central health medicare plan - h5649 · tagalog: mayroon kaming libreng serbisyo sa...

H5649_101414_1090 Accepted

Central Health Medicare Plan - H5649 2015 Medicare Star Ratings* The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans. The two main types of Star Ratings are:

1. An Overall Star Rating that combines all of our plan's scores.

2. Summary Star Rating that focuses on our medical or our prescription drug services.

Some of the areas Medicare reviews for these ratings include:

• How our members rate our plan's services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications.

For 2015, Central Health Medicare Plan received the following Overall Star Rating from Medicare.

3.5 stars

We received the following Summary Star Rating for Central Health Medicare Plan's health/drug plan services:

Health Plan Services: 3.5 stars

Drug Plan Services: 3.5 stars

Image description. 5 stars End of image description. The number of stars shows how well our plan performs.

excellent above average

average below average

poor

Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time at 866-314-2427 (toll-free) or 888-205-7671 (TTY). Current members please call 866-314-2427 (toll-free) or 888-205-7671 (TTY). *Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next.

http://www.medicare.gov/

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or

drug plan. To get an interpreter, just call us at 1-866-314-2427. Someone who speaks

English/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda

tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-

866-314-2427. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如

果您需要此翻译服务，请致电 1-866-314-2427。我们的中文工作人员很乐意帮助您。这是一项免

费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。

如需翻譯服務，請致電 1-866-314-2427。我們講中文的人員將樂意為您提供幫助。這是一項免費

服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga

katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng

tagasaling-wika, tawagan lamang kami sa 1-866-314-2427. Maaari kayong tulungan ng isang

nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions

relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il

vous suffit de nous appeler au 1-866-314-2427. Un interlocuteur parlant Français pourra vous aider. Ce

service est gratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và

chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-866-314-2427 sẽ có nhân viên nói

tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits-

und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-866-314-2427. Man wird Ihnen dort

auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를

제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-866-314-2427 번으로 문의해 주십시오.

한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы

можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться

услугами переводчика, позвоните нам по телефону 1-866-314-2427. Вам окажет помощь

сотрудник, который говорит по-pусски. Данная услуга бесплатная.

H5649_090412_4036_INSERT CMS Accepted

H5649_090412_4036_INSERT CMS Accepted

Arabic: . لدينا األدوية جدول أو بالصحة تتعلق أسئلة أي عن لإلجابة المجانية الفوري المترجم خدمات نقدم إننا

يتحدث ما شخص سيقوم. 4442-414-688-1 على بنا االتصال سوى عليك ليس فوري، مترجم على للحصول

مجانية خدمة هذه. بمساعدتك العربية .

Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त

दभुाषिया सेवाए ँउपिब्ध हैं. एक दभुाषिया प्राप्त करने के लिए, बस हमें 1-866-314-2427 पर फोन करें. कोई

व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul

nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-866-314-2427. Un

nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que

tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do

número 1-866-314-2427. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é

gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan

medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-866-314-2427. Yon moun ki

pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu

odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza

znającego język polski, należy zadzwonić pod numer 1-866-314-2427. Ta usługa jest bezpłatna.

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無

料の通訳サービスがありますございます。通訳をご用命になるには、1-866-314-2427 にお電話

ください。日本語を話す人者が支援いたします。これは無料のサービスです。

Introduction to Summary of Benefits Section I

H5649_090415_1061_MAPD Accepted

CENTRAL HEALTH MEDICARE PLAN (HMO), CENTRAL HEALTH

PREMIER PLAN (HMO), and CENTRAL HEALTH FOCUS PLAN (HMO

SNP)

(a Medicare Advantage Health Maintenance Organization (HMO) offered by

CENTRAL HEALTH PLAN OF CALIFORNIA, INC. with a Medicare

contract)

Summary of Benefits

January 1, 2016 – December 31, 2016

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we

cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the

“Evidence of Coverage.”

You have choices about how to get your Medicare benefits

One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original

Medicare is run directly by the Federal government.

Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Central Health

Medicare Plan (HMO), Central Health Premier Plan (HMO), or Central Health Focus Plan (HMO

SNP)).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Central Health Medicare Plan (HMO),

Central Health Premier Plan (HMO), and Central Health Focus Plan (HMO SNP) cover and what you pay.

If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of

Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

If you want to know more about the coverage and costs of Original Medicare, look in your current

"Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-

MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Sections in this booklet

Things to Know About Central Health Medicare Plan (HMO), Central Health Premier Plan (HMO),

and Central Health Focus Plan (HMO SNP)

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

Covered Medical and Hospital Benefits

Prescription Drug Benefits

This document is available in other formats such as Braille and large print.




2 Introduction to Summary of Benefits

This document may be available in a non-English language. For additional information, call us at 1-866-314-

2427.

Este documento tal vez sea disponible en un lenguaje aparte de Ingles. Para información adicional, llame a

servicio al cliente al número que aparece arriba.

本說明書可能有其他不同的語言版本。詳情請洽上述客戶服務專線。

Things to Know About Central Health Medicare Plan (HMO), Central Health

Premier Plan (HMO), and Central Health Focus Plan (HMO SNP)

Hours of Operations

You can call us 7 days a week from 8:00 A.M. to 8:00 P.M Pacific Time.

Central Health Medicare Plan (HMO), Central Health Premier Plan (HMO), and Central

Health Focus Plan (HMO SNP) Phone Numbers and Website:

If you are a member of this plan, call toll-free 1-866-314-2427.

If you are not a member of this plan, call toll-free 1-866-314-2427.

Our website: http://www.centralhealthplan.com

Who can join?

To join CENTRAL HEALTH MEDICARE PLAN (HMO), you must be entitled to Medicare Part A, be

enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in

California: Los Angeles, Orange*, and San Bernardino*.

To join CENTRAL HEALTH PREMIER PLAN (HMO), you must be entitled to Medicare Part A, be enrolled

in Medicare Part B, and live in our service area. Our service area includes the following counties in California:

Los Angeles, Orange*, and San Bernardino*.

To join CENTRAL HEALTH FOCUS PLAN (HMO SNP), you must be entitled to Medicare Part A, be

enrolled in Medicare Part B, be diagnosed with Cardiovascular Disorders, Chronic Heart Failure, and/or

Diabetes, and live in our service area. Our service area includes the following counties in California: Los

Angeles, Orange*, and San Bernardino*.

*denotes partial county

http://www.centralhealthplan.com/


Introduction to Summary of Benefits 3

Our service area includes this county in California: Los Angeles County

Our service area includes this part of county in California: San Bernardino County, the following zip codes

only:

91701 91708 91709 91710 91729 91730 91737 91739 91743

91758 91759 91761 91762 91763 91764 91766 91784 91785

91786 91798 92301 92307 92308 92313 92316 92317 92318

92321 92322 92324 92325 92326 92329 92331 92334 92335

92336 92337 92340 92341 92342 92344 92345 92346 92350

92352 92354 92357 92358 92359 92368 92369 92371 92372

92373 92374 92375 92376 92377 92378 92382 92385 92391

92392 92393 92394 92395 92397 92399 92401 92402 92043

92404 92405 92406 92407 92408 92410 92411 92412 92413

92415 92416 92418 92420 92423 92427

Our service area includes this part of county in California: Orange County, the following zip codes only:

90620 90621 90622 90623 90624 90630 90631 90632 90633

90638 90680 90720 90721 90740 90742 90743 92602 92603

92604 92605 92606 92612 92614 92615 92616 92617 92618

92619 92620 92623 92626 92627 92628 92646 92647 92648

92649 92650 92655 92683 92684 92685 92697 92701 92702

92703 92704 92705 92706 92707 92708 92711 92712 92725

92728 92735 92780 92781 92782 92799 92801 92802 92803

92804 92805 92806 92807 92808 92809 92811 92812 92814

92815 92816 92817 92821 92822 92823 92825 92831 92832

92833 92834 92835 92836 92837 92838 92840 92841 92842

92843 92844 92845 92846 92850 92856 92857 92859 92861

92862 92863 92864 92865 92866 92867 92868 92869 92870

92871 92885 92886 92887 92899

Which doctors, hospitals, and pharmacies can I use?

