Summary Of Benefits January 1, 2019 - December 31, 2019 Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the Blue Shield Association This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. 2019 Blue Shield Promise AdvantageOptimum Plan (HMO) California: Los Angeles County & partial Orange County On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan Until 12/31/18 H5928_19_271_MK_M Accepted Effective 1/1/2019
2
2019 Summary Of Benefits Blue Shield Promise AdvantageOptimum Plan (HMO) Los Angeles County & partial Orange County, Plan 004 This is a summary of drug and health services covered by Blue Shield Promise AdvantageOptimum Plan (HMO) January 1, 2019 - December 31, 2019. Blue Shield Promise AdvantageOptimum Plan (HMO) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join Blue Shield Promise AdvantageOptimum Plan (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in California: Los Angeles and partial Orange. If you use the providers that are not in our network, we may not pay for these services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. This document is available in other formats such as Braille, large print or audio. For more information, please call us at 1-800-544-0088. (TTY users should call 711), 8:00 a.m. 8:00 p.m. 7 days a week, from October 1 to March 31 and 8:00 a.m. 8:00 p.m. weekdays, from April 1 to September 30 or visit us at www.blueshieldca.com/promise/medicare. 3
Premiums and Benefits Blue Shield Promise AdvantageOptimum Plan (HMO) Monthly Plan Premium Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital You must continue to pay your Medicare Part B premium. No deductible Outpatient Hospital You pay $100 Doctor Visits Primary Specialists Preventive Care (Mammography & influenza vaccines. No referral needed.) Emergency Care Urgently Needed Services Diagnostic Services/Labs/Imaging Procedures/Tests Lab services Therapeutic radiology services (such as radiation treatment for cancer) Hearing Services Routine hearing exam Hearing aid Dental Services Unlimited oral exams every year Cleaning, one every 6 months Fluoride treatment, one every six months X-rays, one full set every two years You pay no more than $999 annually. Includes copays and other costs for medical services for the year. per day for days 1 through 90 for unlimited additional days Other preventive services are available. There are some covered services that have a cost. You pay $85 Waived if admitted You pay $0 in network You pay $45 out of network Waived if admitted You pay 20% of the cost You pay $10 Medicare-covered benefits; You pay $10 routine exams (1 every year) for fitting/evaluation for hearing aid (1 every year) for 2 hearing aids every year $1,500 limit every year You pay $5 Vision Services Routine exam (every year) Eyewear coverage limit Refraction test (one every 2 years) $250 limit for glasses and contacts every year 4
Premiums and Benefits Blue Shield Promise AdvantageOptimum Plan (HMO) Mental Health Services Outpatient group therapy/individual therapy visit Skilled Nursing Facility You pay $25 Physical Therapy You pay $10 Ambulance Services Transportation Services Medicare Part B Drugs for days 1 through 20 You pay $75 for days 21 through 100 No prior hospital stay required $125 copay per trip (each way) Waived if admitted 30 one-way trips to plan approved locations. Transportation must be arranged 24 hours in advance. You pay 20% of the cost for chemotherapy drugs You pay 20% of the cost for other Part B drugs Outpatient Prescription Drugs Deductible Initial Coverage Phase (After you pay your deductible, if applicable, up to the initial coverage limit of $3,820) Standard Retail Rx 30-day supply Mail-Order 90-day supply Tier 1: Preferred Generic Tier 2: Non-Preferred Generic You pay $5 You pay $12.50 Tier 3: Preferred Brand You pay $40 You pay $100 Tier 4: Non-Preferred Brand You pay $80 You pay $200 Tier 5: Specialty Tier You pay 33% You pay 33% Coverage Gap Phase Catastrophic Coverage (When your annual out-of-pocket costs exceed $5,100) Generic (Tiers 1 & 2): $0 and $5 copay Brand Name (Tier 3-5): you pay 25% of the negotiated price for brand name drugs (plus a portion of the dispensing fee) and 37% of the price for generic drugs. Generic drugs: Greater of 5% or $3.40 copay Brand-name drugs: Greater of 5% or $8.50 copay 5
Optional Supplemental Plan Health Club/Fitness Nurse Advice Line Worldwide Emergency/Urgent Care Acupuncture Over-the-Counter Emergency Response System $0 $100 Copay Worldwide Emergency/Urgent Coverage (Waived if admitted) no plan coverage limit $0 copay/24 visits per year $105/Quarter IMPORTANT NOTE: To view important information on non-discrimination requirements, you can go to our website at https://www.blueshieldca.com/promise/affordable-care-act.asp. Blue Shield of California Promise Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California Promise Health Plan depends on contract renewal. Blue Shield of California Promise Health Plan complies with applicable State and Federal civil rights laws and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. This information is not a complete description of benefits. Call 1-800-544-0088 (TTY:711) for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of 2019. ATTENTION: Language assistance services, free of charge, are available to you. Call 1-800-544-0088. (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-544-0088 (TTY: 711). 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 1-800-544-0088(TTY:711) Care1st Health Plan is an independent licensee of the Blue Shield of California. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan. Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association. H5928_19_271_MK_M Accepted Effective 1/1/2019 6
Pre-Enrollment Checklist 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 1-800-544-0088 (TTY/TDD users call 711). 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 www.blueshieldca.com/promise/medicare or call 1-800-544-0088 (TTY/TDD users call 711) 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/coinsurance may change on January 1, 2019. 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. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association H5928_19_271_MK_M Accepted Effective 1/1/2019 7
Discrimination is Against the Law Blue Shield of California Promise Health Plan complies with applicable state and federal civil rights laws and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of California Promise Health Plan does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of California Promise Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: ᴑᴑ Qualified sign language interpreters ᴑᴑ 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: ᴑᴑ Qualified interpreters ᴑᴑ Information written in other languages If you need these services, contact our Member Services Department at 1-800-544-0088 (TTY: 711), 8:00 am 8:00 pm, seven days a week from Oct 1st to Mar 31st and Monday through Friday from Apr 1st to Sept 30th. If you believe that Blue Shield of California Promise Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability, you can file a grievance with the Grievance Coordinator. Mailing Address: ATTN: Civil Rights Coordinator Grievances Department - Blue Shield of California Promise Health Plan (Effective 01/01/2019)* 601 Potrero Grande Dr. Monterey Park, CA 91755 Telephone Number: 1-844-883-2233 (TTY: 711), from 7:00am to 8:00pm, during Monday through Friday Fax Number: 1-323-889-2228 Email Address: CRC@blueshieldca.com *Care1st Health Plan until 12/31/2018 You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Grievance Coordinator at Blue Shield of California Promise Grievance Department is available to help you. Grievances must be submitted to the Grievance Coordinator at Blue Shield of California Promise Grievance Department within 60 calendar days from the time you have become aware of any alleged discrimination action. A complaint must be in writing, or reported verbally, containing your name and address. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought. You can also go to our website at https://www.blueshieldca.com/promise/medicare and submit your complaint. 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: H5928_19_180_CO_C 8
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Such complaints must be filed within 180 days from the date of the alleged discrimination. Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. IMPORTANT NOTE: To view this notice in a different language, you can go to our website at https://www.blueshieldca.com/promise/affordable-care-act.asp. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Effective 1/1/2019 9
For enrollment inquiries please call 1-800- 847-1222 (TTY users should call 711) Member Services representatives will be available to answer your call 8:00 a.m. 8:00 p.m. 7 days a week, from October 1 to March 31 and 8:00 a.m. 8:00 p.m. weekdays, from April 1 to September 30. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan 601 Potrero Grande Dr., Monterey Park, CA 91755 www.blueshieldca.com/promise/medicare