針對 2017 年 Health Net Cal MediConnect 計畫 (Medicare-Medicaid 計畫 ) 承保範圍證明 / 會員手冊之修正表 2017 年 11 月 會員您好 : 本文件是與您 Health Net Cal MediConnect 計畫承保範圍內容變更有關的重要

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1 針對 2017 年 Health Net Cal MediConnect 計畫 (Medicare-Medicaid 計畫 ) 承保範圍證明 / 會員手冊之修正表 2017 年 11 月 會員您好 : 本文件是與您 Health Net Cal MediConnect 計畫承保範圍內容變更有關的重要資訊 我們先前已將承保範圍證明 (EOC)/ 會員手冊寄給了您, 其中提供了您身為計畫參加者可在我們計畫中取得之承保的相關資訊 此次針對 EOC/ 會員手冊的更新反映了 Health Net Cal MediConnect 計畫福利中的變更 下表是描述變更的更新資訊 請保留此資訊, 以供參考 您的 EOC/ 會員手冊的變更 您可以在您 2017 年 EOC/ 會員手冊中的 什麼位置找到此資訊 原始資訊更新資訊這對您來說意味著 什麼 H3237_17_MH_001Amend2_CHI_Approved_ 第 1 頁, 共 6 頁 LTR017195CN00

2 在第 85 頁的第 4 章 此項福利可讓您使用由 如果您確認其他資源無 此變更釐清目前的交通 D 部分 福利表 中, 非 客車 計程車或其他大 法使用, 則此項福利可 運輸福利 此外, 部分 醫療交通運輸福利如下 眾或私人交通工具所提 讓您使用由客車 計程 服務可能需要事先 所列 : 供的交通運輸服務前往 車或其他大眾 / 私人交 授權 接受醫療服務 通工具所提供的交通運 您每年將可享有不限次數的單程接送 輸服務前往接受醫療服務 您可享有不限次數的 往返接送 視服務項 目而定, 可能需要事 先授權 第 2 頁, 共 6 頁

3 在第 100 頁的第 4 章 Denti-Cal 按服務收費方 按服務收費交付系統 ( 稱 此變更釐清 Denti-cal 按 E 部分 Health Net Cal 案有提供牙科福利 如 為 Denti-Cal) 有提供牙 服務收費交付系統 該 MediConnect 以外的承 需更多資訊, 或需要協 科福利 如需更多資 變更也通知保戶, 對於 保福利 中,Medi-Cal 助尋找接受 Denti-Cal 的 訊, 或需要協助尋找接 住在 Sacramento 或 Los 牙科計畫福利如下 牙醫, 請致電 Denti-Cal 受 Denti-Cal 的牙醫, Angeles 郡境內的保戶, 所列 : 受益人客戶服務專線 請致電 Denti-Cal 受益人 也可透過牙科管理照護 ( 聽語障 客戶服務專線 計畫使用牙科福利 專線使用者請致電 ( 聽語障 ) 此為 專線使用者請致電 免付費電話 Medi-Cal ) 此為 牙科方案代表服務時間 免付費電話 Medi-Cal 為週一至週五上午 8:00 牙科方案代表服務時間 至下午 5:00 您也可以 為週一至週五上午 8:00 瀏覽 Denti-Cal 網站 以取得更多 至下午 5:00 您也可以 瀏覽 Denti-Cal 網站 資訊 cal.ca.gov 以取得更多 除了 Denti-Cal 按服務收 資訊 費方案之外, 您還可透 如果您住在 Sacramento 過牙科管理式照護計畫 或 Los Angeles 郡境內, 取得牙科福利 牙科管 也可透過牙科管理照護 理式照護計畫在 Los 計畫使用牙科福利 如 Angeles 郡提供 如果您 果您需要更多有關牙科 需要更多有關牙科計畫 計畫的資訊 需要協助 的資訊 需要協助尋找 尋找牙科計畫或想更換 牙科計畫或想更換牙科 牙科計畫, 請於週一至 計畫, 請於週一至週五 週五上午 8:00 至下午 上午 8:00 至下午 5:00 致 5:00 致電 電 ( 聽語 ( 聽語障 障專線使用者請致電 專線使用者請致電 ) 與醫療 ) 與醫療 保健方案處聯絡 此為第 3 頁, 共保健方案處聯絡 此為 6 頁免付費電話 免付費電話