Central Health Medicare Plan (HMO), Central Health Premier Plan (HMO), and Central Health Focus

Plan (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers

that are not in our network, the plan may not pay for these services.

You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

You can see our plan's provider directory at our website

(http://www.centralhealthplan.com/NetworkProviders/Directory.aspx).

You can see our plan's pharmacy directory at our website

(http://www.centralhealthplan.com/Benefits/PharmacyList.aspx).

Or, call us and we will send you a copy of the provider and pharmacy directories.

http://www.centralhealthplan.com/NetworkProviders/Directory.aspx

http://www.centralhealthplan.com/Benefits/PharmacyList.aspx


4 Introduction to Summary of Benefits

What do we cover?

Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

Our plan members get all of the benefits covered by Original Medicare. For some of these benefits,

you may pay more in our plan than you would in Original Medicare. For others, you may pay less.

Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits

are outlined in this booklet.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered

by your provider.

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our

website, http://www.centralhealthplan.com/Benefits/Formulary.aspx.

Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs?

Our plan groups each medication into one of six "tiers." You will need to use your formulary to locate what tier

your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and

what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after

you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

http://www.centralhealthplan.com/Benefits/Formulary.aspx.

Summary of Benefits Section II

Central Health Medicare Plan (HMO) 5

Central Health Medicare Plan (HMO)

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH

YOU PAY FOR COVERED SERVICES

How much is the monthly

premium?

$0 per month. In addition, you must keep paying your Medicare Part B

premium.

How much is the deductible? This plan does not have a deductible.

Is there any limit on how much

I will pay for my covered

services?

Yes. Like all Medicare health plans, our plan protects you by having yearly

limits on your out-of-pocket costs for medical and hospital care.

Your yearly limit(s) in this plan:

$3,400 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered

hospital and medical services and we will pay the full cost for the rest of the

year.

Please note that you will still need to pay your monthly premiums and cost-

sharing for your Part D prescription drugs.

Is there a limit on how much

the plan will pay?

Our plan has a coverage limit every year for certain in-network benefits.

Contact us for the services that apply.

Central Health Medicare Plan is an HMO plan with a Medicare contract. Enrollment in Central Health Medicare

Plan depends on contract renewal.


6 Central Health Medicare Plan (HMO)

NOTE:

SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION.

SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR.

OUTPATIENT CARE AND SERVICES

COVERED MEDICAL AND HOSPITAL BENEFITS

Acupuncture1,2

For up to 24 visit(s) every year: You pay nothing.

All Central Health Plan members receive 24 acupuncture visits at no cost to

you. Prior authorization may be required. Please consult with your Primary

Care Physician or IPA/Medical Group.

Ambulance1 $50 copay

Chiropractic Care1,2

Manipulation of the spine to correct a subluxation (when 1 or more of the

bones of your spine move out of position): You pay nothing

Dental Services1,2

Limited dental services (this does not include services in connection with

care, treatment, filling, removal, or replacement of teeth): You pay nothing

Preventive dental services:

Cleaning (for up to 2 every year): You pay nothing

Dental x-ray(s) (for up to 1 every six months): You pay nothing

Fluoride treatment (for up to 2 every year): You pay nothing

Oral exam: You pay nothing

Dental benefits are covered through Delta Care®

USA, provided and

administered by Delta Dental of California. Members may contact Delta

Dental Customer Services at 1-866-247-2486, Monday through Friday,

5:00 AM to 6:00 PM (PT). TTY/TDD users may call 1-800-735-2929.

Diabetes Supplies and Services1 Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing

Diagnostic Tests, Lab and

Radiology Services, and X-

Rays (Costs for these services

may vary based on place of

services)1,2

Diagnostic radiology services (such as MRIs, CT scans): You pay nothing

Diagnostic tests and procedures: You pay nothing

Lab services: You pay nothing

Outpatient x-rays: You pay nothing

Therapeutic radiology services (such as radiation treatment for

cancer): 20% of the cost

Doctor's Office Visits1,2

Primary care physician visit: You pay nothing

Specialist visit: You pay nothing

Durable Medical Equipment

(wheelchairs, oxygen, etc.)1

0-20% of the cost, depending on the equipment



Emergency Care

$50 copay

If you are admitted to the hospital within 24 hours, you do not have to pay

your share of the cost for emergency care. See the "Inpatient Hospital Care"

section of this booklet for other costs.

If you are traveling outside the United States and its territories and you

require medically necessary urgent or emergency care, the plan will

reimburse your out-of-pocket expenses up to $50,000 per year after you

provide appropriate documentation and proof of payment.

Foot Care (podiatry services)1,2

Foot exams and treatment if you have diabetes-related nerve damage and/or

meet certain conditions: You pay nothing

Hearing Services1,2

Exam to diagnose and treat hearing and balance issues: You pay nothing

Routine hearing exam (for up to 1 every year): You pay nothing

Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing

Hearing aid: $0 copay

Our plan pays up to $500 every year for hearing aids.

Home Health Care1,2

You pay nothing

Mental Health Care1,2

Inpatient visit:

Our plan covers up to 190 days in a lifetime for inpatient mental health care

in a psychiatric hospital. The inpatient hospital care limit does not apply to

inpatient mental services provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 "lifetime reserve days." These are "extra" days that

we cover. If your hospital stay is longer than 90 days, you can use these

extra days. But once you have used up these extra 60 days, your inpatient

hospital coverage will be limited to 90 days.

You pay nothing

Outpatient group therapy visit: $5 copay

Outpatient individual therapy visit: $5 copay

Outpatient Rehabilitation1,2

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per

day for up to 36 sessions up to 36 weeks): You pay nothing

Occupational therapy visit: You pay nothing

Physical therapy and speech and language therapy visit: You pay nothing

Outpatient Substance Abuse1,2

Group therapy visit: $5 copay

Individual therapy visit: $5 copay

Outpatient Surgery1,2

Ambulatory surgical center: You pay nothing

Outpatient hospital: You pay nothing



Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items.

Members receive a monthly benefit allowance to purchase over-the-counter

items through our mail order program. The allowance does not roll over to

the following month.

There is a $15 maximum monthly benefit.

Prosthetic Devices (braces,

artificial limbs, etc.)1

Prosthetic devices: 10-20% of the cost, depending on the device

Related medical supplies: 10-20% of the cost, depending on the supply

Renal Dialysis1,2 20% of the cost

Transportation1,2 You pay nothing

Members are offered 36-one way trips for medically related services. There

is a 25-mile maximum per trip. Call Member Services and allow 2 business

days’ notice.

To cancel, call at least 2 hours prior to your trip. If you do not cancel in

time, the trips will be deducted from your benefit.

Urgently Needed Services You pay nothing

Vision Services Exam to diagnose and treat diseases and conditions of the eye (including

yearly glaucoma screening): You pay nothing

Routine eye exam (for up to 1 every year): You pay nothing

Contact lenses (for up to 1 every year): $0 copay

Eyeglasses (frames and lenses) (for up to 1 every year): $0 copay

Eyeglass frames (for up to 1 every year): $0 copay

Eyeglass lenses (for up to 1 every year): $0 copay

Eyeglasses or contact lenses after cataract surgery: You pay nothing

Our plan pays up to $200 every year for eyewear.

Preventive Care1,2 You pay nothing

Our plan covers many preventive services, including:

Abdominal aortic aneurysm screening

Alcohol misuse counseling

Bone mass measurement

Breast cancer screening (mammogram)

Cardiovascular disease (behavioral therapy)

Cardiovascular screenings

Cervical and vaginal cancer screening

Colorectal cancer screenings (Colonoscopy, Fecal occult blood test,

Flexible sigmoidoscopy)

Depression screening

Diabetes screenings



INPATIENT CARE

Preventive Care1,2

(continued) HIV screening

Medical nutrition therapy services

Obesity screening and counseling

Prostate cancer screenings (PSA)

Sexually transmitted infections screening and counseling

Tobacco use cessation counseling (counseling for people with no sign of

tobacco-related disease)

Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

"Welcome to Medicare" preventive visit (one-time)

Yearly "Wellness" visit

Any additional preventive services approved by Medicare during the

contract year will be covered.

