Welcome to CCHP. Choose CCHP. Quality and value from a local plan. Senior Program (HMO) Senior Select Program (HMO SNP) 2019 Medicare Information Kit

Transcription

1 Welcome to CCHP Choose CCHP. Quality and value from a local plan. Senior Program (HMO) Senior Select Program (HMO SNP) 2019 Medicare Information Kit This is an advertisement. H0571_2019_06V2_M

2 Notes: Hello! At CCHP, it is our mission to provide high quality affordable healthcare. Medicare rated us 4.5 stars out of 5 for This is just one proof that we are delivering on our promise to our Members. We know you have options when it comes to choosing a health partner and we are here to help. This information kit will explain how CCHP can give you access to the kind of care you want and need. Our Senior Program (HMO) and Senior Select Program (HMO SNP) plans offer all the benefits of original Medicare parts A & B and a whole lot more: Pay nothing for preventive services and labs to maintain your health Choose from over 270 specialists and primary doctors Generous drug coverage Travel worry-free with worldwide emergency coverage Stay well with health, fitness & wellness classes like yoga, tai chi and discounted YMCA membership Please review the information in this booklet and be sure to let us know if you have any questions or when you are ready to join! Call, or Visit Us: By Phone: , (TTY ), 7 days a week from 8 a.m. to 8 p.m. In Person: San Francisco Office #1 445 Grant Avenue, San Francisco, CA M-F 8 a.m. to 8 p.m., Sat. 9 a.m. to 5 p.m., Closed on Sundays San Francisco Office #2 845 Jackson Street, San Francisco, CA M-F 8 a.m. to 8 p.m., Sat. 9 a.m. to 5 p.m., Closed on Sundays Daly City Office 386 Gellert Boulevard, Daly City, CA M-F 9 a.m. to 5 p.m., Closed on Saturdays and Sundays By info@cchphealthplan.com Questions? Thank you for considering CCHP! Deena Louie Deena Louie, CEO CCHP 2

3 Notes: Thank you for considering CCHP Senior Program (HMO) and CCHP Senior Select Program (HMO SNP)*. We are a San Francisco Original that s been providing quality, affordable coverage to thousands of residents of San Francisco and San Mateo counties for over 30 years. This booklet will help you understand the benefits of enrolling in our Medicare Advantage Plans. Once enrolled, you will have the peace-of-mind you are looking for knowing a trusted partner covers your health care needs. Here is what s included: 1) Plan Overview gives you a quick look at our benefits and valuable services 2) Pre-Enrollment Checklist of items for your consideration when shopping for coverage 3) Summary of Plan Benefits for an in-depth look at what s covered 4) Information about discrimination and available language help 5) How you can contact us We invite you to have a look at our plans and be sure to contact us with any questions. Our friendly sales representatives are waiting. *CCHP Senior Select Program (HMO SNP) is available in San Francisco only. Questions?

4 Notes: About CCHP - A Quality and Value Story At CCHP, we understand it s important to get the most out of your health care budget. That s why we designed our plans to suit your unique needs and included some of the extras that may be important to you. No Cost Preventive Services We believe maintaining your health with regular check-ups for preventive services shouldn t cost extra. That s why basic services like an annual screening, labs, x-rays and vaccinations are covered without copay. Physician Network All our Medicare Advantage Plans offer over 270 independent primary care doctors and specialists with offices located throughout San Francisco and San Mateo service area. You are sure to find a great doctor with a convenient location ALAMEDA OAKLAND 580 SAN FRANCISCO DALY CITY COLMA BRISBANE PACIFICA SOUTH SAN FRANCISCO SAN BRUNO 101 LINDA MAR MILLBRAE BURLINGAME MONTARA 1 MOSS BEACH 280 SAN MATEO FOSTER CITY BELMONT SAN CARLOS REDWOOD CITY Questions?

