information. The member is asked to keep both cards with them at all times and to present the cards as identification when requesting services. Below is a sample ID card from and CCHCA. Sample: ID Card Sample: CCHCA- ID Card (Front) Sample: CCHCA- ID Card (Back) CCHCA Physician Handbook, Part II, Section F - 2 -
4 Point of Service Fees Summary of Benefits and Point of Service Fees Benefit Hospital Inpatient Care: Hospital Outpatient Surgery: Hospital Outpatient Services: Preventive and routine care, Point of service fee % of Federal Poverty Level Point of service fee 1-100% of Federal Poverty Level $200/ admit $0 $100/procedure $0 $10/ visit $0 $10/ visit $0 including immunizations Laboratory Services $10/ visit $0 Radiology Services $10/ visit $0 Prescription Drugs: Drugs can be obtained only at: Chinese Hospital Pharmacy Golden Gate Pharmacy Joe s Pharmacy AG Pharmacy Visitacion Pharmacy Thousand Crane Pharmacy Daniel s Pharmacy Emergency care: (Up to 30 day supply) $5 generic $25 Brand $50/visit (Up to 30 day supply) $0 $0 $25/visit Ambulance Services $10 $0 Urgent Care: $10/visit $0 Chinese Hospital only CCHCA Physician Handbook, Part II, Section F - 3 -
5 Mental Health Services provided by: San Francisco Community Behavioral Health Services (SFCBHS) (415) Services provided by: San Francisco Community Behavioral Health Services (SFCBHS) (415) Therapies: PT,OT, ST $10/visit $0 Durable medical equipment $10/each $0 Exclusions: Services that are not covered through Accupuncture Allergy testing and injections Audiology/Hearing Aids and Batteries Chiropractic Cosmetic Services Dental Services Genetic Testing and Counseling Infertility Services Long Term Care Obesity Reduction/Gastric Bypass Surgery Transplants Transportation: Non-Urgent Vision Behavioral Health CCHCA Physician Handbook, Part II, Section F - 4 -
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PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and non-preferred
Important Questions Answers Why this Matters:
Anthem BlueCross BlueShield Blue Access PPO Option 20 / Rx Option 7 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family
Aetna Choice POS II Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK
Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: September 29, 2014 Effective Date: January 1, 2014 Schedule: 8A Booklet Base: 8 For: Aetna Choice POS II - Yale Police Benevolent
Anthem Blue Cross Your Plan: Custom Classic HMO 20/250 Admit (Rx $15/$30/$45/$45) Your Network: Select HMO
Anthem Blue Cross Your Plan: Custom Classic HMO 20/250 Admit (Rx $15/$30/$45/$45) Your Network: Select HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection
Service Participating Providers: Non-participating Providers:
Provider Network: SmartHealth Network PSGOOC.MT.SG.0115 Medical Benefit Summary SmartHealth Value Silver 3000 Annual Deductible Per Person, Per Calendar Year Per Family, Per Calendar Year Participating