由華人保健計劃提供的「東華耆英 (HMO) 保健計劃」

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1 Plan Year 2017 CCHP Senior Select Program (HMO SNP) (HMO SNP) Evidence of Coverage H0571_2017_002CH File & Use

2 (HMO SNP) (HMO SNP) (HMO SNP) (HMOSNP)HMO(Medicaid) (HMOSNP) This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY users should call ) Hours are 7 days a week from 8:00 a.m. to 8:00 p.m. Member Services also has free language interpreter services available for non-english speakers. : TTY Esta información está disponible en otros idiomas sin costo alguno. Por favor llame a nuestro número de Servicios para Miembros al para más información. (Los usuarios de TTY deben llamar al ). Nuestro horario es de 8:00 a.m. a 8:00 p.m., siete días a la semana. Servicio para Miembros también provee servicios de intérpretes gratis para las personas que no hablan ingles TTY Form CMS ANOC/EOC OMB Approval (Approved 03/2014)

3 // H0571_2017_002CH File & Use

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11 4 1.2 (Medicaid) (HMO SNP) () 1.3 (HMO SNP) () (HMO SNP), (HMO SNP) ()

12 A B ( 2.2 A B ) ( 2.3 ) (ESRD) (Medicaid) (Medicaid) (Medicaid) A B AB A()

13 6 B() () 2.3 (Medicaid) (Medicaid) (QMB) AB ()( ) (SLMB)(QI)B ( (QDWI): A 2.4 (HMO SNP) (HMO SNP)

14 7 ( ) ()( )

15 8 (HMO SNP) () 3.2 (Medicaid) () (HMO SNP) ( )

16 9 ( ) www. cchphealthplan.com/medicare 2017,( ) () (HMO SNP) (HMO SNP)

17 10 ( ) 3.4 D(D EOB)D D D ( D EOB) D ( D ) () D 4 (HMO SNP) 4.1 (HMO SNP) 2017 $33.00 Medicaid B ( B (Medicaid)) ( )

18 11 o o D D o 10 2 A B (HMO SNP)(Meciciad) A () B (Meciciad) D IRMAA$85,000() $170,000 D 11 D MEDICARE( ) B D

19 MEDICARE( ) () 1 : 1 Chinese Community Heath Plan $15 2 : (EFT) 15 $15 3 :

20 13 ( ) 4 : 1023 () 1 () D D ()

21 IPA ( (Medicaid)) ()

22 15 () 5 ( 7 ) () ()

23 16 (ESRD) o o (ESRD) 30 () () TRICARE () ID ()

25 (HMO SNP) ( ) 8 9

26 19 1 (HMO SNP) () (HMO SNP) (TTY) Chinese Community Health Plan Member Services Center 445 Grant Avenue, Suite 700 San Francisco, CA

27 20 () (TTY) Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108

28 21 ( ) (TTY) Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108

29 22 ( ) () (TTY) Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA (HMO SNP)

30 23 D D D () D (TTY) Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA D D ()

31 24 D (TTY) Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA D ( ) () D

32 25 (TTY) Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA (HMO SNP) () (TTY)

33 Chinese Community Health Plan 445 Grant Ave, Suite 700 San Francisco, CA (Medicare) () () (CMS) MEDICARE (TTY)

34 27 Medigap () (HMO SNP) (HMO SNP) ( MEDICARE ( ) ) (MEC):

35 28 (ACA) (IRS) 3 (State Health Insurance Assistance Program) () (SHIP) (HICAP). (HICAP)( ) (HICAP) (HICAP) Health Insurance Counseling and Advocacy Program 601 Jackson Street San Francisco, CA

36 29 4 ( ) (Quality Improvement Organization) Livanta Livanta Livanta Livanta Livanta () (TTY) Livanta BFCC-QIO Program, Area Junction Drive, Suite 10 Annapolis Junction, MD

37 30 5 (Social Security) 65 D (TTY)