5 Notes: Hospital Network We contract with several hospitals in our service area including: California Pacific Medical Center, Chinese Hospital, St. Francis Memorial Hospital, St. Mary s Medical Center, Mills-Peninsula Medical Center, Sequoia Hospital, Seton Medical Center, and other providers and institutions to provide quality care to our Members. 24/7 Nurse Advice Line Sometimes you just have a question or need to consult a medical expert when your doctor is not available right away. They can help you get the right care for your specific situation. Acupuncture Services We know it s important for our members to be able to integrate treatments for better healing and maintaining your Chi. Our plans include acupuncture visits so you can balance your health. Health, Wellness and Fitness Classes At CCHP, we want our Members to maintain optimal health. Our educational classes are practical as well as informational so you can stay on top of your health conditions. Our yoga, tai chi, and chi gong classes are designed so you can choose how you stay fit. If you prefer, discounted memberships to all San Francisco area YMCA s are available. Member Portal & App Access your health information at your convenience. With our industry leading portal & app, you can review plan and claims information, test results, and pay your premiums. Personalized Service Whether you reach us by phone, or in person, you will find that, first, we answer right away. You will also find a caring and listening Member Services team member on the other end. You can also speak with us in-person. With two Member Services offices (one in San Francisco and one in Daly City), you will find it comforting to know that we treat you like you would like to be treated. CCHP, we are here for you. Questions?

6 Your Pre-Enrollment Checklist for Senior Program (HMO) Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at , (TTY ). Hours are 7 days a week, 8:00 a.m. to 8:00 p.m. Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit or call , (TTY ) to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/co-insurance may change on January 1, Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). Your Pre-Enrollment Checklist for Senior Select Program (HMO SNP) Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at , (TTY ). Hours are 7 days a week, 8:00 a.m. to 8:00 p.m. Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit or call , (TTY ) to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium, unless your Part B premium is covered by the State for full-dual eligible individuals. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/co-insurance may change on January 1, Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid. 6

7 Notes: Introducing, CCHP Senior Program (HMO) Service Area: Who qualifies?: What does it cost: San Francisco & San Mateo County People enrolled Medicare parts A & B $42 per month Additional benefits include: Vision Coverage Eye Glasses Prescription Drug Coverage Transportation Services for Medical visits Dental Coverage (Optional) Introducing, CCHP Senior Select Program (HMO SNP) Service Area: Who qualifies?: What does it cost: San Francisco People enrolled in Medicare Parts A and B, receives Medi-Cal (Medicaid) benefits $0-$32.40 (Premium may vary based on the level of Extra Help you receive. Please contact the plan for further details.) Additional benefits include: Vision Coverage Eye Glasses Prescription Drug Coverage Transportation Services for Medical visits Questions?

8 CCHP Senior Program (HMO) 2019 Summary of Benefits Service Area: San Francisco & San Mateo County This is a summary of drug and health services covered by CCHP Senior Program (HMO) January 1, December 31, Premiums and Benefits CCHP Senior Program (HMO) Monthly Plan Premium $42 Deductible $0 Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Outpatient Hospital Doctor Visits Preventive Care (e.g. flu vaccine, diabetic screenings) Emergency Care (Worldwide coverage) Urgently Needed Services Diagnostic Services/ Labs/Imaging You must continue to pay your Medicare Part B premium. $6,700 annually Includes copays and other costs for medical services for the year. Days 1-7: $100 copay per day** (at Chinese Hospital) Days 1-7: $280 copay per day** (at all other hospitals) Days 8+: $0 copay per day** $100 copay** (at Chinese Hospital) $295 copay** (at all other hospitals) PCP: $10 copay Specialists: $20 copay** $0 copay Other preventive services are available. There are some covered services that have a cost. $90 copay If you are admitted to the hospital within 24 hours, then you do not have to pay $90. $35 copay Diagnostic Radiology Services: $0 - $200 copay** X-Ray and Lab Services: $0 copay** Hearing Services Dental Services Vision Services Mental Health Services Skilled Nursing Facility (up to 100 days/benefit period) Physical Therapy Routine Hearing Exam: $35 copay** (one routine hearing exam allowed annually) Not Covered $20 copay for refraction** $0 copay for one pair of glasses every two years (maximum $150 allowance) Inpatient Hospital: Days 1-7: $225 copay/day** Days 8-90: $0 copay/day** Days 1-20: $0 copay/day** Days : $135 copay/day** $25 copay** Group and Individual Therapy Sessions: $35 copay** 8 H0571_2019_004_M

