Plan Year 2017 CCHP Senior Select Program (HMO SNP) (HMO SNP) Evidence of Coverage H0571_2017_002CH File & Use 09292016
2017111231 (HMO SNP) 2017 1 1 12 31 (HMO SNP) (HMO SNP) (HMOSNP)HMO(Medicaid) (HMOSNP) This information is available for free in other languages. Please contact our Member Services number at 1-888-775-7888 for additional information. (TTY users should call 1-877-681-8898.) 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. :1-888-775-7888 TTY1-877-681-8898 8 8 Esta información está disponible en otros idiomas sin costo alguno. Por favor llame a nuestro número de Servicios para Miembros al 1-888-775-7888 para más información. (Los usuarios de TTY deben llamar al 1-877-681-8898). 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. 1-888-775-7888 TTY1-877-681-8898 Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Approved 03/2014)
//201811 H0571_2017_002CH File & Use 09292016
2017 ((HMO SNP)) (SHIP) (Medicaid) () () D D ()
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.
1 1 1.2 1.3 2 2.1 2.2 A B 2.3 (Medicaid) 2.4 (HMO SNP) 2.5 3 3.3 4 () (HMO SNP)
2 4.1 4.2 4.3 5 5.1 6 6.1 7 7.1
3 1 1.1 (HMO SNP) (Medicaid) 65 65 ( ) Medi-Cal(Medicaid)() (HMO SNP) (Medicaid) (HMO SNP) () (HMO SNP) (Medicaid) (HMO SNP) (HMO SNP) (Medicaid) (Medicaid) (Medicaid)
4 1.2 (Medicaid) (HMO SNP) () 1.3 (HMO SNP) () 2017111231(HMO SNP),201712 31 (HMO SNP) ()
5 2 2.1 A B ( 2.2 A B ) ( 2.3 ) (ESRD) (Medicaid) (Medicaid) (Medicaid) 3 2.1 2.2 A B AB A()
6 B() () 2.3 (Medicaid) (Medicaid) (QMB) AB ()( ) (SLMB)(QI)B ( (QDWI): A 2.4 (HMO SNP) (HMO SNP)
7 ( ) 5 2.5 3 3.1 ()( )
8 (HMO SNP) () 3.2 (Medicaid) www.cchphealthplan.com/medicare () (HMO SNP) ( )
9 ( ) www.cchphealthplan.com/medicare www. cchphealthplan.com/medicare 2017,( ) www.cchphealthplan.com/medicare 3.3 () (HMO SNP) (HMO SNP)
10 www.cchphealthplan.com/medicare ( ) 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)) 4.1 63 ( )
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 http://www.medicare.gov 24 1-800-MEDICARE(1-800-633-4227) 1-877-486-20481-800-772-1213 1-800-325-0778 20172017 B D
12 2017 http://www.medicare.gov 2017 7 24 1-800-MEDICARE(1-800-633-4227) 1-877-486-2048 4.2 () 1 : 1 Chinese Community Heath Plan $15 2 : (EFT) 15 $15 3 :
13 ( ) 4 : 1023 () 1 () D D () 11 1-888-775-7888 8 8 1-877-681-8898 60
14 4.3 9 1 1 7 5 5.1 IPA ( (Medicaid)) ()
15 () 5 ( 7 ) () 6 6.1 1.4 7 7.1 ()
16 (ESRD) o 65 100 o 65 20 (ESRD) 30 () () TRICARE () ID ()
18 1 5 7 (HMO SNP) ( ) 8 9
19 1 (HMO SNP) () (HMO SNP) - 1-888-775-7888 8 8 (TTY) 1-877-681-8898 1-415-397-2129 8 8 Chinese Community Health Plan Member Services Center 445 Grant Avenue, Suite 700 San Francisco, CA 94108 www.cchphealthplan.com/medicare
20 () 1-888-775-7888 8 8 (TTY) 1-877-681-8898 1-415-397-2129 8 8 Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108
21 ( ) 1-888-775-7888 8 8 (TTY) 1-877-681-8898 1-415-397-2129 8 8 Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108
22 ( ) () 1-888-775-7888 8 8 (TTY) 1-877-681-8898 1-415-397-2129 8 8 Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108 (HMO SNP) www.medicare.gov/medicarecomplaintform/home.aspx.