Hospice You pay nothing for hospice care from a Medicare-certified hospice. You

may have to pay part of the cost for drugs and respite care. Hospice is

covered outside of our plan. Please contact us for more details.

Inpatient Hospital Care1,2

Our plan covers an unlimited number of days for an inpatient hospital stay.

You pay nothing

Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this

booklet.

Skilled Nursing Facility

(SNF)1,2

Our plan covers up to 100 days in a SNF.

You pay nothing per day for days 1 through 20

$75 copay per day for days 21 through 65




PRESCRIPTION DRUG BENEFITS

How much do I pay? For Part B drugs such as chemotherapy drugs1: 20% of the cost

Other Part B drugs1: 20% of the cost

Initial Coverage You pay the following until your total yearly drug costs reach $3,310. Total

yearly drug costs are the total drug costs paid by both you and our Part D

plan.

You may get your drugs at network retail pharmacies and mail order

pharmacies.

Standard Retail Cost-Sharing

Tier One-month

supply

Three-month

supply

Tier 1 (Preferred Generic) $0 $0

Tier 2 (Generic) $5 copay $15 copay

Tier 3 (Preferred Brand) $35 copay $105 copay

Tier 4 (Non-Preferred Brand) $75 copay $225 copay

Tier 5 (Specialty Tier) 33% of the cost Not Offered

Tier 6 (Select Care Drugs) $10 copay $30 copay

Standard Mail Order Cost-Sharing

Tier Three-month

supply

Tier 1 (Preferred Generic) $0

Tier 2 (Generic) $10 copay

Tier 3 (Preferred Brand) $70 copay

Tier 4 (Non-Preferred Brand) $150 copay

Tier 6 (Select Care Drugs) $20 copay

If you reside in a long-term care facility, you pay the same as at a retail

pharmacy.

You may get drugs from an out-of-network pharmacy, but may pay more

than you pay at an in-network pharmacy.

Coverage Gap

Most Medicare drug plans have a coverage gap (also called the "donut

hole"). This means that there's a temporary change in what you will pay for

your drugs. The coverage gap begins after the total yearly drug cost

(including what our plan has paid and what you have paid) reaches $3,310.

After you enter the coverage gap, you pay 45% of the plan's cost for covered

brand name drugs and 58% of the plan's cost for covered generic drugs until

your costs total $4,850, which is the end of the coverage gap. Not everyone

will enter the coverage gap.

Under this plan, you may pay even less for the brand and generic drugs on

the formulary. Your cost varies by tier. You will need to use your formulary

to locate your drug's tier. See the chart that follows to find out how much it



Coverage Gap (continued) will cost you.


Tier Drugs

Covered

One-month

supply

Three-month

supply

Tier 1 (Preferred Generic) All $0 $0

Tier 2 (Generic) All $5 copay $15 copay


Tier Drugs

Covered

Three-month

supply

Tier 1 (Preferred Generic) All $0

Tier 2 (Generic) All $10 copay

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased

through your retail pharmacy and through mail order) reach $4,850, you pay

the greater of:

5% of the cost, or

$2.95 copay for generic (including brand drugs treated as generic) and a

$7.40 copayment for all other drugs.


12 Central Health Premier Plan (HMO)

Central Health Premier Plan (HMO)




premium?

$31.10 per month. In addition, you must keep paying your Medicare Part B

premium.

How much is the deductible? This plan has deductibles for some hospital and medical services, and Part D

prescription drugs.

$147 per year for in-network services. This amount may change for 2016.

$360 per year for Part D prescription drugs except for drugs on Tier 1 and

Tier 2 which are excluded from the deductible.



services?







year.




the plan will pay?



Central Health Premier Plan is an HMO plan with a Medicare contract. Enrollment in Central Health Premier



Central Health Premier Plan (HMO) 13

NOTE:





Acupuncture1,2





Ambulance1 20% of the cost




Dental Services1,2









USA, provided and


Dental Customer Services at 1-866-247-2486, Monday through Friday,

5:00 AM to 6:00 PM (PT). TTY/TDD users may call 1-800-735-2929.

Diabetes Supplies and Services1 Diabetes monitoring supplies: 20% of the cost

Diabetes self-management training: 20% of the cost

Therapeutic shoes or inserts: 20% of the cost





service)1,2

Diagnostic radiology services (such as MRIs, CT scans): 20% of the cost

Diagnostic tests and procedures: 20% of the cost

Lab services: 20% of the cost

Outpatient x-rays: 20% of the cost




Primary care physician visit: 20% of the cost

Specialist visit: 20% of the cost



20% of the cost



Emergency Care

20% of the cost (up to $75)











Hearing Services1,2

Exam to diagnose and treat hearing and balance issues: 20% of the cost




Our plan pays up to $2,000 every year for hearing aids.

Home Health Care1,2

You pay nothing


Inpatient visit:




The copays for hospital and skilled nursing facility (SNF) benefits are based

on benefit periods. A benefit period begins the day you're admitted as an

inpatient and ends when you haven't received any inpatient care (or skilled

care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after

one benefit period has ended, a new benefit period begins. You must pay the

inpatient hospital deductible for each benefit period. There's no limit to the

number of benefit periods.






In 2015 the amounts for each benefit period were:

$1,260 deductible for days 1 through 60


$630 copay per day for 60 lifetime reserve days

These amounts may change for 2016.

Outpatient group therapy visit: You pay nothing

Outpatient individual therapy visit: You pay nothing



Outpatient Rehabilitation1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per

day for up to 36 sessions up to 36 weeks): 20% of the cost

Occupational therapy visit: 20% of the cost


Outpatient Substance Abuse1,2 Group therapy visit: 40% of the cost

Individual therapy visit: 40% of the cost

Outpatient Surgery1,2 Ambulatory surgical center: 20% of the cost

Outpatient hospital: 20% of the cost



items through our mail order program. The monthly allowance does not

roll over to the following month.




Prosthetic devices: 20% of the cost

Related medical supplies: 20% of the cost





days’ notice.



Urgently Needed Services 20% of the cost (up to $65)


yearly glaucoma screening): 20% of the cost






Eyeglasses or contact lenses after cataract surgery: 20% of the cost







INPATIENT CARE

Preventive Care1,2

(continued) Alcohol misuse counseling









Diabetes screenings

HIV screening
















The copays for hospital and skilled nursing facility (SNF) benefits are based

on benefit periods. A benefit period begins the day you're admitted as an

inpatient and ends when you haven't received any inpatient care (or skilled

care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after

one benefit period has ended, a new benefit period begins. You must pay the

inpatient hospital deductible for each benefit period. There's no limit to the

number of benefit periods.



$1,260 deductible for days 1 through 60


$630 copay per day for 60 lifetime reserve days




You pay nothing per day for days 91 and beyond



booklet.


(SNF)1,2



You pay nothing for days 1 through 20

$157.50 copay per day for days 21 through 100







Initial Coverage After you pay your yearly deductible, you pay the following until your total

yearly drug costs reach $3,310. Total yearly drug costs are the total drug

costs paid by both you and our Part D plan.


pharmacies.


Tier One-month

supply

Three-month

supply


Tier 2 (Generic) $0 $0

Tier 3 (Preferred Brand) 25% of the cost 25% of the cost

Tier 4 (Non-Preferred Brand) 25% of the cost 25% of the cost


Tier 6 (Select Care Drugs) $10 copay $30 copay


Tier Three-month

supply


Tier 2 (Generic) $0

Tier 3 (Preferred Brand) 25% of the cost

Tier 4 (Non-Preferred Brand) 25% of the cost

Tier 6 (Select Care Drugs) $30 copay


pharmacy.



Coverage Gap














Coverage Gap (continued) will cost you.


Tier Drugs

Covered

One-month

supply

Three-month

supply


Tier 2 (Generic) All $0 $0


Tier Drugs

Covered

Three-month

supply


Tier 2 (Generic) All $0



the greater of:

5% of the cost, or




20 Central Health Focus Plan (HMO SNP)

Central Health Focus Plan (HMO SNP)




premium?

$0 per month. In addition, you must keep paying your Medicare Part B

premium.

How much is the deductible? This plan does not have a deductible.



services?