4 您無需採取任何行動來回應本文件, 但我們建議您保留此資訊以供日後參考用 如果您有任何疑問, 請撥打下列電話號碼與我們聯絡 : 週一至週五上午 8:00 至晚上 8:00 請致電 ( 聽語障專線 :711) 下班時間 週末及假日請留言 我們將會在下個工作日回電給您 此為免付費電話 Health Net Community Solutions, Inc. 是與 Medicare 和 Medi-Cal 均簽有合約的健保計畫, 同時為計畫參加者提供這兩項方案的福利 You can get this information for free in other languages. Call (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք (TTY 711) հեռախոսահամարով, երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m.-ը: Զանգն անվճար է: این اطالعات را میتوانید بطور مجانی به زبانهای دیگر دریافت کنید. به شماره (711 (TTY: مابین دوشنبه تا جمعه مابین ساعات 8:00 صبح تا 8:00 عصر تلفن کنید. این تلفن رایگان است. 본정보를무료로다른언어로받을수있습니다. 주중 ( 월 - 금 ) 오전 8:00 시에서오후 8:00 시사이에 (TTY: 711) 번으로전화해주십시오. 통화는무료입니다 Эти сведения вы можете бесплатно получить в переводе на другие языки. Позвоните по телефону (TTY: 711), линия работает с понедельника по пятницу с 8:00 до 20:00. Звонки бесплатные. Puede obtener esta información en otros idiomas en forma gratuita. Llame al (TTY: 711), de lunes a viernes, de 8:00 a. m. a 8:00 p. m. La llamada es gratuita. Maaari ninyong makuha nang libre ang impormasyong ito sa iba pang mga wika. Tumawag sa (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Libre ang tawag. 第 4 頁, 共 6 頁

5 Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Xin gọi (TTY: 711), thứ Hai đến thứ Sáu, 8:00 giờ sáng đến 8:00 giờ tối. Cuộc gọi miễn phí. Health Net Cal MediConnect 遵循適用的聯邦民權法規定, 不會基於種族 膚色 原國籍 年齡 殘疾狀態或性別等理由而歧視他人 Health Net Cal MediConnect 也不會因為種族 膚色 原國籍 年齡 殘疾狀態或性別而將他人排除在外或對人有差別待遇 Health Net Cal MediConnect: 為殘疾人士提供免費輔助和服務, 例如 : 合格手語翻譯員 以及其他格式 ( 大字版 無障礙電子版 其他格式 ) 的書面 資訊, 以讓其可以有效地與我們溝通 為非以英語為母語的人士提供免費的語言服務, 例如 : 合 格口譯員以及其他語言版本的書面資訊 如果您需要上述服務, 請於週一至週五上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與 Health Net Cal MediConnect 的客戶聯絡中心聯絡 下班時間 週末及假日請留言 我們將會在下個工作日回電給您 此為免付費電話 如果您認為 Health Net Cal MediConnect 未能提供上述服務或基於種族 膚色 原國籍 年齡 殘疾狀態或性向等理由而透過其他方式歧視他人, 您可致電上列電話號碼提出申訴, 並告知對方您需要協助提出申訴 ;Health Net Cal MediConnect 的客戶聯絡中心將可為您提供協助 您也可向 U.S. Department of Health and Human Services 的民權辦公室提出民權投訴, 您可 透過民權辦公室的投訴入口網站 在線上提出投 第 5 頁, 共 6 頁

6 訴, 或者透過郵件或電話提出投訴, 聯絡資訊如下 :U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, ( 聽語障專線 : ) 您可在 網站找到投訴表 第 6 頁, 共 6 頁

7 Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 年承保範圍證明 (EOC)/ 會員手冊更正表 2017 年十月 會員您好 : 這是與您 Health Net Cal MediConnect Plan 承保變更有關的重要資訊 我們先前曾寄送 承保範圍證明 (ECO)/ 會員手冊 給您, 該文件提供了與您身為本計畫的計畫參加者可享有之承保有關的資訊 此次的 EOC/ 會員手冊 更新旨在反映 Health Net Cal MediConnect Plan 上訴和申訴程序的更正 以下是說明更正項目的更新資訊 請妥善保管本資訊以供您參考用 EOC/ 會員手冊 的變更 2017 年 EOC/ 會員手冊 的變更之處 原始資訊 更正資訊 此項變更對您有何意義 第 9 章 遍及手冊各章節 州公平聽證會 州聽證會 此項變更是一項名稱更正 州公平聽證會 現稱為 州聽證會 您將可在第 9 章的各節發現此項更新 第 9 章的第 181 頁, 第 5.3 節之下的 服務 用品及藥品 ( 非 D 部分藥品 ) 的層級 1 上訴 在大多數情況下, 您必須從層級 1 開始提出上訴 然而, 針對 Medi-Cal 服務, 您不一定要從層級 1 開始提出上訴 如果您不想先向本計畫提出 Medi-Cal 服務的上訴, 您可申請州公平聽證會, 或者在特殊情況下, 您可申請獨立醫療審查 在大多數情況下, 您必須從層級 1 開始提出上訴 如果您不想先向本計畫提出 Medi-Cal 服務的上訴, 在特殊情況下, 您可申請獨立醫療審查 此項變更代表, 針對 Medi-Cal 服務, 您不一定要從層級 1 開始提出上訴 如果您不想先向本計畫提出 Medi-Cal 的上訴, 您可能可以僅申請獨立醫療審查 H3237_17_AGAmend_CHI_Approved_ LTR016915CN00 第 1 頁, 共 5 頁