9 Premiums and Benefits CCHP Senior Program (HMO) Ambulance Services $225 copay per trip Transportation $0 copay per trip, 8 one-way trips per year** Medicare Part B Drugs $0 copay** Part D: Prescription Drug Coverage (for Drugs on CCHP s Formulary) 30-day Supply at Retail Pharmacy 90-day Supply by Mail Order and Preferred Cost-Share Pharmacies* Initial Coverage: Costs for Brand and Specialty drugs after the $100 yearly deductible. Tier 1: Preferred Generic $3 copay $6 copay (no deductible) Tier 2: Non-preferred Generic $7 copay $14 copay (no deductible) Tier 3: Preferred Brand $40 copay $80 copay Tier 4: Non-preferred Brand $60 copay $120 copay Tier 5: Specialty 30% coinsurance Drugs in this tier are not available at this extended day supply. Coverage Gap: Costs after your total yearly drug costs reach $3,820 Generic 37% coinsurance Brand & Specialty 25% coinsurance Catastrophic Coverage: Costs after yearly out-of-pocket drug costs reach $5,100 Generic You pay the greater of 5% or $3.40 copay. Brand & Specialty You pay the greater of 5% or $8.50 copay. *Cost share for 90-day supply may differ at non-preferred cost sharing pharmacies. Optional Dental Coverage $18 per month (in addition to monthly plan premium) **Prior authorizationand referral rules apply. This plan is available to anyone who is enrolled in Medicare Part A and Part B and resides in our service area. Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid program contract for our SNP. This information is not a complete description of benefits. A complete list of services we cover can be found in the Evidence of Coverage on our website or contact us for more information, (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. Chinese Community Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call CCHP s pharmacy network offers limited access to pharmacies with preferred cost sharing in San Francisco and San Mateo Counties. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up to date information about our network pharmacies, including pharmacies with preferred cost sharing, please call or consult the online pharmacy directory at ATTENTION: This information is available for free in other languages. Please contact our Member Services Department at < > (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. ATENCIÓN: Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro departamento de servicio de miembro al (TTY ) de 8:00 a.m. a 8:00 p.m., siete días a la semana. 此文件 其它的語言版本免費提供 了解詳情請致電 與會員服務 心聯絡 ( 聽力殘障 仕請電 TTY ), 每週 7, 午 8 時 晚 8 時 **Prior authorization and referral rules apply. H0571_2019_004_M 9

10 CCHP Senior Select Program (HMO SNP) 2019 Summary of Benefits Service Area: San Francisco County This is a summary of drug and health services covered by CCHP Senior Select Program (HMO SNP) January 1, December 31, Premiums and Benefits Monthly Plan Premium $0 - $32.40* Deductible $0 CCHP Senior Select Program (HMO SNP) You must continue to pay your Medicare Part B premium. * Premium may vary based on the level of Extra Help you receive. Please contact the plan for further details. Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Outpatient Hospital Doctor Visits Preventive Care (e.g. flu vaccine, diabetic screenings) Emergency Care Urgently Needed Services Diagnostic Services/ Labs/Imaging Hearing Services Dental Services Vision Services Mental Health Services Skilled Nursing Facility (up to 100 days/benefit period) Physical Therapy $3,400 annually Includes copays AND other costs for medical services for the year. Days 1-7: $0 copay per day** Days 8+: $0 copay per day** $0 copay** PCP: $0 copay Specialists: $0 copay** $0 $0 copay $0 copay Diagnostic and Procedures: $0 copay** Lab Services: $0 copay** Routine Hearing Exam: $0 copay** Not Covered $0 copay for refraction** $0 copay for one pair of glasses every two years (maximum $150 allowance) Inpatient Hospital: Days 1-90: $0 copay per day** Days 1-100: $0 copay per day** $0 copay** Group and Individual Therapy Sessions: $0 copay** 10 H0571_2019_005_M