In this plan, you will pay nothing for Medicare-covered services from in-

network providers.





year.




the plan will pay?



Central Health Focus Plan is an HMO SNP plan with a Medicare contract. Enrollment in Central Health Focus



Central Health Focus Plan (HMO SNP) 21

NOTE:





Acupuncture1,2





Ambulance1 $50 copay




Dental Services1,2









USA, provided and


Dental Customer Services at 1-866-247-2486, Monday through Friday, 5:00

AM to 6:00 PM (PT). TTY/TDD users may call 1-800-735-2929.

Diabetes Supplies and Services1 Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing





service)1,2

Diagnostic radiology services (such as MRIs, CT scans): You pay nothing

Diagnostic tests and procedures: You pay nothing

Lab services: You pay nothing

Outpatient x-rays: You pay nothing




Primary care physician visit: You pay nothing

Specialist visit: You pay nothing



0-20% of the cost, depending on the equipment



Emergency Care

$50 copay











Hearing Services1,2

Exam to diagnose and treat hearing and balance issues: You pay nothing




Our plan pays up to $1,000 every year for hearing aids.

Home Health Care1,2

You pay nothing


Inpatient visit:









You pay nothing

Outpatient group therapy visit: $5 copay

Outpatient individual therapy visit: $5 copay

Outpatient Rehabilitation1,2

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per

day for up to 36 sessions up to 36 weeks): You pay nothing

Occupational therapy visit: You pay nothing


Outpatient Substance Abuse1,2

Group therapy visit: $5 copay

Individual therapy visit: $5 copay

Outpatient Surgery1,2

Ambulatory surgical center: You pay nothing

Outpatient hospital: You pay nothing





items through our mail order program. The monthly allowance does not

roll over to the following month.




Prosthetic devices: 10-20% of the cost, depending on the device

Related medical supplies: 10-20% of the cost, depending on the supply





days’ notice.



Urgently Needed Services You pay nothing


yearly glaucoma screening): You pay nothing






Eyeglasses or contact lenses after cataract surgery: You pay nothing





Alcohol misuse counseling









Diabetes screenings



INPATIENT CARE

Preventive Care1,2

HIV screening

















You pay nothing


booklet.


(SNF)1,2










Initial Coverage You pay the following until your total yearly drug costs reach $3,310. Total

yearly drug costs are the total drug costs paid by both you and our Part D

plan.


pharmacies.


Tier One-month

supply

Three-month

supply


Tier 2 (Generic) $5 copay $15 copay

Tier 3 (Preferred Brand) $35 copay $105 copay

Tier 4 (Non-Preferred Brand) $75 copay $225 copay


Tier 6 (Select Care Drugs) $0 $0


Tier Three-month

supply


Tier 2 (Generic) $10 copay

Tier 3 (Preferred Brand) $70 copay

Tier 4 (Non-Preferred Brand) $150 copay

Tier 6 (Select Care Drugs) $0


pharmacy.



Coverage Gap














Coverage Gap (continued)

will cost you.


Tier Drugs

Covered

One-month

supply

Three-month

supply


Tier 2 (Generic) All $5 copay $15 copay

Tier 6 (Select Care Drugs) All $0 $0


Tier Drugs

Covered

Three-month

supply


Tier 2 (Generic) All $10 copay

Tier 6 (Select Care Drugs) All $0



the greater of:

5% of the cost, or



Additional Plan Information Section III

Additional Plan Information 27

Diabetic Supplies

Includes Abbott brand:

glucose monitor

glucose test strips

lancet devices and lancets

glucose-control solutions for test strips and monitors

For diabetic members with severe diabetic foot disease, the plan also covers 1 pair of therapeutic custom-

molded shoes and 2 pairs of inserts, or 1 pair of depth shoes and 3 pairs of inserts (not including the provided

removable inserts).

Diabetes self-management training is covered under certain conditions.

Health and Wellness

Plan reimburses up to $40/month for the cost of gym membership, general access to plan-approved sports

facilities, or group fitness classes. Initiation/registration fees, personal training, private lessons, equipment

purchase/rental, weight management programs or aids, spas, golf/country clubs, and classes/activities that take

place in a private residence are not covered. Proof of payment and other documentation required. Other

restrictions apply, please contact Member Services for more details.

Part D Excluded Drugs

Central Health Medicare Plan (HMO) and Central Health Focus Plan (HMO SNP) members pay a $35 copay

for 4 pills Viagra®

per 30-day supply.

Central Health Premier Plan (HMO) members pay a 25% coinsurance for 4 pills Viagra®

per 30-day supply.

Find a DeltaCare USA dentist

Select from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA dental offices:

We’ll do whatever it takes and then some.

Visit our website and click on “Find a Dentist” on our home page. Select “DeltaCare USA” as your plan network.

Call Customer Service for help in finding a DeltaCare USA dentist.

OR

deltadentalins.com

Central Health Medicare Plan (HMO)Plan CAD14 Group No. 76572

Welcome to DeltaCare USA ‑ quality, convenience, predictable costsDeltaCare USA (administered by Delta Dental Insurance Company) provides you with quality dental benefits at an affordable cost. DeltaCare USA is designed to encourage you to visit the dentist regularly to maintain your dental health.

When you enroll, you select a contract dentist to provide services. The DeltaCare USA network consists of private practice dental facilities that have been carefully screened for quality and have agreed to participate in this program.

With DeltaCare USA you’ll enjoy these features:

Quality

• Extensive benefits for you

• No restrictions on pre‑existing conditions covered, except for work in progress

• Large, stable network of dentists, so you can enjoy a long‑term relationship with your dentist

Convenience

• No claim forms to complete

• Easy access to specialty care

• Expanded business hours for toll‑free customer service, from 5 a.m. to 6 p.m., Pacific time

Predictable costs

• No deductibles

• Out‑of‑pocket costs are clearly defined

• Out‑of‑area dental emergency coverage up to $100 per emergency

• No annual or lifetime dollar maximums

DeltaCare®

USA – provided by Delta Dental of California

Administered by Delta Dental Insurance Company

91162_HL_DCU_CAD14_76572_V15_09.10.2015H5649_080515_1097_DENTAL Accepted

What if I have questions about my DeltaCare USA Program?

How your DeltaCare USA program works

Your selected contract dentist will take care of your dental care needs. If you require treatment from a specialist, your contract dentist will handle the referral for you.

After you have enrolled, you will receive a Delta Dental membership packet that includes an identification card and an Evidence of Coverage booklet that fully describes the benefits of your dental program. Also included in this packet are the name, address and phone number of your contract dentist. Simply call the dental facility to make an appointment.

Under the DeltaCare USA program, many services are covered at no cost, while others have copayments (amount you pay your contract dentist) for certain benefits. See the “Description of Benefits and Copayments” for a list of your benefits.

Please note: Dental services that are not performed by your selected contract dentist, or are not covered under provisions for emergency care below, must be preauthorized by Delta Dental to be covered by your DeltaCare USA program.

Provisions for emergency care

Under your DeltaCare USA program, you are covered for out‑of‑network dental emergencies. Your program pays up to $100 for out‑of‑network emergency dental expenses per emergency.

My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA dentists. Can I still receive treatment from this dentist?

You must receive treatment from your selected DeltaCare USA contract dentist. Please note that Delta Dental dentists are not necessarily DeltaCare USA dentists. With more than 3,800 general and specialist dentists, the DeltaCare USA network is one of the largest dental networks in California.

Can I change my contract dentist?

You may change contract dentists by notifying us either by phone or in writing, or by visiting our website (deltadentalins.com). If you contact us by the 21st of the month, the change will become effective the first of the following month.

Highlights of your DeltaCare USA Program

‑ 1 ‑

Description of Benefits and Co‑paymentsPlan CAM61

‑ 3 ‑

Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals.

Highlights of your DeltaCare USA Program

‑ 2 ‑

How long does it take to get an appointment with a DeltaCare USA dentist?

Two to four weeks is a reasonable amount of time to wait for a routine, non‑urgent appointment. If you require a specific time, you may have to wait longer. Most DeltaCare USA dentists are in private group practices, which means greater appointment availability and extended office hours.