8 第 9 章的第 181 頁, 第 5.3 節之下的 概述 : 如何提出層級 1 上訴 對於您想提出上訴的決定, 請在決定日期起的 90 個曆日內提出申請 如果您因為正當理由而錯過此期限, 您可能仍可提出上訴 ( 請參閱第 183 頁 ) 對於您想提出上訴的決定, 請在決定日期起的 60 個曆日內提出申請 如果您因為正當理由而錯過此期限, 您可能仍可提出上訴 ( 請參閱第 183 頁 ) 此項變更代表您有 60 個曆日的時間可以申請上訴 第 9 章的第 183 頁, 第 5.3 節之下的 服務 用品及藥品 ( 非 D 部分藥品 ) 的層級 1 上訴 我有多少時間可以提出上訴 在我們寄信告知您我們的決定之後, 您必須在信函日期起的 90 個曆日內申請上訴 我有多少時間可以提出上訴 在我們寄信告知您我們的決定之後, 您必須在信函日期起的 60 個曆日內申請上訴 此項變更代表您有 60 個曆日的時間可以申請上訴 第 9 章的第 188 頁, 第 5.4 節之下的 服務 用品及藥品 ( 非 D 部分藥品 ) 的層級 2 上訴 2) 州公平聽證會 您可隨時針對 Medi-Cal 承保服務和用品 ( 包括 IHSS) 申請州公平聽證會 如果您的醫師或其他醫療服務提供者申請了我們將不會核准的服務或用品, 或者我們不再繼續給付您已獲得的服務或用品, 您有權申請州公平聽證會 2) 州聽證會 您可針對 Medi-Cal 承保服務和用品 ( 包括 IHSS) 申請州聽證會 如果您的醫師或其他醫療服務提供者申請了我們將不會核准的服務或用品, 或者我們不再繼續給付您已獲得的服務或用品, 還是我們拒絕了您的層級 1 上訴, 您有權申請州聽證會 此項變更代表, 如果我們拒絕您的層級 1 上訴, 您有權申請州聽證會 此外, 在大多數情況下, 在我們郵寄 您的聽證權利 通知給您之後, 您還有 120 天的時間可以申請州聽證會 在大多數情況下, 在我們郵寄 您的聽證權利 通知給您之後, 您將有 90 天的時間可以申請州公平聽證會 在大多數情況下, 在我們郵寄 您的聽證權利 通知給您之後, 您將有 120 天的時間可以申請州聽證會 第 9 章的第 189 頁, 第 5.4 節之下的 服務 用品及藥品 ( 非 D 部分藥品 ) 的層級 2 上訴 如果您的問題是與 Medi-Cal 承保服務或用品有關且您申請了州公平聽證會, 則您將可繼續獲得適用於該服務或用品的 如果您的問題是與 Medi-Cal 承保服務或用品有關且您申請了州聽證會, 則您將可繼續獲得適用於該服務或用品的 此項變更代表, 在我們寄層級 1 上訴決定函告知您維持先前判決之後, 您可在郵寄日期起的 10 天內或在該行動的 第 2 頁, 共 5 頁

9 吾 䑔 Medi-Cal 福利, 直到聽證會作出決定為止 您必須在下列日期當日或之前申請聽證會才能繼續獲得福利, 以日期較晚者為準行動通知郵寄日期起的 10 天內 ; 或該行動的預定生效日期 Medi-Cal 福利, 直到聽證會作出決定為止 您必須在下列日期當日或之前申請聽證會才能繼續獲得福利, 以日期較晚者為準告知您維持先前判決之層級 1 上訴決定函郵寄日期起的 10 天內 ; 或該行動的預定生效日期 預定生效日期之前申請聽證會 第 9 章的第 221 頁, 第 10.1 節之下的 內部投訴 如欲提出內部投訴, 請於週一至週五上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與會員服務部聯絡 與 Medicare D 部分有關的投訴必須在您想投訴之問題發生後的 60 個曆日內提出 其他所有類型的投訴皆必須在您想投訴之問題發生後的 180 個曆日內提出 如欲提出內部投訴, 請於週一至週五上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與會員服務部聯絡 除非是與 D 部分藥品有關的投訴, 否則您可隨時提出投訴 如果您的投訴是與 D 部分藥品有關, 您必須在您想投訴之問題發生後的 60 個曆日內提出 此項變更代表, 提出投訴的期限從您發生問題後的 180 個曆日變更為隨時 如果您的投訴是與 D 部分藥品有關, 您必須在您想投訴之問題發生後的 60 個曆日內提出 您無需採取任何行動來回應本文件, 但我們建議您保留此資訊以供日後參考用 如果您有任何疑問, 請於週一至週五上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與我們聯絡 Health Net Community Solutions, Inc. 是與 Medicare 及 Medi-Cal 均簽有合約的健保計畫, 同時為計畫參加者提供此兩項方案的福利 You can get this information for free in other languages. Call (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք (TTY 711) հեռախոսահամարով, երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m.-ը: Զանգն անվճար է: 㜳㸴㈠吾䑔䔰㸹吠㸴橔䁞橔䁞쳌쳌䁞吠㸴橔吠 ൭ 〼䈱橔〼㐹 吠㱄橔䄵橔 橔㈠㐹㐹 橔㐹㝂橔㐹〼 㠱㐹 ൭ 〼䈱 (TTY: 711) 〼䁓吠 〼䁞 㐹䁞㐹橔 8:00 䁞䈱 䁓吠㐹橔 8:00 䁞 㐹 ൭ 〼䈱㐹〼 䄵 㱄橔䄵橔 第 3 頁, 共 5 頁