11 Premiums and Benefits Ambulance Services Transportation Medicare Part B Drugs Part D: Prescription Drug Coverage (for Drugs on CCHP s Formulary) Initial Coverage Costs for Drugs after Deductible: For beneficiaries receiving no Extra Help, deductible is $415. For some beneficiaries receiving partial subsidy Extra Help, deductible is $85. For most beneficiaries is $0. Catastrophic Coverage: Costs after yearly out-of-pocket drug costs reach $5,100. CCHP Senior Select Program (HMO SNP) $0 copay per trip $0 copay per trip, 48 one-way trips per year** $0 copay** Drug Tier Generic (including brand drugs treated as generic) All Other Drugs Generic (including brand drugs treated as generic) All Other Drugs Copay (may vary based on the level of Extra Help eligibility*) 25% coinsurance; or with Low Income Subsidy (LIS): $0/$1.25/$3.40 copay or 15% coinsurance 25% coinsurance; or with Low Income Subsidy (LIS): $0/$3.80/$8.50 copay or 15% coinsurance You pay the greater of 5% or $3.40 copay. You pay the greater of 5% or $8.50 copay. *Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. **Prior authorizationand referral rules apply. The following services are not covered by CCHP Senior Select Program (HMO SNP) but may be available through Medi-Cal (Medicaid): Long term services and supports Routine foot care Incontinence supplies Certain drugs excluded by Medicare, check the Medi-Cal (Medicaid) formulary for more details Dental Services Hearing Aids This plan is available to anyone who is enrolled in Medicare Part A and Part B, receives Medi-Cal (Medicaid) benefits, and resides in San Francisco County. Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid program contract for our SNP. Enrollment in CCHP depends on contract renewal. This information is not a complete description of benefits. A complete list of services we cover can be found in the Evidence of Coverage on our website or contact us for more information, (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. Chinese Community Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call ATTENTION: This information is available for free in other languages. Please contact our Member Services Department at < > (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. ATENCIÓN: Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro departamento de servicio de miembro al (TTY ) de 8:00 a.m. a 8:00 p.m., siete días a la semana. 此文件有其它的語言版本免費提供 了解詳情請致電 與會員服務中心聯絡 ( 聽力殘障人仕請電 TTY ), 每週 7 天, 上午 8 時至晚上 8 時 **Prior authorization and referral rules apply. H0571_2019_005_M 11

12 Discrimination is Against the Law Chinese Community Health Plan (CCHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Chinese Community Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact CCHP Member Services. If you believe that CCHP 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 file a grievance with us in person, by phone, by mail, or by fax at: CCHP Member Services 445 Grant Ave, Suite 700, San Francisco, CA , TTY Fax You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at 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, , (TDD) Complaint forms are available at 華人保健計劃 (CCHP 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 華人保健計劃 (CCHP) 不因種族 膚色 民族血統 年齡 殘障或性別而排斥任何人或以不同的方式對待他們 華人保健計劃 (CCHP): 向殘障人士免費提供各種援助和服務, 以幫助他們與我們進行有效溝通, 如 : o 合格的手語翻譯員 o 以其他格式提供的書面資訊 ( 大號字體 音訊 無障礙電子格式 其他格式 ) 向母語非英語的人員免費提供各種語言服務, 如 : o 合格的翻譯員 o 以其他語言書寫的資訊如果您需要此類服務, 請聯絡華人保健計劃 (CCHP) 如果您認為華人保健計劃 (CCHP) 未能提供此類服務或者因種族 膚色 民族血統 年齡 殘障或性別而透過其他方式歧視您, 您可以親自提交投訴, 或者以郵寄 傳真或電郵的方式向我們提交投訴 :