Are pre‑existing dental conditions and work in progress covered?

Treatment for pre‑existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals and impressions for dentures).

How does the DeltaCare USA program encourage preventive care?

Your DeltaCare USA program is designed to encourage regular visits to the dentist by having no copayments (fees you pay to the contract dentist) on most diagnostic and preventive benefits. See the enclosed “Description of Benefits and Copayments.”

Does my DeltaCare USA program cover specialists’ services?

Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics or periodontics with an approved contract specialist. If there is no contract specialist within your service area, a referral to an out‑of‑network specialist will be authorized at no extra cost, other than the applicable copayment. If you are assigned to a dental school clinic for specialty services, those services may be provided by a dentist, a dental student, a clinician or a dental instructor.

What if I have questions about my DeltaCare USA program?

Call Delta Dental Customer Service at 866‑247‑2486, TTY/TDD 1‑800‑735‑2929. We have multilingual representatives available from 5 a.m. to 6 p.m. Pacific time, Monday through Friday. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals.

‑ 3 ‑

Description of Benefits and Co‑paymentsPlan CAD14

SCHEDULE A

Description of Benefits and Copayments

The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the Program. Please refer to Schedule B for further clarification of Benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT‑2015 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

CODE DESCRIPTION ENROLLEE PAYSD0100‑D0999 I. DIAGNOSTICD0120 Periodic oral evaluation ‑ established patient ................................................................No CostD0140 Limited oral evaluation ‑ problem focused .....................................................................No CostD0150 Comprehensive oral evaluation ‑ new or established patient .........................................No CostD0180 Comprehensive periodontal evaluation ‑ new or established patient .............................No CostD0190 Screening of a patient ...................................................................................................No CostD0191 Assessment of a patient ................................................................................................No CostD0210 Intraoral ‑ complete series of radiographic images

‑ limited to 1 series every 24 months .............................................................................No CostD0220 Intraoral ‑ periapical first radiographic image .................................................................No CostD0230 Intraoral ‑ periapical each additional radiographic image...............................................No CostD0240 Intraoral ‑ occlusal radiographic image ..........................................................................No CostD0250 Extraoral ‑ first radiographic image ................................................................................No CostD0260 Extraoral ‑ each additional radiographic image ..............................................................No CostD0270 Bitewing ‑ single radiographic image .............................................................................No CostD0272 Bitewings ‑ two radiographic images .............................................................................No CostD0273 Bitewings three radiographic images .............................................................................No CostD0274 Bitewings ‑ four radiographic images ‑ limited to 1 series every 6 months ......................No CostD0330 Panoramic radiographic image ......................................................................................No CostD0999 Unspecified diagnostic procedure, by report ‑ includes office visit, per visit

(in addition to other services) ........................................................................................No Cost

D1000‑D1999 II. PREVENTIVED1110 Prophylaxis cleaning ‑ adult ‑ 2 per 12 month period .....................................................No CostD1208 Topical application of fluoride ‑ excluding varnish ‑ 2 D1206 or D1208 per

12 month period ...........................................................................................................No CostD1310 Nutritional counseling for control of dental disease .......................................................No Cost


‑ 4 ‑

D1320 Tobacco counseling for the control and prevention of oral disease ................................No CostD1330 Oral hygiene instructions ...............................................................................................No Cost

D2000‑D2999 III. RESTORATIVE- Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures.‑ When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $125.00 per crown, beyond the 6th unit.‑ Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old.D2140 Amalgam ‑ one surface, primary or permanent ...............................................................No CostD2150 Amalgam ‑ two surfaces, primary or permanent .............................................................No CostD2160 Amalgam ‑ three surfaces, primary or permanent ...........................................................No CostD2161 Amalgam ‑ four or more surfaces, primary or permanent ................................................No CostD2330 Resin‑based composite ‑ one surface, anterior ..............................................................No CostD2331 Resin‑based composite ‑ two surfaces, anterior .............................................................No CostD2332 Resin‑based composite ‑ three surfaces, anterior ..........................................................No CostD2335 Resin‑based composite ‑ four or more surfaces or involving incisal angle (anterior) .......No CostD2720 Crown ‑ resin with high noble metal ............................................................................. $220.00D2721 Crown ‑ resin with predominantly base metal ................................................................No CostD2722 Crown ‑ resin with noble metal .................................................................................... $180.00D2740 Crown ‑ porcelain/ceramic substrate ........................................................................... $220.00D2750 Crown ‑ porcelain fused to high noble metal ................................................................ $295.00D2751 Crown ‑ porcelain fused to predominantly base metal ....................................................$75.00D2752 Crown ‑ porcelain fused to noble metal ........................................................................ $255.00D2780 Crown ‑ ¾ cast high noble metal ................................................................................. $220.00D2781 Crown ‑ ¾ cast predominantly base metal ................................................................... $180.00D2782 Crown ‑ ¾ cast noble metal ......................................................................................... $180.00D2783 Crown ‑ ¾ porcelain/ceramic ...................................................................................... $180.00D2790 Crown ‑ full cast high noble metal ................................................................................ $220.00D2791 Crown ‑ full cast predominantly base metal ...................................................................No CostD2792 Crown ‑ full cast noble metal ....................................................................................... $180.00D2794 Crown ‑ titanium .......................................................................................................... $220.00D2920 Re‑cement or re‑bond crown ..........................................................................................No CostD2921 Reattachment of tooth fragment, incisal edge or cusp (anterior) ....................................No CostD2931 Prefabricated stainless steel crown ‑ permanent tooth ...................................................No CostD2940 Protective restoration ....................................................................................................No CostD2941 Interim therapeutic restoration ‑ primary dentition ........................................................No CostD2949 Restorative foundation for an indirect restoration ..........................................................No CostD2950 Core buildup, including any pins when required ............................................................No CostD2951 Pin retention ‑ per tooth, in addition to restoration ........................................................No CostD2952 Post and core in addition to crown, indirectly fabricated

‑ includes canal preparation ........................................................................................ $100.00D2953 Each additional indirectly fabricated post ‑ same tooth ‑ includes canal preparation ......$75.00D2954 Prefabricated post and core in addition to crown ‑ base metal post;

includes canal preparation ............................................................................................No Cost

‑ 5 ‑


D3000‑D3999 IV. ENDODONTICSD3110 Pulp cap ‑ direct (excluding final restoration) .................................................................No CostD3120 Pulp cap ‑ indirect (excluding final restoration) ..............................................................No CostD3310 Root canal ‑ endodontic therapy, anterior tooth (excluding final restoration) ..................No CostD3320 Root canal ‑ endodontic therapy, bicuspid tooth (excluding final restoration) ................No CostD3330 Root canal ‑ endodontic therapy, molar (excluding final restoration) ..............................No CostD3331 Treatment of root canal obstruction; non‑surgical access ...............................................No CostD3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth .................No CostD3346 Retreatment of previous root canal therapy ‑ anterior.....................................................No CostD3347 Retreatment of previous root canal therapy ‑ bicuspid ...................................................No CostD3348 Retreatment of previous root canal therapy ‑ molar ........................................................No CostD3410 Apicoectomy ‑ anterior ..................................................................................................No CostD3421 Apicoectomy ‑ bicuspid (first root) .................................................................................No CostD3425 Apicoectomy ‑ molar (first root) .....................................................................................No CostD3426 Apicoectomy (each additional root) ...............................................................................No CostD3427 Periradicular surgery without apicoectomy.....................................................................No Cost

D4000‑D4999 V. PERIODONTICS‑ Includes preoperative and postoperative evaluations and treatment under a local anesthetic.D4341 Periodontal scaling and root planing ‑ four or more teeth per quadrant

‑ limited to 4 quadrants during any 12 consecutive months ...........................................No CostD4342 Periodontal scaling and root planing ‑ one to three teeth per quadrant

‑ limited to 4 quadrants during any 12 consecutive months ...........................................No CostD4355 Full mouth debridement to enable comprehensive evaluation and diagnosis

‑ limited to 1 treatment in any 12 consecutive months ...................................................No CostD4381 Localized delivery of antimicrobial agents via a controlled release vehicle into

diseased crevicular tissue, per tooth .............................................................................No CostD4910 Periodontal maintenance ‑ limited to 1 treatment each 6 month period..........................No CostD4921 Gingival irrigation ‑ per quadrant ...................................................................................No Cost