23 D D D () D 1-888-775-7888 8 8 (TTY) 1-877-681-8898 8 8 1-415-397-2129 Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108 www.cchphealthplan.com/medicare D D ()
24 D 1-888-775-7888 8 8 (TTY) 1-877-681-8898 1-415-397-2129 8 8 Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108 www.cchphealthplan.com/medicare D ( ) () D 1-888-775-7888 8 8
25 (TTY) 1-877-681-8898 1-415-397-2129 8 8 Chinese Community Health Plan Attn: Grievances and Appeals 445 Grant Avenue, Suite 700 San Francisco, CA 94108 (HMO SNP) www.medicare.gov/medicarecomplaintform/home.aspx. () 1-888-775-7888 8 8 (TTY) 1-877-681-8898
26 1-415-397-2129 8 8 Chinese Community Health Plan 445 Grant Ave, Suite 700 San Francisco, CA 94108 www.cchphealthplan.com/medicare 2 (Medicare) () 65 65 () (CMS) 1-800-MEDICARE 1-800-633-4227 24 (TTY) 1-877-486-2048
27 http://www.medicare.gov Medigap () (HMO SNP) (HMO SNP) www.medicare.gov/medicarecomplaintform/home.aspx ( 1-800-MEDICARE (1-800-633-4227) 24 1-877-486-2048) (MEC):
28 (ACA) (IRS) http://www.irs.gov/affordable-care-act/individuals-and-families 3 (State Health Insurance Assistance Program) () (SHIP) (HICAP). (HICAP)( ) (HICAP) 1-800-434-0222 (HICAP) Health Insurance Counseling and Advocacy Program 601 Jackson Street San Francisco, CA 94133 www.aging.ca.gov/hicap
29 4 ( ) (Quality Improvement Organization) Livanta Livanta Livanta Livanta Livanta () 1-877-588-1123 1-855-887-6668 (TTY) Livanta BFCC-QIO Program, Area 5 9090 Junction Drive, Suite 10 Annapolis Junction, MD 20701 www.bfccqioarea5.com
30 5 (Social Security) 65 D 1-800-772-1213 7 7 24 (TTY) 1-800-325-0778 7 7 http://www.ssa.gov
31 6 (Medicaid ) ( ) (Medicaid) (QMB)AB ()(QMB (QMB+)) (SLMB)B(SLMB (SLMB+)) (QI)B(QI20121231) (QDWI): A 1-916-445-4171 Department of Health Care Services P.O. BOX 997417, MS 4607 Sacramento, CA 95899-7417 www.medi-cal.ca.gov
32 (Medicaid) 1-888-452-8609 www.dhca.ca.gov/services/medical/pages/mmcdofficeoftheo mbudman.aspx 1-800-231-4024 www.aging.ca.gov/programs/ltcop 7
33 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048 24 1-800-772-1213 7 7 1-800-325-0778 (Medicaid)( 6 ) ( ) D 50%()2017 50% 10% 40% D (D EOB) 10% 49% 51% 49%
34 () ADAP ADAP ADAP ADAP / ADAP D ADAP ADAP ADAP D D ADAP ADAP- 1-415-554-9172 1-415-554-9172 D
35 (SHIP)( 3 ) 24 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048 8 1-877-772-5772 9 3 24 () (TTY) 1-312-751-4701 http://www.rrb.gov