10 䁉稀 τ Ϩτ τ Αϳτ ҎҎ ϳ m Ϩ ϳ Ҏ Ҏ ϴ Ϩ Ҏm. Ҏ ma 711) (TTY: Ҏ. Rτ Ϩτ Ҏm Ϩτ. Ҏm Ҏm R 䁉 8:00 m R 8:00 䁉 R Ҏ Ҏma m RҎa 본정보를무료로다른언어로받을수있습니다. 주중 ( 월 - 금 ) 오전 8:00 시에서오후 8:00 시사이에 (TTY: 711) 번으로전화해주십시오. 통화는무료입니다 Эти сведения вы можете бесплатно получить в переводе на другие языки. Позвоните по телефону (TTY: 711), линия работает с понедельника по пятницу с 8:00 до 20:00. Звонки бесплатные. Puede obtener esta información en otros idiomas en forma gratuita. Llame al (TTY: 711), de lunes a viernes, de 8:00 a. m. a 8:00 p. m. La llamada es gratuita. Maaari ninyong makuha nang libre ang impormasyong ito sa iba pang mga wika. Tumawag sa (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Libre ang tawag. Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Xin gọi (TTY: 711), thứ Hai đến thứ Sáu, 8:00 giờ sáng đến 8:00 giờ tối. Cuộc gọi miễn phí. Health Net Cal MediConnect 遵守適用的聯邦民權法, 不會基於種族 膚色 原國籍 年齡 殘疾或性別等理由而歧視他人 Health Net Cal MediConnect 不會因為種族 膚色 原國籍 年齡 殘疾或性別而將他人排除在外或對人有差別待遇 Health Net Cal MediConnect: 為殘疾人士提供免費輔助和服務, 以讓其可以有效地與我們溝通, 例如 : 合格手語翻譯員以及其他格式 ( 大字版 無障礙電子版 其他格式 ) 的書面資訊 為非以英語為母語的人士提供免費的語言服務, 例如 : 合格口譯員以及其他語言版本的書面資訊 如果您需要上述服務, 請於上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與 Health Net Cal MediConnect 的客戶聯絡中心聯絡 如果您認為 Health Net Cal MediConnect 未能提供上述服務或基於種族 膚色 原國籍 年齡 殘疾或性別等理由而透過其他方式歧視他人, 您可致電上列電話號碼提出申訴, 並告知對方您需要協助提出申訴 ;Health Net Cal MediConnect 的客戶聯絡中心將可為您提供協助 第 4 頁, 共 5 頁

11 您也可向 U.S. Department of Health and Human Services 的民權辦公室 (Office for Civil Rights) 提出民權投訴, 您可透過民權辦公室的投訴入口網站 在線上提出投訴, 或者透過郵件或電話提出投訴, 聯絡資訊如下 :U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, ( 聽障專線 : ) 您可在 網站找到投訴表 第 5 頁, 共 5 頁

12 H3237_2017_0239_CHI CMS Accepted Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) (CBAS) (IHSS) (MSSP) (NF) Cal MediConnect Health Net Community Solutions, Inc. Health Net Community Solutions, Inc. Health Net Cal MediConnect Plan (Medicare- Medicaid Plan) :00 8:00 Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով:զանգահարեք (TTY 711) հեռախոսահամարով, երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m.-ը:զանգն անվճար է: អនកអ ចទទ លប នព ត ម ន ដ យឥតគ ត ថលកន ងភ ស ផសនងនទ ត ន ហ ទ រស ពទ (TTY: 711) ថងចនទដល ថងស រក វល ម ង 8:00 រព កដល ម ង 8:00 ល ងច ហ ទ រស ពទ ន គ ឥតគ ត ថល EOC009889CO00 H

13 1 را ميتوانيد بطور مجانی به زبانھای ديگر دريافت کنيد. به شماره (711 (TTY: مابين اين اطالعات دوشنبه تا جمعه مابين ساعات 8:00 صبح تا 8:00 عصر تلفن کنيد. اين تلفن رايگان است. 본정정정무무무다다언언무받받수있있있다. 주주 ( 월 - 금 ) 오오 8:00 시시시오오 8:00 시사사시 (TTY: 711) 번번무오전전주주시오. 통전통무무무있다 Эти сведения вы можете бесплатно получить в переводе на другие языки.позвоните по телефону (TTY: 711), линия работает с понедельника по пятницу с 8:00 до 20:00. Звонки бесплатные. Puede obtener esta información en otros idiomas en forma gratuita.llame al (TTY: 711), de lunes a viernes, de 8:00 a. m. a 8:00 p. m.la llamada es gratuita. Maaari ninyong makuha nang libre ang impormasyong ito sa iba pang mga wika.tumawag sa (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Libre ang tawag. Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác.xin gọi (TTY: 711), thứ Hai đến thứ Sáu, 8:00 giờ sáng đến 8:00 giờ tối. Cuộc gọi miễn phí :00 8:00 Health Net Community Solutions, Inc. Medicare Medi-Cal Health Net Cal MediConnect Health Net Cal MediConnect 1 1 2