D5000‑D5899 VI. PROSTHODONTICS (removable)‑ For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist’s facility where the denture was originally delivered.‑ Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months.‑ Replacement of a denture or a partial denture requires the existing denture to be 5+ years old.D5110 Complete denture ‑ maxillary .........................................................................................No CostD5120 Complete denture ‑ mandibular .....................................................................................No CostD5130 Immediate denture ‑ maxillary .......................................................................................No CostD5140 Immediate denture ‑ mandibular ...................................................................................No CostD5211 Maxillary partial denture ‑ resin base (including any conventional clasps,

rests and teeth) .............................................................................................................No CostD5212 Mandibular partial denture ‑ resin base (including any conventional clasps,

rests and teeth) .............................................................................................................No Cost


‑ 6 ‑

D5213 Maxillary partial denture ‑ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) ............................................................................No Cost

D5214 Mandibular partial denture ‑ cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) .....................................................No Cost

D5225 Maxillary partial denture ‑ flexible base (including any clasps, rests and teeth) ........... $220.00D5226 Mandibular partial denture ‑ flexible base (including any clasps, rests and teeth) ....... $220.00D5410 Adjust complete denture ‑ maxillary...............................................................................No CostD5411 Adjust complete denture ‑ mandibular ...........................................................................No CostD5421 Adjust partial denture ‑ maxillary ...................................................................................No CostD5422 Adjust partial denture ‑ mandibular ...............................................................................No CostD5510 Repair broken complete denture base ...........................................................................No CostD5520 Replace missing or broken teeth ‑ complete denture (each tooth) ..................................No CostD5610 Repair resin denture base ..............................................................................................No CostD5640 Replace broken teeth ‑ per tooth ...................................................................................No CostD5650 Add tooth to existing partial denture .............................................................................No CostD5660 Add clasp to existing partial denture .............................................................................No CostD5710 Rebase complete maxillary denture ................................................................................$50.00D5711 Rebase complete mandibular denture ............................................................................$50.00D5720 Rebase maxillary partial denture ....................................................................................$50.00D5721 Rebase mandibular partial denture.................................................................................$50.00D5730 Reline complete maxillary denture (chairside) ...............................................................No CostD5731 Reline complete mandibular denture (chairside) ............................................................No CostD5740 Reline maxillary partial denture (chairside) ....................................................................No CostD5741 Reline mandibular partial denture (chairside) ................................................................No CostD5750 Reline complete maxillary denture (laboratory) ..............................................................No CostD5751 Reline complete mandibular denture (laboratory) ..........................................................No CostD5760 Reline maxillary partial denture (laboratory) ...................................................................$50.00D5761 Reline mandibular partial denture (laboratory) ...............................................................$50.00D5850 Tissue conditioning, maxillary .......................................................................................No CostD5851 Tissue conditioning, mandibular ...................................................................................No Cost

D5900‑D5999 VII. MAXILLOFACIAL PROSTHETICS ‑ Not Covered

D6000‑D6199 VIII. IMPLANT SERVICES ‑ Not Covered

D6200‑D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge])

‑ When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $125.00 per unit, beyond the 6th unit.‑ Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old.D6240 Pontic ‑ porcelain fused to high noble metal ................................................................ $295.00D6241 Pontic ‑ porcelain fused to predominantly base metal ....................................................$75.00

‑ 7 ‑


D6242 Pontic ‑ porcelain fused to noble metal ........................................................................ $255.00D6750 Crown ‑ porcelain fused to high noble metal ................................................................ $295.00D6751 Crown ‑ porcelain fused to predominantly base metal ....................................................$75.00D6752 Crown ‑ porcelain fused to noble metal ........................................................................ $255.00

D7000‑D7999 X. ORAL AND MAXILLOFACIAL SURGERY‑ Includes preoperative and postoperative evaluations and treatment under a local anesthetic.D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) ...............No CostD7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning

of tooth, and including elevation of mucoperiosteal flap if indicated .............................No CostD7220 Removal of impacted tooth ‑ soft tissue .........................................................................No CostD7230 Removal of impacted tooth ‑ partially bony ....................................................................No CostD7240 Removal of impacted tooth ‑ completely bony ...............................................................No CostD7241 Removal of impacted tooth ‑ completely bony, with unusual surgical complications ......No CostD7250 Surgical removal of residual tooth roots (cutting procedure) ..........................................No CostD7310 Alveoloplasty in conjunction with extractions ‑ four or more teeth or tooth spaces,

per quadrant .................................................................................................................No CostD7311 Alveoloplasty in conjunction with extractions ‑ one to three teeth or tooth spaces,

per quadrant .................................................................................................................No CostD7320 Alveoloplasty not in conjunction with extractions ‑ four or more teeth or tooth spaces,

per quadrant .................................................................................................................No CostD7321 Alveoloplasty not in conjunction with extractions ‑ one to three teeth or tooth spaces,

per quadrant .................................................................................................................No CostD9219 Evaluation for deep sedation or general anesthesia ......................................................No Cost

D8000‑D8999 XI. ORTHODONTICS ‑ Not Covered

D9000‑D9999 XII. ADJUNCTIVE GENERAL SERVICESD9310 Consultation ‑ diagnostic service provided by dentist or physician other than

requesting dentist or physician .....................................................................................No CostD9931 Cleaning and inspection of a removable appliance ........................................................No Cost

If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized by the Plan. The Enrollee pays the Copayment specified for such services.

Procedures not listed above are not covered, however, may be available at the Contract Dentist’s Filed Fees. Filed Fees means the Contract Dentist’s fees on file with the Plan. Questions regarding these fees should be directed to the Customer Service Department at 866‑247‑2486, Monday through Friday, from 5 a.m. to 6 p.m. Pacific time (TTY/TDD users call 1‑800‑735‑2929).

Plan CAD14

‑ 8 ‑

Limitations and Exclusions of Benefits

SCHEDULE B

Limitations of Benefits

1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and Copayments.

2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $125.00 above the listed Copayment for each of these services after the sixth unit has been provided.

3. Fixed bridges are only covered as described below. An anterior fixed bridge is covered subsequent to the recent extraction of up to two anterior teeth when:

a) Those extracted teeth are the only missing teeth in the arch (other than 3rd molars), and;

b) The attachment teeth immediately adjacent to the extraction sites have a good prognosis.

Exclusions of Benefits

1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments.

2. Any procedure that in the professional opinion of the Contract Dentist:

a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or

b. is inconsistent with generally accepted standards for dentistry.

3. Services solely for cosmetic purposes, with the exception of procedure D9975, (External bleaching for home application, per arch), or for conditions that are a result of hereditary or developmental defects, including but not limited to cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel.

4. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges).

5. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ).

6. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures.

7. Implant‑supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant.

8. Consultations for non‑covered benefits.

Plan CAD14 Limitations and Exclusions of Benefits

9. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as described in the Contract and/or Benefit booklet.

10. All related fees for admission, use, or stays in a hospital, out‑patient surgery center, extended care facility, or other similar care facility.

11. Prescription drugs.

12. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee’s eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics unless qualified for the orthodontic treatment in progress provision.

13. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services.

‑ 9 ‑

‑ 10 ‑

Central Health Medicare Plan is an HMO plan with a Medicare contract. Enrollment in Central Health Medicare Plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copayments, and restrictions may apply.

Benefits, and/or co‑payments may change on January 1 of each year.

Co‑pays may vary based on the level of Extra Help you receive. Please contact the plan for further details.

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Central Health Advance Plan (HMO SNP) is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care or resides in a nursing home.

Central Health Focus Plan (HMO SNP) is available to anyone with Medicare who has been diagnosed with Diabetes, Chronic Heart Failure, or Cardiovascular Disorders.

Central Health Medi‑Medi Plan (HMO SNP) is available to anyone who has both Medical Assistance from the State and Medicare.

This information is available for free in other languages. Please call our customer service number at 1‑866‑314‑2427, TTY/TDD 1‑888‑205‑7671, 7 days a week, 8:00 AM to 8:00 PM (PT).