13 CCHP Member Services 445 Grant Ave, Suite 700, San Francisco, CA , 聽力殘障人仕電話 傳真 您還可以向 U.S. Department of Health and Human Services( 美國衛生及公共服務部 ) 的 Office for Civil Rights( 民權辦公室 ) 提交民權投訴, 透過 Office for Civil Rights Complaint Portal 以電子方式投訴 : 或者透過郵寄或電話的方式投訴 : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD)( 聾人用電信設備 ) 登入 可獲得投訴表格 Chinese Community Health Plan (CCHP) cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Chinese Community Health Plan no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. Chinese Community Health Plan: Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas capacitados. o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes: o Intérpretes capacitados. o Información escrita en otros idiomas. Si necesita recibir estos servicios, comuníquese con CCHP Member Services. Si considera que CCHP no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: CCHP Member Services 445 Grant Ave, Suite 700, San Francisco, CA , TTY Fax También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Puede obtener los formularios de reclamo en el sitio web

14 English: ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ) Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: ). Hindi: ध य न द: यद आप हद ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) ): Punjabi: ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: ) 'ਤ ਕ ਲ ਕਰ Cambodian: របយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: ) Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. rau (TTY: ). Thai: เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: ). Persian (Farsi): توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با -1 (TTY: ( تماس بگیرید. H0571_2017_97 Multi-language Interpreter Services Hu

15 Call: Visit: Pine St Powell St Pacific Ave Stockton St Grant Ave Kearny St Callan Blvd Serramonte Blvd Gellert Blvd Jackson St Bush St Hickey Blvd 845 Jackson Street San Francisco, CA Grant Avenue San Francisco, CA Gellert Boulevard Daly City, CA Go Online: Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid program contract for our SNP. Enrollment in CCHP depends on contract renewal. This information is not a complete description of benefits. Call our Member Services Department at for more information. Every year, Medicare evaluates plans based on a 5-star rating system. Chinese Community Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: This information is available for free in other languages. Please contact our Member Services Department at (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. ATENCIÓN: Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro departamento de servicio de miembro al (TTY ) de 8:00 a.m. a 8:00 p.m., siete días a la semana. 此文件有其它的語言版本免費提供 了解詳情請致電 與會員服務中心聯絡 ( 聽力殘障人仕請電 TTY ), 每週 7 天, 上午 8 時至晚上 8 時

16 Chinese Community Health Plan - H Medicare Star Ratings* The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans. The two main types of Star Ratings are: 1. An Overall Star Rating that combines all of our plan's scores. 2. Summary Star Rating that focuses on our medical or our prescription drug services. Some of the areas Medicare reviews for these ratings include: How our members rate our plan's services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications. For 2019, Chinese Community Health Plan received the following Overall Star Rating from Medicare. Image description. 4.5 Stars End of image description. 4.5 Stars We received the following Summary Star Rating for Chinese Community Health Plan's health/drug plan services: Image description. 4 Stars End of image description. Health Plan Services: 4 Stars Image description. 4 Stars End of image description. Drug Plan Services: 4 Stars The number of stars shows how well our plan performs. Image description. 5 stars End of image description. 5 stars - excellent Image description. 4 stars End of image description. 4 stars - above average Image description. 3 stars End of image description. 3 stars - average Image description. 2 stars End of image description. 2 stars - below average Image description. 1 star End of image description. 1 star - poor Learn more about our plan and how we are different from other plans at You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time at (toll-free) or (TTY). Current members please call (toll-free) or (TTY). *Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next. H0571_2019_25_M

