STAGE DEV MAY, 2013

A Medicare Advantage HMO Plan for people with both Medicare and Medi-Cal benefits

A Medicare Advantage HMO Plan for people with both Medicare and Medi-Cal benefits

CCHP Senior Select Program (HMO SNP) is our Medicare Advantage plan, which includes Part D prescription drug coverage, for Members with Medicare who also receive Medi-Cal benefits. As an enrolled Member, you enjoy important benefits, such as preventive services, fitness classes, health and wellness education, and more. Our plan also includes worldwide emergency coverage, acupuncture services, and transportation services for medical visits.

CCHP Senior Select Program (HMO SNP) also includes Supplemental Dental Plan coverage through DeltaCare USA (Underwritten by Delta Dental of California). Be sure to learn more about it.

All your plan benefit materials can be accessed below for your convenience. For additional questions, you are invited to call our friendly Member Services staff that is available by phone or in-person to take care of your needs.

The CCHP Member Services Center can be reached at 1-888-775-7888 or TTY 1-877-681-8898 for our hearing impaired Members, seven days a week, 8:00 a.m. - 8:00 p.m.

If you have any feedback or concerns about CCHP Senior Select Program (HMO SNP), you may submit them directly to Medicare using the form below.

tab01 medicare-advantage-hmo-plan-people-both-medicare-and-medi-cal-benefits

2018 Benefit Highlights

  • $0 - $26.10 monthly premium*
  • Free personal care coordinator
  • Free transportation services for medical visits (48 one-way trips per year)
  • Free doctor visits
  • Free eyeglasses through VSP (every 2 years)
  • Part D benefits with a national network of pharmacies including approximately 154 locations within our service area
 

Cost Summary

Monthly Plan Premium
(If you are eligible for this plan, Medi-Cal may pay for your monthly plan premium)
$0 - $26.10*
Doctor Visits

$0
copay**

Diagnostic Services/Labs/Imagingw
Emergency Care
Ambulance Services
Transportation (48 one-way trips per year)**
Personal Care Coordinator
Inpatient Hospital
Outpatient Hospital
Skilled Nursing Facility (up to 100 days/benefit period)
Physical Therapy
Part D: Prescription Drug Coverage (for Drugs on CCHP's Formulary) Drug Tier
Copay (may vary based on the level of Extra Help eligibility *)
Initial Coverage Costs for
Drugs after Deductible:
 
• For beneficiaries receiving no
Extra Help, deductible is $405
• For some beneficiaries receiving partial subsidy Extra Help, deductible is $83
• For most beneficiaries is $0
 

Generic (including brand drugs treated as generic)

25% coinsurance; or with Low Income Subsidy (LIS): $0 /$1.25 /$3.35 copay or 15% coinsurance

All Other Drugs 25% coinsurance; or with Low Income Subsidy (LIS): $0 /$3.70 /$8.35 copay or 15% coinsurance
Catastrophic Coverage:
Costs after yearly out-of-pocket
drug costs reach $5,000.
Generic (including brand
drugs treated as generic)

You pay the greater of 5% or $3.35 copay.

All Other Drugs

You pay the greater of 5% or $8.35 copay.

 

*Some people, depending on the level of Medi-Cal (Medicaid) coverage, will have different premium payments and cost-sharing for their drugs. Please refer to the LIS Rider or contact the CCHP Member Services Center for more details.
**Some services require prior authorization. See Evidence of Coverage.

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

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
 

(By clicking on this link, you will leave CCHP's website.)

 

 

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.

Disclaimer

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. This plan is available to anyone who is enrolled in Medicare Part A and Part B, receives Medi-Cal benefits, and resides in San Francisco County. You must continue to pay your Medicare Part B premium. The Part B premium is covered by the State for dual eligible individuals. 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. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

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),每週七天,上午8 時至晚上 8 時。

H0571_2018_275 Approved

Last updated 12052017

tab02 medicare-advantage-hmo-plan-people-both-medicare-and-medi-cal-benefits

2017 Benefit Highlights

  • $0 - $33 monthly premium*
  • Free personal care coordinator
  • Free transportation services for medical visits (24 one-way trips per year)
  • Free doctor office visits
  • Free eyeglasses through VSP (every 2 years)
  • Part D benefits with a national network of pharmacies including approximately 161 locations within our service area
 

Cost Summary

Monthly Plan Premium
(If you are eligible for this plan, Medi-Cal may pay for your monthly plan premium)
$0 - $33*
Doctor Office Visits $0
copay
X-Rays, Lab
Diagnostic Radiology Services
Worldwide Emergency Care
Ambulance Services
Outpatient Surgery
Transportation (up to 24 one-way medical trips / per year)
Personal Care Coordinator
Outpatient Surgery
Hospitalization Services
Skilled Nursing Facility
Durable Medical Equipment
Acupuncture
Home Health Care
Part D: Prescription Drug Coverage (for Drugs on CCHP's Formulary) Copay / Coinsurance *
Deductible* $0-400
Initial Coverage*
25% of the drugs cost
Catastrophic Coverage*
5% of the cost of the drug or
$3.30 for a generic drug
$8.25 for all other drugs
Conditions and Limitations See Evidence of Coverage
 
 

*Some people, depending on the level of Medi-Cal (Medicaid) coverage, will have different premium payments and cost-sharing for their drugs. Please refer to the LIS Rider or contact the CCHP Member Services Center for more details.

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

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

 

(By clicking on this link, you will leave CCHP's website.)

 

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.

Disclaimer

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. This plan is available to anyone who is enrolled in Medicare Part A and Part B, receives Medi-Cal benefits, and resides in San Francisco County. You must continue to pay your Medicare Part B premium. The Part B premium is covered by the State for dual eligible individuals. 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. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

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),每週七天,上午8 時至晚上 8 時。

H0571_2017_275 Approved

Last updated 11162017