38 31 6 (Medicaid ) ( ) (Medicaid) (QMB)AB ()(QMB (QMB+)) (SLMB)B(SLMB (SLMB+)) (QI)B(QI ) (QDWI): A Department of Health Care Services P.O. BOX , MS 4607 Sacramento, CA

39 32 (Medicaid) mbudman.aspx

40 MEDICARE ( ) (Medicaid)( 6 ) ( ) D 50%() % 10% 40% D (D EOB) 10% 49% 51% 49%

41 34 () ADAP ADAP ADAP ADAP / ADAP D ADAP ADAP ADAP D D ADAP ADAP D

42 35 (SHIP)( 3 ) MEDICARE ( ) TTY () (TTY)

43 36 9 / () MEDICARE ( )

45 (HMO SNP) PCP

46 (HMO SNP)

47 (HMO SNP) (HMO SNP) (HMO SNP) ()

48 (HMO SNP) (PCP) ( 2.1 ) o 2.3 o ( 2.2 ) ( 2 ) () o 3 o 2.4 o

49 (HMO SNP) (PCP) PCP PCP X PCP () PCP PCP PCP () PCP PCP (PCP) PCP PCPPCP PCPPCP (PCP)PCP PCP

50 (HMO SNP) PCP PCP() PCP PCPPCP PCP 2.2 PCP PCP X ( ) 2.3 PCP(HMO SNP) (2.2

51 (HMO SNP) )() PCP() 2.1 PCP PCP PCP 30 () 2.4 ()

52 (HMO SNP) PCP 48

53 (HMO SNP) ( 3.2 ) 3.2 ( )

54 (HMO SNP) (HMO SNP)() () ()

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60 53 () ()

61 54 1 (HMO SNP) 1.1 (Medicaid) 1.2 (HMO SNP)(Mecicaid) ( 2 ) (HMO SNP)2017 $3,400 ( D ) $3,400 B ( B ) (HMO SNP)

62 55 Medicaid () (PCP) () ( MEDICARE ( ) TTY l ) 2017

63 56 (Medicaid)

64 57 : $0 18 ($0)

65 58 B ($0) 12 B 12 ( ) 24 ( X ) :

66 59 ($0) () (60 )( ) 24 12

67 60 ($0) ( ) 12 (gfobt) (FIT) 3 DNA 24 () 10 (120 ) 48 ( X )

68 61 ( ) ($0) ( )( ) 12

69 62 () () ( ) () ($0)

70 63 ($0) ($0)

71 64 ($0) HIV HIV 12 HIV 3

72 65 ($0) ( 8 35 ) 6 (HMO SNP) A B A B

73 66 A B : A B () (HMO SNP) A B A B (HMO SNP) D 9.4 ( )

74 67 B B D () ($0) (/ ) X

75 68 / 4 3

76 MEDICARE ( ) ($0)

77 70 () X () () ( ) ( ) 1 1

78 71 B B B ($0) ( ) ( A ) ( ) ( EpogenProcrit, Epoetin AlfaAranesp Darbepoetin Alfa) D D

79 72 (BMI)30 X () ($0) X ( X ) ($0) ($0)

80 73 ($0) X MEDICARE ( )

81 74 ($0) ($0) : (CORFs) ($0) ($0) ($0)

82 75 ($0) ($0) / ($0) ($0)

83 76 ( ) ( ) ($0) (PSA) (PSA) () ( ) ($0)

84 77 (COPD) ($0) () ( ) (LDCT) 12 LDCT LDCT LDCT LDCTLDCT

85 78 (STIs) (STI) 12 (STI) ($0) ( ) () ( ) (

86 79 ) B B B (SNF) ( SNFs) ($0) 100 () ( ) SNFs SNFs SNFs X SNFs

87 80 / SNF () () : $0 /

88 81 ($0) ( ) 50 ( ) VSP VSP ($0) ($0) VSP VSP ($0)

89 82 $80 $80 () B () (Medicaid) (Medicaid)()

90 83 ( 6.3 ) ( 5 ) *

91 84

92 85 LASIK ( ) *

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94 87 D 1.1 D 1.2 D D

95 (LTC)