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31 D Health Net Cal MediConnect E. Health Insurance Counseling and Advocacy Program (HICAP) Health Insurance Counseling and Advocacy Program (HICAP) Medicare HICAP HICAP HICAP 20

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83 4 (vivitrol) 72

84 4»»»»»»» (PSA) 73

85 4 (COPD) COPD (STI) B STI 12 STI

86 4 X 75

87 4 2 * $250* ** $250* ** *** **** **** * ** $250 20% $250 *** **** 76

88 4 Medicare Medicare PCP F 77

89 4 Medicare Medicare Medicare B 12 Medicare Medicare 1 1 $50, District of Columbia Puerto Rico Virgin Islands Guam Northern Mariana Islands American Samoa E. Medicare Medi-Cal (CCT) (CCT) 90 Medi-Cal CCT 365 CCT Department of Health Care Services CCT CCT Medi-Cal 78

90 4 CCT Health Net Cal MediConnect Health Net Cal MediConnect CCT D CCT 5 CCT CCT 8:00 8: Health Net Cal MediConnect Medi-Cal Medi-Cal X Denti-Cal Denti-Cal Denti-Cal Medi-Cal 8:00 5:00 Denti-Cal Denti-Cal Los Angeles County 8:00 5: D Medicare 79

91 4 D Health Net Cal MediConnect Medicare A B Medicare Medicare Medicare A B Medicare Medicare Medicare A B Health Net Cal MediConnect Medicare D 5 8:00 8: Health Net Cal MediConnect F. Health Net Cal MediConnect Medicare Medi-Cal Medicare Medi-Cal 9 Medicare Medi-Cal Medicare Medicare 45 Medicare 80

92 4 (VA) VA VA (TMS) 5 (DSM 5) V Health Net Health Net (ECT) Health Net Medi-Cal 81

93 4 Medicare (LASIK) LASIK (CRT)

94 A B C

95 5 D E F Medicare G

96 5 Medicare D Medi-Cal 6 Medicare A Medicare B Medicare B 4 1. (PCP) Food and Drug Administration Medi-Cal 85

97 5 A. 7 86

98 (

99 B. Medicare D Medi-Cal 88

100 5 9 D Medicaid Medicare A B Medicare A B Food and Drug Administration Medicare Medi-Cal Viagra Cialis Levitra Caverject 3 89

101 5 1 $0.00 $3.30 Medi-Cal 2 $0.00 $8.25 Medi-Cal 3 $0.00 Medi-Cal 6 C A B A B A A B 90

102 5 4. D

103 (LTC) (LTC)

104 5 9 E

105 5 F Medicare Medicare Medicare D 4 94

106 5 G. (MTM) 95

107 6 Medicare Medi-Cal A. (EOB) B C. Medicare D D E F G. HIV/AIDS AIDS Drug Assistance Program (ADAP) ADAP ADAP H Medicare D

108 6 Medicare Medi-Cal Medicare D Medi-Cal Medi-Cal Medicare Medicare D»» 3»

109 6 Medicare Medi-Cal A. (EOB) EOB EOB 1 1 Medicare 98

110 6 Medicare Medi-Cal B AIDS D 4. 99

111 6 Medicare Medi-Cal C. Medicare D Medicare D

112 6 Medicare Medi-Cal D $0.00 $3.30 Medi-Cal 2 $0.00 $8.25 Medi-Cal 3 $0.00 Medi-Cal (OTC)

113 6 Medicare Medi-Cal $0.00 $3.30 $0.00 $3.30 $0.00 $3.30 $0.00 $3.30 D Medi-Cal Medi-Cal Medi-Cal Medi-Cal 2 $0.00 $8.25 $0.00 $8.25 $0.00 $8.25 $0.00 $8.25 D Medi-Cal Medi-Cal Medi-Cal Medi-Cal 3 $0.00 $0.00 $0.00 $0.00 Medi-Cal OTC 102

114 6 Medicare Medi-Cal $4,950 $4,950 E. 2 $4,950 Medicare F. 30 $1.20 $ $0.28 $ G. HIV/AIDS AIDS Drug Assistance Program (ADAP) AIDS Drug Assistance Program (ADAP) HIV/AIDS HIV ADAP ADAP Medicare D California Department of Public Health AIDS 103

115 6 Medicare Medi-Cal ADAP ADAP ADAP ADAP ADAP ADAP Medicare D Medicare D ADAP ADAP H. Medicare D Medicare D D Medicare D 4 Medicare D Medicare D Medicare D 1. Medicare D 104

116 6 Medicare Medi-Cal 2. Medicare D 3. Medicare D 105

117 7 A B C D

118 7 A

119 B. ( Cal MediConnect Health Net Community Solutions, Inc. P.O. Box Lexington, KY

120 7 Health Net Community Solutions, Inc. Attn: Pharmacy Claims PO Box Rancho Cordova, CA C. 3 5 Medicare D 9 D