36 9 / () 1-800-MEDICARE (1-800-633-4227 1-877-486-2048)
(HMO SNP)- 2017 38 1 1.1 1.2 2 2.2 PCP 2.3 2.4 3 3.1 3.2 3.3 4 4.1 4.2 5 5.1
(HMO SNP)- 2017 39 5.2 6 6.1 7
(HMO SNP)- 2017 40 1 1.1 1.2 (HMO SNP) (HMO SNP) ()
(HMO SNP)- 2017 41 (PCP) ( 2.1 ) o 2.3 o ( 2.2 ) ( 2 ) () o 3 o 2.4 o
(HMO SNP)- 2017 42 2 2.1 (PCP) PCP PCP X PCP () PCP PCP PCP () PCP PCP (PCP) PCP PCPPCP PCPPCP (PCP)PCP PCP
(HMO SNP)- 2017 43 PCP PCP() PCP PCPPCP PCP 2.2 PCP PCP X ( ) 2.3 PCP(HMO SNP) (2.2
(HMO SNP)- 2017 44 )() PCP() 2.1 PCP PCP PCP 30 () 2.4 ()
(HMO SNP)- 2017 45 3 3.1 911 PCP 48
(HMO SNP)- 2017 46 ( 3.2 ) 3.2 ( )
(HMO SNP)- 2017 47 3.3 www.cchphealthplan.com/medicare 2.5 4 4.1 4.2 (HMO SNP)() () ()
(HMO SNP)- 2017 48 5 5.1 () () 1. 2. ()
(HMO SNP)- 2017 49 5.2 CT CT http://www.medicare.gov 24 1-800-MEDICARE (1-800-633-4227)1-877-486-2048
(HMO SNP)- 2017 50 6 6.1 A () 6.2 o o ()
(HMO SNP)- 2017 51 7 7.1 13 (HMO SNP) ( ) 13 13 13 13
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53 () 1 1.1 1.2 2 2.1 3 3.1 ()
54 1 (HMO SNP) 1.1 (Medicaid) 1.2 (HMO SNP)(Mecicaid) ( 2 ) (HMO SNP)2017 $3,400 ( D ) $3,400 B ( B ) 2 2.1 (HMO SNP)
55 Medicaid () (PCP) () ( 2017 www.medicare.gov 24 1-800-MEDICARE (1-800-633-4227) TTY l 1-877-486-2048) 2017
56 (Medicaid)
57 : $0 18 ($0)
58 B 12 12 ($0) 12 B 12 ( ) 24 ( X ) : 35 39 40 12 24
59 ($0) () (60 )( ) 24 12
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61 ( ) ($0) ( )( ) 12
62 () () ( ) () ($0) www.cchphealthplan.com/medicare
63 ($0) ($0)
64 ($0) HIV HIV 12 HIV 3
65 ($0) ( 8 35 ) 6 (HMO SNP) A B A B
66 A B : A B () (HMO SNP) A B A B (HMO SNP) D 9.4 ( )
67 B B D () ($0) (/ ) X
68 / 4 3
69 http://www.medicare.gov/publications/pubs/pdf/11435.pdf 24 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048 190 ($0)
70 () X () () ( ) ( ) 1 1
71 B B B ($0) ( ) ( A ) ( ) ( EpogenProcrit, Epoetin AlfaAranesp Darbepoetin Alfa) D D
72 (BMI)30 X () ($0) - 4 3 1 X ( X ) ($0) ($0)
73 ($0) X http://www.medicare.gov/publications/pubs/pdf/11435.pdf 24 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048
74 ($0) ($0) : (CORFs) ($0) ($0) ($0)
75 ($0) ($0) / ($0) ($0)
76 ( ) ( ) ($0) 50 12 (PSA) (PSA) () ( ) ($0)
77 (COPD) ($0) () ( ) (LDCT) 12 LDCT 55-77 30 15 LDCT LDCT LDCTLDCT
78 (STIs) (STI) 12 (STI) 2030 6 ($0) ( ) () ( ) (
79 ) B B B (SNF) ( SNFs) ($0) 100 () ( ) 4 3 1 SNFs SNFs SNFs X SNFs