17 Three easy ways to enroll: How to Enroll in CCHP Senior Program (HMO) 445 Grant Ave, Suite700 San Francisco, CA Tel: Fax: Fill out and mail the enclosed enrollment form. You can also ask our sales representative to assist you. Please be sure to read all enrollment materials and fill them out carefully. 2. You may enroll through the CMS Medicare Online Enrollment Center at Click the Find health & drug plans button Under Additional Tools on your right, click on the Enroll now link Enter your ZIP Code and the Plan Name CCHP Senior Program (HMO) in the box, and click on the Find Plans button. Scroll down until you find CCHP Senior Program (HMO) and check Enroll button. If you do not see it, click View 20 above the Sort button. Do not select CCHP Senior Select Program (HMO SNP). Follow the step-by-step instruction on the form and submit. 3. Or, you can print a copy of the enrollment form from our website at ( and mail it to CCHP, Attn: Sales Department, 445 Grant Avenue, Suite 700, San Francisco, CA Click on the Looking for coverage button Click on the CCHP Senior Program (HMO) button on your left under the title Medicare Advantage Plans Scroll down until you find Enrollment Form and click on button When we receive your enrollment confirmation from Medicare, we will send you a member packet enclosed with your new member ID card. If you need assistance, please contact our friendly sales representative at (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. CCHP Senior Program (HMO) is an HMO plan with a Medicare contract. Enrollment in CCHP Senior Program (HMO) depends on contract renewal. H0571_2019_22_M

18 445 Grant Ave, Suite700 San Francisco, CA Tel: Fax: How to Enroll in CCHP Senior Select Program (HMO SNP) Two easy ways to enroll: 1. Fill out and mail the enclosed enrollment form. You can also ask our sales representative to assist you. Please be sure to read all enrollment materials and fill them out carefully. 2. Or, you can print a copy of the enrollment form from our website at ( and mail it to CCHP, Attn: Sales Department, 445 Grant Avenue, Suite 700, San Francisco, CA Click on the Looking for coverage button Click on the CCHP Senior Select Program (HMO SNP) button on your left under the title Medicare Advantage Plans Scroll down until you find Enrollment Form and click on button Please note: Enrollment through CMS Medicare website is not available. When we receive your enrollment confirmation from Medicare, we will send you a member packet enclosed with your new member ID card. If you need assistance, please contact our friendly sales representative at (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. CCHP Senior Select Program (HMO SNP) is an HMO plan with a Medicare contract and a contract with the California Medicaid program. Enrollment in CCHP Senior Select Program (HMO SNP) depends on contract renewal. H0571_2019_78_M

19 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT REQUEST FORM 445 Grant Avenue, Suite 700, San Francisco, CA Tel: (415) Fax: (415) Please contact CCHP if you need information in another language or format (Braille). To Enroll in Chinese Community Health Plan (CCHP), Please Provide the Following Information: Please check which plan you want to enroll in: CCHP Senior Program (HMO) CCHP Senior Select Program (HMO SNP)* $42 per month $0 - $32.40* per month * Note: To enroll in CCHP Senior Select Program (HMO SNP), you must receive Medi-Cal benefits. Monthly premium depends on level of Low-Income Subsidy. Last Name: First Name: Middle Initial: Mr. Mrs. Ms. Date of Birth (MM/DD/YYYY): Sex: Home Phone Number: M F ( ) Permanent Residence Street Address (P. O. Box is not allowed): Alternate Phone Number: ( ) City: State: Zip Code: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: Zip Code: Emergency Contact: Phone Number: Relationship to You: Address: Please Provide your Medicare Insurance Information Please take out your Medicare card to complete this section. Fill out this information as it appears on your Medicare card. NAME MEDICARE NUMBER -OR- Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board. IS ENTITLED TO: HOSPITAL (PART A) MEDICAL (PART B) EFFECTIVE DATE: You must have Medicare Part A and Part B to join a Medicare Advantage plan. H0571_2019_16_M Approved Page 1 of 4

20 Paying Your Plan Premium You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay CCHP the Part D-IRMAA. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at TTY users should call You can also apply for Extra Help online at If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. If you don t select a payment option, you will get a bill each month. Please select a premium payment option: Get a bill monthly Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following: Account holder name: Account type: Checking Saving Bank routing number: Bank account number: Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. I get monthly benefits from: Social Security RRB (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.) Please read and answer these important questions: 1. Do you have End-Stage Renal Disease (ESRD)? Yes No If you have had a successful kidney transplant and/or you don t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis, otherwise we may need to contact you to obtain additional information. 2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. H0571_2019_16_M Approved Page 2 of 4

