STAGE DEV MAY, 2013

CCHP Senior Program (HMO)

CCHP Senior Program (HMO)

This is our most popular plan. As a Member of our CCHP Senior Program (HMO), you will enjoy more benefits than from Original Medicare alone. Our CCHP Senior Program (HMO) offers important benefits like preventive services, fitness classes, health and wellness education, and includes Medicare Part D prescription drug coverage.

As a Member, you will appreciate our friendly Member Services staff that is available by phone or in-person to take care of your needs.

tab01 cchp-senior-program-hmo

2018 Benefit Highlights

  • Preventive services: $0 copay
  • One pair of eyeglasses every 2 years
  • Emergency Care (Worldwide coverage): If you are admitted to the hospital within 24 hours, then you do not have to pay $80
  • Optional Dental Coverage: $18 per month (in addition to monthly plan premium)
  • Part D benefits with a national network of pharmacies including approximately 154 locations within our service area
 
 

Cost Summary

Monthly Plan Premium $42 (you must continue to pay your Medicare Part B premium)
Optional Dental Coverage $18 per month (in addition to monthly plan premium)
Doctor Office Visits PCP: $10 copay
Specialist: $20 copay**
Diagnostic Services/Labs/Imaging Diagnostic Radiology Services: $0 - $200 copay
X-Ray and Lab Services: $0 copay
Prior authorization required for some services.
Emergency Care (Worldwide coverage) $80 copay
If you are admitted to the hospital within 24 hours, then you do not have to pay $80.
Ambulance Services $225 copay
Outpatient Hospital $100 copay** (at Chinese Hospital)
$295 copay** (at all other hospitals)
Inpatient Hospital 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**
Mental Health Services Inpatient Hospital:
Days 1-7: $225 copay/day**
Days 8-90: $0 copay/day**
Group and Individual Therapy Sessions: $35 copay**
Skilled Nursing Facility
(up to 100 days each benefit period)
Days 1-20: $0 copay/day**
Days 21-100: $135 copay/day**
Part D: Prescription Drug Coverage
(for Drugs on CCHP's Formulary)
Drug Tier 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 are after the $100 yearly deductible
Preferred Generic
(no deductible)
$3 copay $6 copay
Non-preferred Generic (no deductible) $7 copay $14 copay
Preferred Brand $40 copay $80 copay
Non-preferred Brand $60 copay $120 copay
Specialty 30% coinsurance Drugs in this tier are not available at this extended day supply.
Coverage Gap:
After your total yearly drug costs reach $3,750
Generic 44% coinsurance
Brand &
Specialty
35% coinsurance
Catastrophic Coverage:
Costs after yearly out-of-pocket drug costs reach $5,000
Generic You pay the greater of 5% or $3.35 copay
Brand & Specialty You pay the greater of 5% or $8.35 copay.
Vision Services $20 copay for refraction**
$0 copay for one pair of glasses every two years (maximum $150 allowance)
Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $6,700
Includes copays and other costs for medical services for the year.
Conditions and Limitations See Evidence of Coverage
 
 

*Cost share for 90-day supply may differ at non-preferred cost sharing pharmacies.
**Prior authorization required.

For more information on your benefits and coverage, please refer to:

The formulary contains information about how the list of covered drugs may change during the year

Can the formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by the Plan, call our Member Services Center at 1-888-775-7888 from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 1-877-681-8898. If we make any mid-year non-maintenance changes to the formulary, we will send an errata sheet to you. You can also find the changes on our Web site. 

Find a doctor

To search for a CCHP doctor by specialty, gender or zip code, or to find a doctor who speaks additional languages, click on the link below and it will take you to our medical group's (Chinese Community Health Care Association) Web site.

Hospitals

We contract with several hospitals, including:

  • Chinese Hospital (By clicking on this link, you will leave CCHP's Medicare Advantage plan website.)
  • St. Francis Memorial Hospital
  • California Pacific Medical Center
  • St. Mary's Medical Center
  • Seton Medical Center

Medicare Advantage Enrollment Period

Initial Coverage Election Period (ICEP)

The Initial Coverage Election Period is the time when an individual who is newly eligible for a Medicare Advantage (MA) plan may make an initial election to enroll in a Medicare Advantage plan. ICEP is a seven-month (7) election period that begins three months immediately before the individual's entitlement to both Medicare Part A & Part B and ending on the last day of the third month following the month of entitlement.

Beneficiaries entitled to Medicare Part A who delay enrollment into Part B will have an ICEP upon enrollment into Part B. The ICEP then becomes a three-month (3) election period, occurring the three months preceding the Part B effective date. The MA effective date will be same as the Part B effective date.

Once an ICEP election is made and enrollment takes effect, the ICEP election has been utilized.