80 / SNF () () 12 4 12 4 24 : $0 /
81 ($0) ( ) 50 ( ) VSP VSP ($0) ($0) VSP VSP ($0)
82 $80 $80 () B 12 3 3.1 () (Medicaid) (Medicaid)()
83 ( 6.3 ) ( 5 ) *
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92 2.2 www.cchphealthplan.com/medicare() () www.cchphealthplan.com/medicare (LTC) D D //( ) FDA ()
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94 1. () 2. NM 84 90 2.3 2.5 24 ( ) ( ) ( )
95 ( )( 2.1 3.1 D () D ( 1.1 D ) (Medicaid) 1-916-445-4171 TTY1-916-445-0553 ( ) -- (DRUGDEX USPDI )
96 (Medicaid) 1-916-445-4171 TTY1-916-445-0553 ( 7.1 ) 3.2 3 1. 2. www.cchphealthplan.com/medicare 3. ()
97 4.1 ( 7.2 ) 10 100 4.2 ( )
98 A B A A B 4.3 ( ) www.cchphealthplan.com/medicare ( 7.2 )
99 5.1 4 () 5.2 5.2 ()
100 1. -- -- ( 4 ) 2. (LTC) 90 90 30 30 30 (LTC) 90 90 93 93 93 ( ) (LTC) 31 ()
101 () 5.3 ( ) 6.1 (1 1 )
102 ( 4 ) 6.2 60 1 1 1 1 1 1 1 1 60 60
103 o 60 o ( ) o 7.1 (Medicaid) D ( 7.5 ) (Medicaid) D D A B o DRUGDEX
104 USPDI (Medicaid) 1-916-445-4171 TTY1-916-445-0553 () ViagraCialisLevitra Caverject 8.1 8.2
105 ( 2.1 ) 9.1 D 9.2 (LTC) ( LTC) () (LTC) 90 93 ( ) 90 31
106 7.4 9.3 / (secondary) D 9.4
107 D (D) 10.1 () 10.2 (MTM)
108 (MTM) ()
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110 D
111
112? (Medicaid) D (LIS Rider) (LIS Rider)( 1.1 D D D D A B (Medicaid) () o o () www.cchphealthplan.com/medicare
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114 51% ( () D $4,950 2017 12 31 ) ( 7 ) $3,700 $400 ( 5 ) 6 $0 $82 LIS Rider $0 $82 $82 4 3.1 D (D EOB)
115 D (D EOB) 1 1 3.2 ( 2 ) o o o
116 (ADAP) D (D EOB) () 4.1 $400 $82 LIS Rider 2017 $400 D
117 $400 5.1 ( ) 5.2 2.5
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119 5.4 ( 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
120 D (D EOB) $3,700 $3,700 6.1 $ 4,950 40% 51% 49% 2017 $4,950 $4,950 6.2
121 ( D ) o o o ()$4,950
122 D A B TRICARE () () D D EOB ( 3 )$4,950 3.2
123 7.1 $4,950 $0 o 5% o $3.30$8.25 o 8.1 D 2.1 D ( )
124 1. () () D 2. 3. D 1 ( ) 2
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127 65 65 65 9.3 D o TRICARE o o 2017 24 (1-800-633-4227) 1-877-486-2048 63
128 D D 9.4 60 () 10.1 D D D ()$85,000 $170,000 D 10.2 D IRS (MAGI)
129 D 2015 2015 ( ) 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 $76.20 10.3 D? 1-800-772-1213 TTY 1-800-325-0778 10.4 D D () D
131 2.1
132 1.1 ( ) 1.
133 2. 1.3 3. ( ) ( ) 4.