96 (MTM)

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98 91 (Medicaid) TTY D () CMS ( 2 ) ()( 3 ) ( 3 ) 2.1 ( 2.5 ) D

99 () (LTC) D D //( ) FDA ()

100 93 ( ) 2.3 NM TTY ) Costco () Costco ( ) 2.3

101 94 1. () 2. NM ( ) ( ) ( )

102 95 ( )( D () D ( 1.1 D ) (Medicaid) TTY ( ) -- (DRUGDEX USPDI )

103 96 (Medicaid) TTY ( 7.1 ) ()

104 ( 7.2 ) ( )

105 98 A B A A B 4.3 ( ) ( 7.2 )

106 () ()

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108 101 () 5.3 ( ) 6.1 (1 1 )

109 102 ( 4 )

110 103 o 60 o ( ) o 7.1 (Medicaid) D ( 7.5 ) (Medicaid) D D A B o DRUGDEX

111 104 USPDI (Medicaid) TTY () ViagraCialisLevitra Caverject

112 105 ( 2.1 ) 9.1 D 9.2 (LTC) ( LTC) () (LTC) ( ) 90 31

113 / (secondary) D 9.4

114 107 D (D) 10.1 () 10.2 (MTM)

115 108 (MTM) ()

116 D

117 110 D

118 111

119 112? (Medicaid) D (LIS Rider) (LIS Rider)( 1.1 D D D D A B (Medicaid) () o o ()

120 113 () () (HMO SNP) (HMO SNP) D %

121 114 51% ( () D $4, ) ( 7 ) $3,700 $400 ( 5 ) 6 $0 $82 LIS Rider $0 $82 $ D (D EOB)

122 115 D (D EOB) ( 2 ) o o o

123 116 (ADAP) D (D EOB) () 4.1 $400 $82 LIS Rider 2017 $400 D

124 117 $ ( )

125 118 D ( 30 ) (LTC) ( 31 ) ( )( 14 ) 1 25% 25% 25% 5.3 o (30 )$31$1 7 $1 7 $7

126 ( 90 ) () 90 (2.4 ) ( 90 ) D 1 ( 90 ) 25% ( 90 ) 25% 5.5 $3,700 $3,700 D ( 6.2 ) o $400 o 2017 D

127 120 D (D EOB) $3,700 $3, $ 4,950 40% 51% 49% 2017 $4,950 $4,

128 121 ( D ) o o o ()$4,950

129 122 D A B TRICARE () () D D EOB ( 3 )$4,

130 $4,950 $0 o 5% o $3.30$8.25 o 8.1 D 2.1 D ( )

131 () () D D 1 ( ) 2

132 125 ( ) () 9.1 D D D

133 126 D 63 D ) 63 D 9.2 D 63 1% 14 14% 2017 $ %$35.63$4.98 $ ( ) D

134 D o TRICARE o o ( )

135 128 D D () 10.1 D D D ()$85,000 $170,000 D 10.2 D IRS (MAGI)

136 129 D ( ) 2015 $85,000 $85,000 $170,000 $0 $85,000 $170,000 $13.30 $107,000 $214,000 $107,000 $214,000 $34.20 $160,000 $320,000 $160,000 $85,000 $320,000 $55.20 $214,000 $129,000 $428,000 $214,000 $129,000 $428,000 $ D? TTY D D () D

137

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141 134 ( 2.5) () 2.1

142 135 () Chinese Community Health Plan Attn: Claims Department 445 Grant Avenue, Suite 700 San Francisco, CA Navitus Health Solutions Opertions Division Claims P.O.Box 1039 Appleton, WI ()

143 ( D ) 3.2 ( )