121 A B C D E F G. Cal MediConnect H I J

122 8 A. We must tell you about the plan s benefits and your rights in a way that you can understand. We must tell you about your rights each year that you are in our plan. To get information in a way that you can understand, call Member Services.Our plan has people who can answer questions in different languages. Our plan can also give you materials in languages other than English and in formats such as large print, braille, or audio.if you would like Health Net Cal MediConnect to send you member materials on an ongoing basis in other formats, such as braille or large print, or in a language other than English, please contact Member Services.Tell Member Services that you would like to place a standing request to get your material in another format or language. You can also get this handbook in the following languages for free simply by calling Member Services at (TTY: 711), Monday through Friday, 8:00 a.m.- 8:00 p.m.: o Arabic o Armenian o Cambodian o Chinese o Farsi o Korean o Russian o Spanish o Tagalog o Vietnamese If you are having trouble getting information from our plan because of language problems or a disability and you want to file a complaint, call Medicare at MEDICARE ( ).You can call 24 hours a day, seven days a week.tty users should call For information on filing a complaint with Medi-Cal, please contact Member Services at (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. 111

123 8 112

124 8 Մենք պետք է տեղեկացնենք ձեզ ծրագրի նպաստների և ձեր իրավունքների մասին ձեզ հասկանալի ձևով:մենք պետք է տեղեկացնենք ձեզ ձեր իրավունքների մասին յուրաքանչյուր տարի, քանի դեռ դուք մեր ծրագրի անդամ եք: Ձեզ հասկանալի ձևով տեղեկություն ստանալու համար զանգահարեք Անդամների սպասարկում:մեր ծրագիրը մարդիկ ունի, ովքեր կարող են հարցերի պատասխանել տարբեր լեզուներով: Մեր ծրագիրը կարող է նաև ձեզ նյութեր տրամադրել անգլերենից բացի այլ լեզուներով և այլ ձևաչափերով, ինչպիսիք են խոշոռ տառատեսակը, Բրեյլը կամ ձայնագրությունը: Եթե ցանկանում եք խնդրել Health Net Cal MediConnect-ին, որ ձեզ միշտ ուղարկեն անդամի տեղեկատվական նյութերն այլընտրանքային ձևաչափով, ինչպես օրինակ Բրեյլը կամ խոշոռ տառատեսակը, կամ անգլերենից բացի այլ լեզվով, խնդրում ենք դիմել Անդամների սպասարկում:ասացեք Անդամների սպասարկմանը, որ ցանկանում եք մշտական խնդրանք ներկայացնել, որ միշտ ստանաք ձեր նյութերն այլ ձևաչափով կամ լեզվով: Կարող եք նաև անվճար ստանալ այս տեղեկագիրքը հետևյալ լեզուներով զանգահարելով Անդամների սպասարկում հեռախոսահամարով (TTY 711), երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m-ը: o Արաբերեն o Հայերեն o Կամբոջերեն o Չինարեն o Պարսկերեն o Կորեերեն o Ռուսերեն o Իսպաներեն o Տագալոգ o Վիետնամերեն Եթե խնդիրներ ունեք մեր ծրագրի մասին տեղեկություններ ստանալու հարցում լեզվի 113

125 8 կամ հաշմանդամության պատճառով, ու ցանկանում եք բողոք ներկայացնել, զանգահարեք Medicare`1-800-MEDICARE ( ) հեռախոսահամարով:կարող եք զանգահարել օրը 24 ժամ, շաբաթը յոթ օր: TTY օգտագործողները պետք է զանգահարեն հեռախոսահամարով:medi-cal-ին բողոք ներկայացնելու մասին լրացուցիչ տեղեկությունների համար խնդրում ենք դինել Անդամների սպասարկում հեռախոսահամարով (TTY 711), երկուշաբթիից ուրբաթ օրերին, ժամը 8:00 a.m.-ից 8:00 p.m-ը: 114

126 8 115

127 8 我們必須透過您能夠瞭解的方式告知您計畫的各項福利以及您的權利 在您參加本計畫期間, 我們必須每年均告知您有關您的權利 如欲透過您能夠瞭解的方式取得資訊, 請致電與會員服務部聯絡 本計畫備有可使用不同語言為您解答疑問的工作人員 本計畫也可為您提供英文以外之其他語言版本以及如大字版 點字版或語音版等格式的資料 如果您想請 Health Net Cal MediConnect 持續寄其他格式 ( 如點字版或大字版 ) 或英文以外之其他語言版本的會員資料給您, 請與會員服務部聯絡 請告知會員服務部您想提出長期申請, 以取得其他格式或語言版本的會員資料 您也可以免費取得本手冊的下列語言版本, 您僅需於週一至週五上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與會員服務部聯絡即可 o 阿拉伯文 o 亞美尼亞文 o 柬埔寨文 o 中文 o 波斯文 o 韓文 o 俄文 o 西班牙文 o 塔加拉文 o 越南文 如果您因為語言問題或殘障而無法透過本計畫取得資訊而您想提出投訴, 請致電 MEDICARE ( ) 與 Medicare 聯絡 您每週七天, 每天 24 小時均可致電 聽障專線使用者請致電 如需有關向 Medi-Cal 提出投訴的資訊, 請於週一至週五上午 8:00 至晚上 8:00 致電 ( 聽障專線 :711) 與會員服務部聯絡 116