134 ( 2.5) 5. 6. () 2.1
135 www.cchphealthplan.com/medicare () Chinese Community Health Plan Attn: Claims Department 445 Grant Avenue, Suite 700 San Francisco, CA 94108 Navitus Health Solutions Opertions Division Claims P.O.Box 1039 Appleton, WI 54912-1039 1 30 ()
136 3.1 ( D ) 3.2 ( ) 5 5 4 6.3 7.5
137 4.1
139 1.3 1.4 1.6 1.7 1.9 2.1
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 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-2048. 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 1-800-MEDICARE (1-800-633-4227), 24 horas al día, 7 días a la semana, y dígales que usted quiere presentar una queja. Los usuarios de TTY deben llamar al 1-877-486-2048.
141 1.1 () 1-800-MEDICARE (1-800-633-4227) 7 24 TTY 1-877-486-2048 1.2 1-800-368-1019 ( 1-800-537-7697) ( ). 1.3 (PCP) ()(
142 ) () D 11 ( 5 ) 1.4
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156 2.1 (SHIP) SHIP 3 24 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048 (http://www.medicare.gov) (Medicaid)
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221 ( CMS) 1964 1973 1975 1557 CMS 42 422.108 423.462 CMS 42 411 B D
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224 (CORF) $10 $20 (1)(2) (3) ( )
225-30 30 1 () () (Medicaid) 1) 2)
226 (EOC) ()( ) () (FDA) () (IRMAA) $85,000 $170,000
227 B 5% $3,700 A B 65 65 3 65 3 ( 65 ) 7 (SNP), 90 (LTC),(ICF/MR) () (SNP),,., 63 ( ) D D () (LIS)
228 A B (Medicaid 1 (Medicaid)) 6 3 65 65 ( ) PACE (MA) C A B HMO PPO (PFFS)(MSA) D () A B ( ) (HMO)(CMP) 1876(h)
229 D A B A B A B /( PACE ) ( D ) A B Medigap () () () (Medicaid)(CMS)
230 () A () B () PACE PACE (LTC) PACE C (MA)
231 D ( D ) D D D ( ) D (PPO) - PPO PPO (PCP) 2.1 PCP
232 (QIO) 4 () (SNF) Medicaid (SSI) 65
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 700 1-888-775-7888 TTY 1-877-681-8898 Fax 1-415-397-2129 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: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Multi-language Interpreter Services English: ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-888-775-7888 (TTY: 1-877-681-8898). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-775-7888 (TTY: 1-877-681-8898). Chinese: 1-888- 775-7888 (TTY: 1-877-681-8898) Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-775-7888 (TTY: 1-877-681-8898). Vietnamese: CHÚ Ý: Nu bn nói Ting Vit, có các dch v h tr ngôn ng min phí dành cho bn. Gi s 1-888-775-7888 (TTY: 1-877-681-8898). Korean: :,. 1-888-775-7888 (TTY: 1-877-681-8898). Russian: 1-888-775-7888 ( 1-877-681-8898) Arabic: 7888-775-888-1.(8898-681-877-1 Japanese: 1-888-775 7888 (TTY: 1-877-681-8898) H0571_2017_94
Armenian:, : 1-888- 775-7888 (TTY () 1-877-681-8898): Punjabi:, 1-888-775 7888 (TTY: 1-877-681-8898) ' Cambodian:, 1-888-775 7888 (TTY: 1-877-681-8898) Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-888-775 7888 (TTY: 1-877-681-8898). Thai: : 1-888-775 7888 (TTY: 1-877- 681-8898). Persian (Farsi):. :. 1-888-775-7888 (TTY: 1-877-681-8898)
(HMO SNP) 1-888-775-7888 88 1-877-681-8898 88 1-415-397-2129 Chinese Community Health Plan Member Services Center 445 Grant Avenue, Suite 700 San Francisco, CA 94108 www.cchphealthplan.com/medicare (HICAP) HICAP 1-800-434-0222 Health Insurance Counseling And Advocacy Program 601 Jackson Street San Francisco, CA 94133 www.aging.ca.gov/hicap 445 Grant Avenue, Suite 700, San Francisco, CA 94108 Tel 1-415-955-8800 Fax 1-415-955-8818 www.cchphealthplan.com/medicare