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147 140 Section 1.1 We must provide information in a way that works for you (in languages other than English, in Braille, in large print, or other alternate formats, etc.) To get information from us in a way that works for you, please call Member Services (phone numbers are printed on the back cover of this booklet). Our plan has people and free language interpreter services available to answer questions from non-english speaking members. We can give you information in Spanish and Chinese languages. We can also give you information in Braille, in large print, or other alternate formats if you need it. If you are eligible for Medicare because of a disability, we are required to give you information about the plan s benefits that is accessible and appropriate for you. To get information from us in a way that works for you, please call Member Services (phone numbers are printed on the back cover of this booklet). If you have any trouble getting information from our plan because of problems related to language or a disability, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call Sección 1.1 Debemos proporcionarle información en formatos que funcionen para usted (en otros idiomas además del inglés, en Braille, letra grande, u otros formatos alternos, etc.) Para obtener información de nosotros en formatos que funcionen para usted, por favor llame a Servicios para Miembros (los números telefónicos aparecen en la contraportada de este folleto). Nuestro plan tiene servicios de intérpretes gratis proporcionados por personas que están disponibles para contestar las preguntas de miembros que no hablan inglés. También podemos darle información en Braille, letra grande, u otros formatos alternos si usted lo necesita. Si usted califica para Medicare debido a una discapacidad, tenemos la obligación de proveerle información sobre los beneficios del plan que sea accesible y apropiada para usted. Para obtener información de nosotros en una forma que sea adecuada para usted, por favor llame a Servicios para Miembros (los números de teléfono están impresos en la contraportada de este folleto). Si tiene alguna dificultad para obtener información de nuestro plan debido a problemas relacionados al idioma o a una discapacidad, por favor llame a Medicare al MEDICARE ( ), 24 horas al día, 7 días a la semana, y dígales que usted quiere presentar una queja. Los usuarios de TTY deben llamar al

148 () MEDICARE ( ) 7 24 TTY ( ) ( ). 1.3 (PCP) ()(

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216 209 (Medicaid) (Medicaid) 6 (Medicaid) (Medicaid) (Medicaid)

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231 224 (CORF) $10 $20 (1)(2) (3) ( )

232 () () (Medicaid) 1) 2)

233 226 (EOC) ()( ) () (FDA) () (IRMAA) $85,000 $170,000

234 227 B 5% $3,700 A B ( 65 ) 7 (SNP), 90 (LTC),(ICF/MR) () (SNP),,., 63 ( ) D D () (LIS)

235 228 A B (Medicaid 1 (Medicaid)) ( ) PACE (MA) C A B HMO PPO (PFFS)(MSA) D () A B ( ) (HMO)(CMP) 1876(h)

236 229 D A B A B A B /( PACE ) ( D ) A B Medigap () () () (Medicaid)(CMS)

237 230 () A () B () PACE PACE (LTC) PACE C (MA)

238 231 D ( D ) D D D ( ) D (PPO) - PPO PPO (PCP) 2.1 PCP

239 232 (QIO) 4 () (SNF) Medicaid (SSI) 65

240 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: ible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: 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 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

241 Multi-language Interpreter Services 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: (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: Nu bn nói Ting Vit, có các dch v h tr ngôn ng min phí dành cho bn. Gi s (TTY: ). Korean: :, (TTY: ). Russian: ( ) Arabic: ( Japanese: (TTY: ) H0571_2017_94

242 Armenian:, : (TTY () ): Punjabi:, (TTY: ) ' Cambodian:, (TTY: ) Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ). Thai: : (TTY: ). Persian (Farsi):. : (TTY: )

243 (HMO SNP) Chinese Community Health Plan Member Services Center 445 Grant Avenue, Suite 700 San Francisco, CA (HICAP) HICAP Health Insurance Counseling And Advocacy Program 601 Jackson Street San Francisco, CA Grant Avenue, Suite 700, San Francisco, CA Tel Fax

LIP 2016 ANOC-EOC Chinese

LIP 2016 ANOC-EOC Chinese 年度福利更動通告承保證書生活改善計劃 ( 管理式保健計劃 - 特殊需要計劃 ) 2016 Life Improvement Plan (HMO SNP) 紐約市拿索郡及威徹斯特郡 2016 年 1 月 1 日至 2016 年 12 月 31 日 H3359 021 H3359_LGL16_01ch 021 Accepted