128 8 117

129 8 당사통반드시귀하께시사전하실수있통방법번무정험플랜의혜택및귀하의권리정알려드려야합있다. 또한귀하께시당사의정험플랜시계속전가무전있통한매년반드시귀하의권리정공지전드려야합있다. 귀하께시사전하실수있통방법번무정정정얻번시려면회원시비스부무오전전주주시오. 여러다다언언무질문시답변전드릴수있통직원들사근무하고있있있다. 당사플랜은영언사외의다다언언및대형인쇄체, 점자혹은오디언형식번무된자무도제공전드릴수있있있다. Health Net Cal MediConnect 무하여금항상회원정정자무정점자, 대형인쇄체, 혹은영언사외의다다언언무된대체형식번무우송전드리길원하시면회원시비스부무연락전주주시오. 회원정정자무정항상대체형식또통다다언언무받기위한지속요청받신청하고자한다고회원시비스부담당자시게밝혀주주시오. 주주 ( 월 - 금 ) 오오 8:00 시시시오오 8:00 시사사시회원시비스부시 (TTY: 711) 번번무오전하여본안내시정다음언언무받아정실수도있있있다. o 아라비아언 o 아르메있아언 o 캄정디아언 o 주국언 o 페르시아언 o 한국언 o 러시아언 o 스페인언 o 타갈무그언 o 베트남언 언언문제또통장애무인전당사정험플랜번무부터정정정얻통데곤란받겪고있언불만받제기하고싶번시면 Medicare MEDICARE( ) 무오전전주주시오. 연주무휴 24 시간항시오전하실수있있있다.TTY 사용자통 번번무오전하주시오.Medi- Cal 시불만받제기하통것시대전좀더알고싶번시면주주 ( 월 - 금 ) 오오 8:00 시시시오오 8:00 시사사시회원시비스부시 (TTY: 711) 번번무오전전주주시오. 118

130 8 Об обслуживании, покрываемом планом, и о ваших правах мы должны сообщать вам в понятной вам форме.пока вы остаетесь участником нашего плана, мы должны каждый год сообщать вам о ваших правах. Для того чтобы получать эти сведения в удобной для вас форме, позвоните в наш отдел обслуживания.в нашем плане работают люди, которые могут отвечать на вопросы участников плана, говорящих на разных языках. Кроме того, вы можете получить материалы нашего плана в переводе на другие языки или в других формах, например в виде аудиозаписи или напечатанными крупным шрифтом или шрифтом Брайля. Если вы хотите, чтобы план Health Net Cal MediConnect всегда присылал вам свои материалы в переводе на другие языки или в других формах, например в виде аудиозаписи или напечатанными крупным шрифтом или шрифтом Брайля, обратитесь в наш отдел обслуживания.ответившему сотруднику отдела скажите, что вы хотите обратиться с просьбой (standing request) о том, чтобы материалы и письма вам всегда присылали в альтернативной форме или в переводе на выбранный вами язык. Телефон нашего отдела обслуживания (TTY: 711), линия работает с понедельника по пятницу с 8:00 утра до 8:00 вечера.позвоните по этому телефону, и вам бесплатно пришлют этот справочник в переводе на выбранный вами язык из следующего списка: o Арабский. o Армянский. o Кхмерский. o Китайский. o Фарси. o Корейский. o Русский. o Испанский. o Тагальский. o Вьетнамский. Если из-за инвалидности или недостаточного знания английского языка вам трудно разбираться в информации, которую мы вам сообщаем, вы можете подать жалобу в программу Medicare.Телефон программы Medicare MEDICARE ( ).Звонить в программу Medicare можно круглосуточно и без выходных. 119

131 8 Если вы пользуетесь линией TTY, звоните по телефону Если вы хотите узнать о том, как подать жалобу в программу Medi-Cal, позвоните в наш отдел обслуживания, телефон (TTY: 711).Линия работает с понедельника по пятницу с 8:00 до 20:00. Le explicaremos los beneficios de su plan y sus derechos de una manera que usted pueda comprender.haremos esto cada año de cobertura de nuestro plan. Para obtener información de una manera que usted pueda comprender, llame al Departamento de Servicios al Afiliado.Nuestro plan cuenta con personas que pueden responder a sus preguntas en varios idiomas. También podemos proporcionarle material en otros idiomas, además del inglés, y en distintos formatos como en braille, en audio o en letra grande. Si desea que Health Net Cal MediConnect siempre le envíe los materiales informativos para afiliados en otros formatos, como en braille o en letra grande, o en un idioma que no sea inglés, comuníquese con el Departamento de Servicios al Afiliado.Dígale al representante que desea realizar una solicitud permanente para que siempre le envíen los materiales informativos para afiliados en otro formato o idioma. También puede obtener este manual en forma gratuita en los siguientes idiomas llamando al Departamento de Servicios al Afiliado al (TTY: 711), de lunes a viernes, de 8:00 a. m. a 8:00 p. m.: o Árabe o Armenio o Camboyano o Chino o Farsi o Coreano o Ruso o Español o Tagalo o Vietnamita Si tiene dificultades para obtener información de parte de nuestro plan por problemas relacionados con el idioma o con una discapacidad y desea presentar una queja, 120