21 Will you have other prescription drug coverage in addition to this Plan? Yes No If yes, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage: ID # for this coverage: Group # for this coverage: 3. Are you resident in a long-term care facility, such as a nursing home? Yes No If yes, please provide the following information: Name of Institution: Address & Phone Number of Institution (number and street): 4. Are you enrolled in your State Medicaid program? Yes No If yes, please provide your Medicaid number: 5. Do you receive full Medicaid benefits? Yes No 6. Do you receive partial Medicaid benefits? Yes No 7. Do you or your spouse work? Yes No Please choose the name of a Primary Care Physician (PCP), clinic, or health center: Please check one of the boxes below if you would prefer us to send you information in a language other than English or in accessible format: Chinese Spanish Large Print Please contact CCHP at if you need information in another format or language than what is listed above. Our office hours are 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call Please Read This Important Information If you currently have health coverage from an employer or union, joining CCHP could affect your employer or union health benefits. You could lose your employer or union health coverage if you join CCHP. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. Please Read and Sign Below By completing this enrollment application, I agree to the following: CCHP is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 December 7 of every year), or under certain special circumstances. H0571_2019_16_M Approved Page 3 of 4

22 CCHP serves a specific service area. If I move out of the area that CCHP serves, I need to notify the Plan so I can disenroll and find a new plan in my new area. Once I am a member of CCHP, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from CCHP when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date CCHP coverage begins, I must get all of my health care from CCHP, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by CCHP and other services contained in my CCHP Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR CCHP WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with CCHP, he/she may be paid based on my enrollment in CCHP. Release of information: By joining this Medicare health plan, I acknowledge that CCHP will release my information to Medicare and other plans as is necessary for treatment, payment, and health care operations. I also acknowledge that CCHP will release my information, including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature: Today s Date: If you are the authorized representative, you must sign above and complete the following information: Name: Address: Phone Number: Relationship to Enrollee: Office Use Only Name of staff member/agent/broker (if assisted in enrollment): Date: Effective Date of Coverage: Plan ID: ICEP/IEP AEP RECEIVED DATE STAMP SEP(type): Not Eligible: H0571_2019_16_M Approved Page 4 of 4

23 Attestation of Eligibility for an Enrollment Period H0571_2019_12_M Approved Name: Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. I am new to Medicare. I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP). I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date). I recently was released from incarceration. I was released on (insert date). I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date). I recently obtained lawful presence status in the United States. I got this status on (insert date). I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on (insert date). I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date). I have both Medicare and Medicaid or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven t had a change. I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on (insert date). I recently left a PACE program on (insert date). I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare s). I lost my drug coverage on (insert date). I am leaving employer or union coverage on (insert date). I belong to a pharmacy assistance program provided by my state.

24 My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date). I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date). I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster. If none of these statement applies to you or you re not sure, please contact Chinese Community Health Plan at (TTY users should call ) to see if you are eligible to enroll. We are open 8:00 a.m. to 8:00 p.m., seven days a week. H0571_2019_12_M Approved

25 445 Grant Ave., Suite 700, San Francisco, CA Tel: (415) Fax: (415) CCHP use only Finance: Entry date Member Services or Sales: Recv d date DST entry date Chinese Community Health Plan Medicare Advantage Plans Automatic Bank Withdrawal Authorization Form (Please complete all of the information in this form) Member Information Subscriber Name: (as shown on your Member ID card) Member ID: Phone: Address: City: State: Zip Code: Address: Financial Institution Information Name of Financial Institution: Account Holder Name: Account Type: Checking Savings Bank Routing Number: Bank Account Number: Premium Amount: $ per month beginning Please attach a voided check or deposit slip here. We will use this information to withdraw your monthly plan premium from the account that you specify on the form. NOTE: If you select automatic withdrawal as your payment option for your plan premium, you will receive monthly premium billing and you do not need to send your payment to us. The plan premium amount will be automatically withdrawn from the account. Your bank confirmation will be the prove of payment. If there are insufficient funds in the account or if the account is frozen/closed on the date of the withdrawal, you will be charged a $15 fee separately by CCHP. CCHP_MA_AutoPayment_OnlineForm Page 1 of 2