Annual Election Period (AEP)

The annual election period (AEP) begins on October 15 and ends December 7. During this time, you can review your health coverage and your prescription drug coverage. You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans:

  • Another Medicare Advantage plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
  • Original Medicare with a separate Medicare prescription drug plan.
  • Original Medicare without a separate Medicare prescription drug plan.

Your membership will end when your new plan's coverage begins on January 1.

Medicare Advantage Disenrollment Period (MADP)

The Medicare Advantage Disenrollment Period (MADP) runs between January 1 and February 14 of each year and allows beneficiaries to disenroll from their Medicare Advantage plan and return to Original Medicare. You cannot switch from one Medicare Advantage plan to another or enroll in a Medicare Advantage plan during the MADP. If you disenroll from a Medicare Advantage plan, you have a coordinating Special Election Period (SEP) to enroll in a stand-alone Part D prescription drug plan. The SEP ends February 14 or when you enroll in a stand-alone Part D plan, whichever is sooner.

Special Election Period (SEP)

Enrollment in a Medicare Advantage plan may be available at other times during the year if one of the following situations applies to you:

  • You recently became eligible for Medicare.
  • You were enrolled in a plan and recently moved.
  • You entered a nursing home.
  • You are entitled to both Medicare and Medi-Cal. If you are entitled to full benefits under Medi-Cal, consider our CCHP Senior Select Program (HMO SNP).
  • You recently qualified for Medicare's low-income subsidy program, which provides extra help paying for prescription drugs.
  • You are disenrolling from an employer group health plan.
  • You involuntarily lost creditable prescription drug coverage.

For more information about these and other special election eligibility issues, please call Medicare at 1-800-633-4227 (1-800-MEDICARE) (toll free). TTY/TDD users should call 1-877-486-2048 (hearing impaired), 24 hours a day, 7 days a week. Or, visit Medicare online at www.medicare.gov. (By clicking on this link, you will leave CCHP's Medicare Advantage plan website.)

Disclaimer

CCHP Senior Program (HMO) is an HMO plan with a Medicare contract. Enrollment in CCHP Senior Program (HMO) depends on contract renewal.

You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.  The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

 

This information is available for free in other languages. Please contact our customer service number at 1-888-775-7888 (TTY 1-877-681-8898) from 8:00 a.m. to 8:00 p.m., seven days a week.

Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro número de servicio al cliente al 1-888-775-7888 (TTY 1-877-681-8898) 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 1-888-775-7888 與會員服務中心聯絡( 聽力殘障人士請電 TTY 1-877-681-8898 ),每週 7 天,上午 8 時至晚上 8 時。

 

H0571_2018_274 Pending

Last updated 10132017

tab02 cchp-senior-program-hmo

2017 Benefit Highlights

  • Preventive services: $0 copay
  • One pair of eyeglasses every 2 years: $0 copay
  • Acupuncture services
  • Worldwide emergency coverage
  • Additional Dental Option: DeltaCare USA (underwritten by Delta Dental of California for an additional premium of $16/month)
  • Part D benefits with a national network of pharmacies including approximately 161 locations within our service area
 
 

Cost Summary

Monthly Plan Premium $50  (in addition to your monthly Medicare Part B premium)
Optional Dental Coverage $16 per month (in addition to monthly plan premium)
Doctor Office Visits PCP: $10 copay
Specialist: $15 copay
X-Rays, Lab $0 copay
Diagnostic Radiology Services $0-$200 copay
Worldwide Emergency Care $75 copay
Ambulance Services $200 copay
Outpatient Surgery $150 copay (at Chinese Hospital)
$295 copay (at all other hospitals)
Hospitalization Services Days 1 - 7: $100 copay/day (at Chinese Hospital)
Days 1 - 7: $280 copay/day (at all other hospitals)
Days 8+: $0 copay/day
Inpatient Mental
Health Care
Days 1 - 7: $225 copay/day
Days 8 - 90: $0 copay/day
Skilled Nursing Facility
(up to 100 days each benefit period)
Days 1 - 20: $0 copay/day
Days 21 - 100: $135 copay/day
Durable Medical Equipment 20% of the cost per item
Part D: Prescription Drug Coverage
(for Drugs on CCHP's Formulary)
Drug Tier 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 are after the $400 yearly deductible
Preferred Generic
(no deductible)
$3 copay $6 copay
Non-preferred Generic (no deductible) $7 copay $14 copay
Preferred Brand $40 copay $80 copay
Non-preferred Brand $60 copay $120 copay
Specialty 25% coinsurance Drugs in this tier are not available at this extended day supply.
Coverage Gap:
After your total yearly drug costs reach $3,700, you pay 40% for brand name and specialty drugs and pay 51% for generic drugs until your yearly out-of-pocket drug costs reach $4,950.
Generic 51% coinsurance
Brand &
Specialty
40% coinsurance
Catastrophic Coverage:
Costs after yearly out-of-pocket drug costs reach $4,950
Generic You pay the greater of 5% or $3.30 copay
Brand & Specialty You pay the greater of 5% or $8.25 copay.
Vision Services
$20 copay / visit for refraction
$0 copay for one pair of glasses every two years (maximum $150 allowance)
Annual Out-of-Pocket Maximum $4,500
Conditions and Limitations See Evidence of Coverage
 