132 8 comuníquese con Medicare, al MEDICARE ( ).Puede llamar las 24 horas del día, los 7 días de la semana.los usuarios de TTY deben llamar al Si desea información sobre cómo presentar una queja ante Medi-Cal, comuníquese con el Departamento de Servicios al Afiliado al (TTY: 711), de lunes a viernes, de 8:00 a. m. a 8:00 p. m. Dapat naming sabihin sa iyo ang tungkol sa mga benepisyo sa plan at ang iyong mga karapatan sa isang paraan na maiintindihan mo.dapat naming sabihin sa iyo ang tungkol sa iyong mga karapatan bawat taon na nasa plan ka namin. Para makakuha ng impormasyon sa isang paraan na maiintindihan mo, tawagan ang Member Services (Mga Serbisyo sa Miyembro).Ang aming plan ay mayroong mga tao na makakasagot sa iyong mga tanong sa iba t ibang mga wika. Mabibigyan ka rin ng aming plan ng mga materyales na nasa mga wika maliban sa Ingles at nasa mga format tulad ng malalaking letra, braille, o audio. Kung gusto mong hilingin sa Health Net Cal MediConnect na patuloy kang padalhan ng mga materyales para sa miyembro na nasa iba pang mga format, tulad ng braille o malalaking letra, o nang nasa wika maliban sa Ingles, mangyaring makipag-ugnayan sa Member Services.Sabihin sa Member Services na gusto mong maglagay ng patuloy na kahilingan para palaging makakuha ng mga materyales na nasa altenatibong format o wika. Maaari mo ring makuha ang handbook na ito sa mga sumusunod na wika nang libre sa pamamagitan lang ng pagtawag sa Member Services sa (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m.- 8:00 p.m: o Arabic o Armenian o Cambodian o Chinese o Farsi o Korean o Russian o Espanyol o Tagalog 121

133 8 o Vietnamese Kung nagkakaproblema kang makakuha ng impormasyon mula sa aming plan dahil sa mga problema sa wika o isang kapansanan at gusto mong maghain ng reklamo, tawagan ang Medicare sa MEDICARE ( ).Maaari kang tumawag nang 24 na oras sa isang araw, pitong araw sa isang linggo.dapat tawagan ng mga gumagamit ng TTY ang Para sa impormasyon sa paghahain ng reklamo sa Medi-Cal, mangyaring makipag-ugnayan sa Member Services sa (TTY: 711), Lunes hanggang Biyernes, 8:00 a.m. hanggang 8:00 p.m. Chúng tôi phải cho quý vị biết về các phúc lợi trong chương trình và quyền của quý vị theo cách mà quý vị có thể hiểu được.chúng tôi phải cho quý vị biết về các quyền của quý vị vào mỗi năm mà quý vị tham gia chương trình của chúng tôi. Để nhận thông tin theo cách thức quý vị có thể hiểu được, hãy gọi cho bộ phận Dịch Vụ Thành Viên.Chương trình của chúng tôi có những người có thể trả lời các câu hỏi của quý vị bằng các ngôn ngữ khác nhau. Chương trình của chúng tôi cũng cung cấp cho quý vị tài liệu bằng các ngôn ngữ khác ngoài tiếng Anh và ở các định dạng như bản in khổ lớn, chữ nổi braille, hoặc bản âm thanh. Nếu quý vị muốn Health Net Cal MediConnect phải liên tục gửi cho quý vị các tài liệu dành cho thành viên bằng định dạng khác, như chữ nổi braille hoặc bản in khổ lớn hoặc bằng ngôn ngữ khác ngoài tiếng Anh, vui lòng liên lạc với Dịch Vụ Thành Viên.Cho Dịch Vụ Thành Viên biết quý vị muốn yêu cầu lâu dài rằng quý vị phải luôn nhận được tài liệu của quý vị bằng định dạng hoặc ngôn ngữ khác. Quý vị cũng có thể nhận sổ tay này miễn phí bằng các ngôn ngữ dưới đây chỉ cần gọi đến Dịch Vụ Thành Viên theo số (TTY: 711), Thứ Hai đến Thứ Sáu, 8 giờ sáng đến 8 giờ tối: o Tiếng Ả Rập o Tiếng Armenia o Tiếng Campuchia o Tiếng Trung o Tiếng Ba Tư o Tiếng Hàn o Tiếng Nga o Tiếng Tây Ban Nha 122

134 8 o Tiếng Tagalog o Tiếng Việt Nếu quý vị đang gặp khó khăn với việc tiếp nhận thông tin từ chương trình của chúng tôi do các vấn đề về ngôn ngữ hoặc do khuyết tật và quý vị muốn nộp đơn khiếu nại, hãy gọi cho Medicare theo số MEDICARE ( ).Quý vị có thể gọi 24 giờ một ngày, bảy ngày một tuần.người dùng TTY cần gọi số Để biết thông tin về cách nộp đơn khiếu nại cho Medi-Cal, vui lòng liên lạc bộ phận Dịch Vụ Thành Viên theo số điện thoại (TTY: 711), Thứ Hai đến Thứ Sáu, 8 giờ sáng đến 8 giờ tối. 123

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