26 Please Read and Sign Below This agreement is between Chinese Community Health Plan ( CCHP ) and the CCHP member for the automatic withdrawal of funds. The funds will be transferred between the 10th and the 15th day of each month and will be used to pay the plan premium. I authorize Chinese Community Health Plan to instruct my financial institution to make plan premium payments from the account indicated above. I understand that if I decide to discontinue this method of payment at any time, I will notify CCHP in writing and make the plan premium payment using an alternative method. Signature: Date: Please submit form by fax: or mail to CCHP, 445 Grant Ave, Suite 700, San Francisco, CA by the 20th of the month for changes to be effective the first day of the following month. If you have any questions or if you need help completing the form, please contact the CCHP Member Services Center at (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. Other Payment Methods: 1. Pay online at CCHP website: 2. Pay in different ways at locations below: Locations/Payment Methods Pay in Person Credit Card Online Pay in Person Credit Card Pay in Person Personal Check Cashier s Check Money Order Pay by Mail Personal Check Cashier s Check Money Order Chinese Community Health Plan 445 Grant Avenue, #700, San Francisco, CA Member Services Center 845 Jackson Street, San Francisco, CA Gellert Health Services 386 Gellert Boulevard, Daly City, CA Pay with Cash: Please bring the billing payment stub and pay by cash at: Bank of the Orient 1023 Stockton Street, San Francisco, CA Page 2 of 2

27 445 Grant Avenue, Suite 700 San Francisco, CA T F Access Your EOC, Formulary, and Provider and Pharmacy Directory Online What is the Evidence of Coverage (EOC)? The Evidence of Coverage (EOC) booklet gives you the details about your Medicare health care and prescription drug coverage. It explains how to get coverage for the health care services and prescription drugs you need and provides details about your rights and responsibilities, what your plan covers, how much you pay, and more. What is a Formulary (drug list)? A Formulary is the list of covered drugs selected by Chinese Community Health Plan (CCHP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. CCHP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. More information on how to fill your prescriptions, can be found in your Evidence of Coverage. What is a Provider and Pharmacy Directory? A Provider Directory is a list of doctors, other health care providers, and hospitals that we have contracted with to provide medical care to Plan members. These providers are called network providers. You may go to any of our network providers listed in the Provider Directory for your health care and vision services; however, some services may require a referral. To get detailed information about your health care coverage, please see your Evidence of Coverage. A Pharmacy Directory is a list of our network pharmacies where we have made arrangements with them to provide prescription drugs to Plan members. In most cases, your prescriptions are covered only if they are filled at a network pharmacy or through our mail order pharmacy service. Once you go to one pharmacy, you are not required to continue going to the same pharmacy to fill your prescription but can switch to any other of our network pharmacies. We can fill prescriptions at non-network pharmacies under certain circumstances as described in your Evidence of Coverage. Where to find your EOC, Formulary (drug list), and Provider and Pharmacy Directory Online? Your 2019 EOC, Formulary (drug list), and Provider and Pharmacy Directory is available online beginning October 15, You can access the documents by following these steps: 1. Go to: 2. Click: Already a Member 3. Select your plan: CCHP Senior Program (HMO) or CCHP Senior Select Program (HMO SNP) 4. Scroll down to find Evidence of Coverage, Comprehensive Formulary, or Provider and Pharmacy Directory and other plan materials We are Here to Help: If you would like your EOC, Formulary or Provider and Pharmacy Directory mailed to you, have questions about your covered drugs, or need help finding a network pharmacy, please contact our Member Services number at Hours are 7 days a week, 8:00 a.m. to 8:00 p.m. Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid program contract for our SNP. Enrollment in CCHP depends on contract renewal. H0571_2019_1156 NM