 

For more information on your benefits and coverage, please refer to:

The formulary contains information about how the list of covered drugs may change during the year

Can the formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by the Plan, call our Member Services Center at 1-888-775-7888 from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 1-877-681-8898. If we make any mid-year non-maintenance changes to the formulary, we will send an errata sheet to you. You can also find the changes on our Web site. 

Find a doctor

To search for a CCHP doctor by specialty, gender or zip code, or to find a doctor who speaks additional languages, click on the link below and it will take you to our medical group's (Chinese Community Health Care Association) Web site.

Hospitals

We contract with several hospitals, including:

  • Chinese Hospital (By clicking on this link, you will leave CCHP's Medicare Advantage plan website.)
  • St. Francis Memorial Hospital
  • California Pacific Medical Center
  • St. Mary's Medical Center
  • Seton Medical Center

Medicare Advantage Enrollment Period

Initial Coverage Election Period (ICEP)

The Initial Coverage Election Period is the time when an individual who is newly eligible for a Medicare Advantage (MA) plan may make an initial election to enroll in a Medicare Advantage plan. ICEP is a seven-month (7) election period that begins three months immediately before the individual's entitlement to both Medicare Part A & Part B and ending on the last day of the third month following the month of entitlement.

Beneficiaries entitled to Medicare Part A who delay enrollment into Part B will have an ICEP upon enrollment into Part B. The ICEP then becomes a three-month (3) election period, occurring the three months preceding the Part B effective date. The MA effective date will be same as the Part B effective date.

Once an ICEP election is made and enrollment takes effect, the ICEP election has been utilized.

Annual Election Period (AEP)

The annual election period (AEP) begins on October 15 and ends December 7. During this time, you can review your health coverage and your prescription drug coverage. You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans:

  • Another Medicare Advantage plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs.)
  • Original Medicare with a separate Medicare prescription drug plan.
  • Original Medicare without a separate Medicare prescription drug plan.

Your membership will end when your new plan's coverage begins on January 1.

Medicare Advantage Disenrollment Period (MADP)

The Medicare Advantage Disenrollment Period (MADP) runs between January 1 and February 14 of each year and allows beneficiaries to disenroll from their Medicare Advantage plan and return to Original Medicare. You cannot switch from one Medicare Advantage plan to another or enroll in a Medicare Advantage plan during the MADP. If you disenroll from a Medicare Advantage plan, you have a coordinating Special Election Period (SEP) to enroll in a stand-alone Part D prescription drug plan. The SEP ends February 14 or when you enroll in a stand-alone Part D plan, whichever is sooner.

Special Election Period (SEP)

Enrollment in a Medicare Advantage plan may be available at other times during the year if one of the following situations applies to you:

  • You recently became eligible for Medicare.
  • You were enrolled in a plan and recently moved.
  • You entered a nursing home.
  • You are entitled to both Medicare and Medi-Cal. If you are entitled to full benefits under Medi-Cal, consider our CCHP Senior Select Program (HMO SNP).
  • You recently qualified for Medicare's low-income subsidy program, which provides extra help paying for prescription drugs.
  • You are disenrolling from an employer group health plan.
  • You involuntarily lost creditable prescription drug coverage.

For more information about these and other special election eligibility issues, please call Medicare at 1-800-633-4227 (1-800-MEDICARE) (toll free). TTY/TDD users should call 1-877-486-2048 (hearing impaired), 24 hours a day, 7 days a week. Or, visit Medicare online at www.medicare.gov. (By clicking on this link, you will leave CCHP's Medicare Advantage plan website.)

Disclaimer

CCHP Senior Program (HMO) is an HMO plan with a Medicare contract. Enrollment in CCHP Senior Program (HMO) depends on contract renewal.

You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.  The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

 

This information is available for free in other languages. Please contact our customer service number at 1-888-775-7888 (TTY 1-877-681-8898) from 8:00 a.m. to 8:00 p.m., seven days a week.

Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro número de servicio al cliente al 1-888-775-7888 (TTY 1-877-681-8898) 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 1-888-775-7888 與會員服務中心聯絡( 聽力殘障人士請電 TTY 1-877-681-8898 ),每週 7 天,上午 8 時至晚上 8 時。

 

H0571_2017_274 Approved

Last updated 10102017

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STAGE DEV MAY, 2013