CCHP Senior Program (HMO)
A Medicare Advantage HMO Plan for people with Medicare
CCHP Senior Program (HMO) Members receive all the benefits of traditional Medicare, plus more, including the new Medicare Part D drug benefit. You are invited to a free seminar where you will learn about the benefits of the CCHP Senior Program (HMO).
You may be eligible for our CCHP Senior Program (HMO) if you:
- Are enrolled in both Medicare Parts A and B. (This includes those who are disabled.)
- Live within the City and County of San Francisco and northern San Mateo County.
- Agree to continue paying your Medicare premiums, and to use CCHP providers.
For benefit and enrollment information, review the following downloadable PDFs:
Please click on the plan year tabs (2012) below for downloadable PDFs.- Summary of Plan premiums & deductibles Chinese Spanish
- Summary of Benefit (including information about the Medication Therapy Management Program) Chinese Spanish
- Annual Notice of Change and Evidence of Coverage (including appeals /grievance information and transition process) Chinese Spanish
- Comprehensive Formulary (including information about Formulary Exceptions and Transition process) Chinese Spanish
- Provider & Pharmacy Directory Chinese Spanish
- Enrollment Form Chinese Spanish
- Low Income Subsidy (LIS) Premium Summary Chart
- Notice of Privacy Practices
Introducing our new Optional Supplemental Dental Plan
Introducing our new Optional Supplemental Dental Plan through DeltaCare USA
In 2012, as a member of the CCHP Senior Program (HMO), you have the option to enroll in the Delta Dental Plan for an additional monthly premium of $14.60. This is in addition to CCHP Senior Program (HMO) $35 monthly plan premium, and you must also continue to pay your monthly Medicare Part B premiums.
Cost Sharing and Deductibles
| Monthly Plan Premium | $35 | ||
| Optional Dental Coverage | $14.60 per month (in addition to plan premium) | ||
| Doctor Office Visits | $0-15 copay | ||
| X-Rays, Lab | $0 copay | ||
| Diagnostic Radiology Services | $0-$100 | ||
| Worldwide Emergency Care | $50 copay | ||
| Ambulance Services | $150 copay | ||
| Outpatient Surgery | $195 copay (at Chinese Hospital) $270 copay (at all other hospitals) |
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| Hospitalization Services | Days 1 - 6: $195 copay/day (at Chinese Hospital) Days 1 - 6: $270 copay/day (at all other hospitals) Days 7+: $0 copay/day |
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| Inpatient Mental Health Care |
Days 1 - 6: $270 copay per day Days 7 - 90: $0 copay per day |
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| Skilled Nursing Facility (up to 100 days each benefit period) |
Days 1 - 20: $0 copay / day Days 21 - 100: $135 copay / day |
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| Durable Medical Equipment | 20% of the cost per item | ||
| Part D: Prescription Drug Coverage (for Drugs on CCHP Formulary) |
Drug Tier | 30 day Supply at Retail Pharmacy | 90 day Supply by Mail Order or Chinese Hospital Pharmacy |
Initial Coverage: Costs for Brand and Specialty drugs are after the $320 yearly deductible |
Generics (no deductible) |
$10 copay | $20 copay |
| Brand | $40 copay | $80 copay | |
| Specialty | 20% copay | Not applicable | |
Coverage Gap: After your total yearly drug costs reach $2,930, you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4,700 |
Generics | 14% discount | |
| Brand & Specialty |
50% discount | ||
Catastrophic Coverage: Costs after yearly out-of-pocket drug costs reach $4,700 |
Generics | You pay the greater of 5% or $2.60 copay | |
| Brand & Specialty |
You pay the greater of 5% or $6.50 copay | ||
| Vision Services | $15 copay/visit - One pair of glasses every two years | ||
| Annual Out-of-Pocket Maximum | $3,400 | ||
The formulary contains information on how it might be changed during the year
Can the Formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a dug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by the Plan call Member Services at 1-888-775-7888, 7 days a week from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call (877) 681-8898. In the event of a mid-year non-maintenance formulary change you can find the changes on our Web site at www.cchphmo.com.
Find a Doctor
To search for a CCHP doctor by specialty, gender or zip code, or to find a doctor who speaks additional languages, click on the link below and it will take you to our medical group's (Chinese Community Health Care Association's) Web site.
Hospitals
We contract with several hospitals, including:- Chinese Hospital
- St. Francis Memorial Hospital
- California Pacific Medical Center
- St. Mary's Medical Center
- Seton Medical Center
Medicare Advantage HMO Plan Enrollment Period
- Initial Coverage Election Period (ICEP)
- Annual Election Period (AEP)
- Medicare Advantage Disenrollment Period (MADP)
- Special Election Period (SEP)
- Help and contact information
Initial Coverage Election Period (ICEP)
Initial Coverage Election Period is when an individual newly eligible for the Medicare Advantage (MA) plan may make an initial election to enroll into a MA plan. ICEP is a seven (7) month election period that begins three months immediately before the individual's entitlement to both Medicare's Part A & Part B and ending on the last day of the third month following the month of entitlement.
Beneficiaries entitled to Medicare Part A, who delays enrollment into Part B will have an ICEP upon enrollment into Part B. The ICEP then becomes a three (3) month election period, occurring the three months preceding the Part B effective date. The MA effective date will be same as the Part B effective date.
Once an ICEP election is made and enrollment takes effect, the ICEP election has been used.
Annual Election Period (AEP)
The annual election period (AEP) begins on October 15 and ends December 7. During this time, you can review your health coverage and your prescription drug coverage. You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a anew plan, you can choose any of the following types of plans:
- Another Medicare Advantage Plan. (You can choose a plan that covers prescription drugs or one that does not cover prescription drug.)
- Original Medicare with a separate Medicare Prescription Drug Plan.
- - or - Original Medical without a separate Medicare Prescription Drug Plan.
Your membership will end when your new plan's coverage begins
on January 1.
Medicare Advantage Disenrollment Period (MADP)
The Medicare Advantage Disenrollment Period (MADP) runs between January 1 and February 14 of each year and allows beneficiaries to disenroll from their MA plan and return to Original Medicare. You cannot switch from on MA plan to another or enroll in an MA plan during the MADP. If you disenroll fro an MA plan, you have a coordinating SEP to enroll in a stand-alone Part D prescription drug plan. The SEP end February 14 or when you enroll in a stand-alone Part D plan, whichever is sooner.
If there is a plan in your area that is accepting new member, you may
- switch to Original Medicare, and enroll in a Medicare Prescription Drug Plan
Special Election Period (SEP)
Enrollment in a Medicare Advantage Program may be available at other times during the year, if one of the following situations applies to you:
- You recently became eligible for Medicare.
- You were enrolled in a plan and recently moved.
- You entered a nursing home.
- You are entitled to both Medicare and Medi-Cal. If you are entitled to full benefits under Medi-Cal, consider our CCHP Senior Select Program (HMO SNP).
- You qualify for Medicare's low-income subsidy program, which provides extra help paying for prescription drug costs
- You are disenrolling from an employer group health plan.
- You involuntarily lost creditable prescription drug coverage.
For more information about these and other special election eligibility issues, please call Medicare at 1-800-633-4227 (1-800-MEDICARE). TTY/TDD users should call 1-877-486-2048 (hearing impaired) 24 hours a day, 7 days a week. Or visit them online at www.medicare.gov.
H0571_2012_174 CMS Approved MMDDYYYY Pending CMS Approval
Last updated 02022012