Esta información es disponible gratuitamente en otros lenguajes. Favor llame a nuestro número de servicio al cliente al 1‑866‑314‑2427, TTY/TDD 1‑888‑205‑7671, los 7 días de la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico).

Free Newsletter

DeltaCare USA Customer Service

866‑247‑2486, TTY/TDD 1‑800‑735‑2929deltadentalins.com

Get the latest in oral health with Dental Wire, our bi‑monthly e‑mail newsletter. Sign up at: deltadentalins.com/oral_health.

NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN.The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. A Delta Dental Evidence of Coverage will be sent to you upon enrollment. If you wish to review a Delta Dental Evidence of Coverage prior to enrollment, you may request a copy by calling the Customer Service department at 866‑247‑2486 (TTY/TDD users call 1‑800‑735‑2929).

In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products.

Customer Service 866‑247‑2486 (TTY/TDD users call 1‑800‑735‑2929) Monday through Friday 5 a.m. to 6 p.m., Pacific time

Provided by: Delta Dental of California 17871 Park Plaza Drive, Suite 200 Cerritos, CA 90703

Administered by: Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA 30023

Enrollment Instructions

Thank you for your interest in Central Health Medicare Plan. Our product offerings include Central Health Medicare Plan (HMO), Central Health Premier Plan (HMO) and Central Health Focus Plan (HMO SNP). The Centers for Medicare & Medicaid Services (CMS) require that you are eligible for both Medicare Part A and Part B in order to enroll in our Plan. You must also reside in our service area. If you are enrolling in Central Health Focus Plan, a Special Needs Plan, you must also be diagnosed with Cardiovascular Disorder, Chronic Heart Failure (CHF) and/or Diabetes. If you have End-Stage Renal Disease (ESRD), you may not enroll in our Plan unless you no longer need regular dialysis or have had a successful kidney transplant (documentation may be required). If you are qualified to enroll, please follow these simple steps below:

1. Using a pen, complete the Enrollment Application. If you make any corrections, please write your initials next to the corrected fields.

2. If you have not received your Medicare card, please attach a copy of your Letter of Verification from the Social Security Administration or the Railroad Retirement Board.

3. Please sign and date the last page of the Enrollment Application.

4. After you have completed the Enrollment Application, please fax the Enrollment

Application to us at 1-626-388-2371. Alternatively, you may tear out the yellow copy for your records and mail us the white copy at the following address:

Central Health Medicare Plan ATTN: Enrollment Department

1540 Bridgegate Drive Diamond Bar, CA 91765

If your Enrollment is assisted by a contracted Agent/Broker: your Agent/Broker will fill out the Agent/Broker portion of the Application and fax the completed Application to us on your behalf. Your Agent/Broker will retain the white copy and give you the yellow copy for your records.

5. You do not have to mail in the Enrollment Application if you choose to fax it to us. Your Enrollment Application will be processed upon receipt and submitted to CMS for approval. You will receive a confirmation notice from us with your effective date of membership once your enrollment has been approved. If CMS determines that you are not eligible for enrollment in our Plan, we will send you a letter explaining why you cannot enroll at this time.

H5649_090915_1097_2016APP001 Approved

If you have any questions or need help completing the Enrollment Application, please call Member Services toll free at 1-866-314-2427, 7 days a week from 8:00 AM to 8:00 PM (PT). TTY/TDD users please call 1-888-205-7671. Central Health Medicare Plan is an HMO plan with a Medicare and Medi-Cal contract. Enrollment in Central Health Medicare Plan depends on contract renewal. Central Health Focus Plan is available to anyone with Medicare who has been diagnosed with Cardiovascular Disorder, Chronic Heart Failure (CHF) and/or Diabetes. This information is available for free in other languages. Please call our customer service number at 1-866-314-2427, TTY/TDD 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PT). Esta información es disponible gratuitamente en otros lenguajes. Favor de ponerse en contacto con nuestro numero de servicio al cliente al 1-866-314-2427, TTY/TDD 1-888-205-7671, los 7 días a la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico).

H5649_090915_1097_2016APP001 Approved

H5649_07214_4011_2015SOA Accepted

Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services requires agents to document the scope of a

marketing appointment prior to any face-to-face sales meeting to ensure understanding of

what will be discussed between the agent and the Medicare beneficiary (or their authorized

representative). All information provided on this form is confidential and should be

completed by each person with Medicare or his/her authorized representative.

Please initial below beside the type of product(s) you want the agent to discuss.

Medicare Advantage Prescription Drug Plans (Parts C & D)

Medicare Health Maintenance Organization (HMO) —A Medicare Advantage Plan

that provides all Original Medicare Part A and Part B health coverage and sometimes

covers Part D prescription drug coverage. In most HMOs, you can only get your care from

doctors or hospitals in the plan’s network (except in emergencies).

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit

package designed for people with special health care needs. Examples of the specific

groups served include people who have both Medicare and Medicaid, people who reside in

nursing homes, and people who have certain chronic medical conditions.

By signing this form, you agree to a meeting with a sales agent to discuss the types of

products you initialed above. Please note, the person who will discuss the products is

either employed or contracted by a Medicare plan. They do not work directly for the Federal

government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current or future

Medicare enrollment status, or automatically enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

___________________________________________________________________________

Signature:

___________________________________________________________________________

Signature Date:

If you are the authorized representative, please sign above and print below:

Representative’s Name: _______________________________________________________

Your Relationship to the Beneficiary: ____________________________________________

Central Health Medicare Plan is an HMO plan with a Medicare contract. Enrollment in

Central Health Medicare Plan depends on contract renewal.

Central Health Medi-Medi Plan (HMO SNP) is available to anyone who has both Medical

Assistance from the State and Medicare.

Central Health Focus Plan (HMO SNP) is available to anyone who has been diagnosed with

Diabetes Mellitus.

Central Health Medi-Medi Plan (HMO SNP) and Central Health Focus Plan (HMO SNP)

have been approved by the National Committee for Quality Assurance (NCQA) to operate as

a Special Needs Plan (SNP) until 2017 based on a review of Central Health Medi-Medi Plan

(HMO SNP) and Central Health Focus Plan (HMO SNP)’s Model of Care.

This information is available for free in other languages. Please call our customer service

number at 1-866-314-2427, TTY/TDD 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM

(PT).

Esta información es disponible gratuitamente en otros lenguajes. Favor de ponerse en

contacto con nuestro numero de servicio al cliente al 1-866-314-2427, TTY/TDD 1-888-205-

7671, los 7 días a la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico).

To be completed by Agent:

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone :

Beneficiary Address (Optional):

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)

Agent’s Signature:

Plan(s) the agent represented during this meeting:

Date Appointment Completed:

*Scope of Appointment documentation is subject to CMS record retention requirements*

Agent: If the form was not signed by the beneficiary prior to the appointment, provide

explanation why SOA was not documented prior to meeting:

Please contact Central Health Medicare Plan if you need information in another language or format (Braille).

Please check which plan you want to enroll in: (Check ONLY one plan)

To Enroll in Central Health Medicare Plan, Please Provide the Following Information:

Enrollment Application1540 Bridgegate Drive

Diamond Bar, CA 91765

*If you receive Extra Help for drugs, the Extra Help program will pay all or part of your monthly plan premium.

City: County:State: ZIP Code:

Mailing Address Street Address: (only if different from your Permanent Residence Address):

City: County:State: ZIP Code:

E-mail Address (optional):

LAST NAME: FIRST NAME: Middle Initial: Mr. Mrs. Ms.

Male Female

Permanent Residence Street Address (P.O. Box is not allowed):

Birth Date:

(__ __/__ __/__ __ __ __) M M / D D / Y Y Y Y

Home Phone Number:

( __ __ __ ) __ __ __ – __ __ __ __

Alternate Phone Number:(optional)

( __ __ __ ) __ __ __ – __ __ __ __ Permission to send Text Message

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Central Health Medicare Plan (HMO) $0 per monthMA 001(LA/Partial OC/Partial SB)

$31.10* per month

(LA/Partial OC/Partial SB)MA 004

Central Health Premier Plan (HMO)

(LA/Partial OC/Partial SB)MA 006$0 per month

Central Health Focus Plan (HMO SNP)

- OR - •

S A M P L E O N L Y

Name: _________________________________

Medicare Claim Number Sex _______

__ __ __ - __ __ - __ __ __ __ __

Is Entitled To Effective Date

HOSPITAL (Part A) _____________________

MEDICAL _____________________(Part B)

Please Provide Your Medicare Insurance Information

Please take out your Medicare card to complete this section.

Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

• Please fill in these blanks so they matchyour red, white and blue Medicare card.

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

H5649_090415_1070_2016APP Approved

For plans with no premium: If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Central Health Medicare Plan the Part D-IRMAA.

For plans with premium: You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Central Health Medicare Plan the Part D-IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online atwww.socialsecurity.gov/prescriptionhelp.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option:

Get a bill

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Applicant Name:__________________________

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If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

Paying Your Plan Premium

Please read and answer these important questions:

1. Do you have End-Stage Renal Disease (ESRD)? Yes No

2. Some individuals may have other drug coverage, including other private insurance, TRICARE,Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistanceprograms.

Will you have other prescription drug coverage in addition to Central Health Medicare Plan? Yes No

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage: Name of other coverage: ID # for this coverage: Group # for this coverage:

_______________________________ ____________________ _____________________

3. Are you a resident in a long-term care facility, such as a nursing home? Yes NoIf “yes,” please provide the following information:

4. Are you enrolled in your State Medicaid program? Yes NoIf “yes”, please provide the following information:Medicaid Number Displayed on I.D. Card: _______________________________________

5. Do you or your spouse work? Yes No

6. Do you have Cardiovascular Disorder, Chronic Heart Failure (CHF) and/or Diabetes? Yes No

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, pleaseattach a note or records from your doctor showing you have had a successful kidney transplant or youdon’t need dialysis, otherwise we may need to contact you to obtain additional information.

Name of Institution: ____________________________________________________________________ Address: _______________________________________________________________________________

Phone Number of Institution:______________________________________________________________

Admission Date of Institution: From ______/______/______ To _______/________/_______

Medicaid DOB Displayed on I.D.Card:____________/_______________/_______________

Please choose the name of a DeltaCare USA Provider: (Optional)

PCP First Name:

Physician Group Name:

Name of Dentist or Facility Name:

Facility ID:

PCP Last Name:

PCP ID#:

PCP M.I. :

Applicant Name:__________________________

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Please choose the name of a Primary Care Physician (PCP) and Physician Group:

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format:

Spanish Chinese Vietnamese Korean Braille

Please contact Central Health Medicare Plan at 1-866-314-2427 if you need information in another format or language than what is listed above. Our office hours are 7 days a week, 8 AM - 8 PM (TTY/TDD users should call 1-888-205-7671).

Please Read This Important Information

Please Read and Sign Below:

If you currently have health coverage from an employer or union, joining Central Health Medicare Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Central Health Medicare Plan. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing this enrollment application, I agree to the following:Central Health Medicare Plan is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.

Central Health Medicare Plan serves a specific service area. If I move out of the area that Central Health Medicare Plan serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Central Health Medicare Plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Central Health Medicare Plan when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date Central Health Medicare Plan coverage begins, I must get all of my health care from Central Health Medicare Plan, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Central Health Medicare Plan and other services contained in my Central Health Medicare Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR CENTRAL HEALTH MEDICARE PLAN WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Central Health Medicare Plan, he/she may be paid based on my enrollment in Central Health Medicare Plan.

Applicant Name:__________________________

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Release of Information: By joining this Medicare health plan, I acknowledge that Central Health Medicare Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Central Health Medicare Plan will release my information, including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.

Signature: Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: _____________________________________________________________________________Address: ___________________________________________________________________________

Phone Number: (________) ________–_____________ Relationship to Enrollee ________________________

Attestation of Eligibility for an Enrollment Period

I am new to Medicare. I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date) __________/___________/______________. I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) ____________/____________/____________. I have both Medicare and Medicaid or my state helps pay for my Medicare premiums. I get extra help paying for Medicare prescription drug coverage. I no longer qualify for extra help paying for my Medicare prescription drugs. I stopped receiving extra help on (insert date) _________/___________/___________. I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility)..I moved/will move into/out of the facility on (insert date) From______/_______/_________To______/________/________. I recently left a PACE program on (insert date)_____________/__________/____________. I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s).

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment periodfrom October 15 through December 7 of each year. There are exceptions that may allow you to enroll ina Medicare Advantage plan outside of this period.

Applicant Name:__________________________

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I lost my drug coverage on (insert date)_________/_________/_____________.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am leaving employer or union coverage on (insert date) From____/_____/_____To____/____/____. I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date) ______/_________/________.

If none of these statements applies to you or you’re not sure, please contact Central Health Medicare Plan at 1-866-314-2427 (TTY users should call 1-888-205-7671) to see if you are eligible to enroll. We are open 7 days a week 8:00 AM - 8:00 PM.

Agent / Broker Information:

Central Health Medicare Plan Office Use Only:

Please Read and Sign Below:

Name of Agent/Broker (if assisted in enrollment):_______________________________________

General Agency (GA) Name (if applicable):___________________________________________

Agent/Broker Signature (if assisted in enrollment):______________________________________

CA Insurance License No:__________________Application Receive Date:______/______/_____

Proposed Effective Date:___________________

Effective Date of Coverage:______________________

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Applicant Name:__________________________

• I am licensed and certified by Central Health Medicare Plan to market and sell the plan.

• I have provided a complete and accurate explanation to the beneficiary of the plan’seligibility requirements, benefits and restrictions, with particular emphasis on thebeneficiary’s needs.

• I have reviewed the application in its entirety to ensure that all fields are complete andaccurate to my knowledge.

Please note: Completed applications must be faxed to Enrollment Department at 626-388-2371 within 24 hours of receipt by the broker.

ICEP/IEP:___________AEP:__________SEP(TYPE):__________NOT ELIGIBLE:____________

CENTRAL HEALTH FOCUS PLAN (HMO SNP) Qualification Assessment Tool

Applicant Information Last Name: First Name: MI:

Medicare ID Number: Date of Birth: Phone Number:

Chronic Condition Questions Have you ever been told by your doctor that you have diabetes (too much sugar in the blood)? Have you had problems with high blood sugar? Are you currently taking medication/insulin and/or have you been put on a special diet to control your blood sugar?

Licensed Practitioner Who Can Verify Your Chronic Condition Physician Name: Phone Number: Fax Number:

Physician Address:

Yes No I Don’t Know







Have you been diagnosed with chronic (or congestive) heart failure (CHF)?Have you had problems with rapid, erratic heart beats?Have you had problems with chest pain or tightness, shortness of breath, heart attack, or stroke?Has your doctor told you that you have problems with blood clots?

Authorization For Use of Disclosure of Health InformationI hereby authorize the disclosure of my health information by the provider listed above to Central Health Medicare Plan in order to verify that I have been diagnosed with a chronic condition which qualifies me for enrollment in Central Health Focus Plan. This authorization applies to all health information maintained by the provider concerning my medical history for the chronic condition(s) indicated above.

Note: Information disclosed as a result of this authorization will be protected by Central Health Medicare Plan in accordance with applicable state and federal laws and requirements.

Print Name of Applicant Signature of Applicant Date

Please complete the following section with your Enrollment Application. If you can answer “Yes” or “I Don’t Know” to any of the following questions, you may be eligible to join Central Health Focus Plan (HMO SNP). Prior to the end of the first month of enrollment, Central Health Plan of California will confirm from a licensed practitioner that you have the qualifying condition necessary for enrollment in the Central Health Focus Plan. If at any time, or at some subsequent time, it is determined you do not have the qualifying condition, Central Health Plan of California is required to disenroll you from Central Health Focus Plan.

For more information or for assistance with this form, please call Central Health Medicare Plan Member Services at 1-866-314-2427. Our office hours are 7 days a week, 8 AM - 8 PM (TTY/TDD USERS SHOULD CALL 1-888-205-7671)

central health medicare plan - h5649 · tagalog: mayroon kaming libreng serbisyo sa...

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