summary of benefits - anthem€¦ · anthem blue cross cal mediconnect plan: summary of benefits ....

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Summary of Benefits

Santa Clara County, CA2018

Have questions? Call us toll free at 1-855-817-5785 (TTY 711)Monday through Friday from 8 a.m. to 8 p.m. Pacific time or visit mss.anthem.com/CAmmp. H6229_18_33043_R CMS Approved 09/21/2017

Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

http://mss.anthem.com/CAmmphttp://mss.anthem.com/CAmmp

Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan): Summary of Benefits H6229_18_33043_R CMS Approved 09/21/2017

If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at 1-855-817-5785 (TTY 711), Monday

through Friday from 8 a.m. to 8 p.m. Pacific Time. The call is free. For more information, visit mss.anthem.com/CAmmp. 1 ?

This is a summary of health services covered by Anthem Blue Cross Cal MediConnect Plan for

2018. This is only a summary. Please read the Member Handbook for the full list of benefits.

Anthem Blue Cross Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide

benefits of both programs to enrollees. It is for people with both Medicare and Medi-Cal.

Under Anthem Blue Cross Cal MediConnect Plan you can get your Medicare and Medi-Cal services in one health

plan. An Anthem Blue Cross Cal MediConnect Plan case manager will help manage your health care needs.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more

information contact the plan or read the Member Handbook.

Limitations, copays, and restrictions may apply. For more information, call Anthem Blue Cross Cal MediConnect Plan

Member Services or read the Anthem Blue Cross Cal MediConnect Plan Member Handbook.

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you

a notice before we make a change that affects you.

Benefits and/or copays may change on January 1 of each year.

Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more

details.

If you speak English, language assistance services, free of charge, are available to you. Call

1-855-817-5785 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free.

Si habla espaol, le ofrecemos servicios de asistencia de idiomas sin cargo. Llame al 1-855-817-5785

(TTY 711), de lunes a viernes, de 8 a.m. a 8 p.m., hora del Pacfico. La llamada no tiene costo.

1-855-817-5785 711) 8 8

http://mss.anthem.com/CAmmp

Anthem Blue Cross Cal MediConnect Plan: Summary of Benefits


through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/CAmmp. 2 ?

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Tumawag sa 1-855-817-5785 (TTY 711), Lunes hanggang Biyernes mula 8 a.m. hanggang 8 p.m. oras sa

Pasipiko. Libre ang tawag.

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th Hai n th Su, 8 gi sng n 8 gi ti, gi Thi Bnh Dng. Cuc gi ny min ph.You can get this

document for free in other formats, such as large print, braille or audio. Call 1-855-817-5785 (TTY 711), Monday

through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free.

You can make a standing request to get this and future information for free in other languages and formats. Call 1-855-817-5785 (TTY 711) Monday through Friday form 8 a.m. to 8 p.m. Pacific time. The call is free.




The following chart lists frequently asked questions.

Frequently Asked Questions (FAQ)

Answers

What is a Cal MediConnect plan? A Cal MediConnect Plan is an organization made up of doctors, hospitals, pharmacies, providers of long-term services, and other providers. It also has case managers to help you manage all your providers and services. They all work together to provide the care you need. Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) is a Cal MediConnect Plan that provides benefits of Medi-Cal and Medicare to enrollees.

What is an Anthem Blue Cross Cal MediConnect Plan case manager?

An Anthem Blue Cross Cal MediConnect Plan case manager is one main person for you to contact. This person helps manage all your providers and services and makes sure you get what you need.

What are Long-Term Services and Supports (LTSS)?

LTSS are for beneficiaries who need assistance to do everyday tasks like taking a bath, getting dressed, making food, and taking medicine. Most of these services are provided at your home or in your community but could be provided in a nursing home or hospital.

LTSS include the following programs: Multipurpose Senior Services Program (MSSP), Community-Based Adult Services (CBAS), and long-term skilled nursing care provided by Nursing Facilities (NF).





Answers

Will you get the same Medicare and Medi-Cal benefits in Anthem Blue Cross Cal MediConnect Plan that you get now?

You will get most of your covered Medicare and Medi-Cal benefits directly from Anthem Blue Cross Cal MediConnect Plan. You will work with a team of providers who will help determine what services will best meet your needs. This means that some of the services you get now may change. When you enroll in Anthem Blue Cross Cal MediConnect Plan, you and your care team will work together to develop an Individualized Care Plan to address your health and support needs, reflecting your personal preferences and goals.

Also, if you are taking any Medicare Part D prescription drugs that Anthem Blue Cross Cal MediConnect Plan does not normally cover, you can get a temporary supply and we will help you to transition to another drug or get an exception for Anthem Blue Cross Cal MediConnect Plan to cover your drug if medically necessary.

Can you go to the same doctors you see now?

Often that is the case. If your providers (including doctors and pharmacies) work with Anthem Blue Cross Cal MediConnect Plan and have a contract with us, you can keep going to them. Providers who have an agreement with us are in-network. You must use the providers in Anthem Blue Cross Cal MediConnect Plans network. If you need urgent or emergency care or out-of-area dialysis services, you can use providers outside of Anthem Blue Cross Cal MediConnect's plan.

To find out if your doctors are in the plans network, call Member Services or read Anthem Blue Cross Cal MediConnect Plans Provider and Pharmacy Directory.

If Anthem Blue Cross Cal MediConnect Plan is new for you, we will work with you to develop an Individualized Care Plan to address your needs. You can continue seeing the doctors you go to now for 12 months for Medicare-covered services and 12 months for Medi-Cal-covered services.





Answers

What happens if you need a service but no one in Anthem Blue Cross Cal MediConnect Plans network can provide it?

Most services will be provided by our network providers. If you need a service that cannot be provided within our network, Anthem Blue Cross Cal MediConnect Plan will pay for the cost of an out-of-network provider.

Where is Anthem Blue Cross Cal MediConnect Plan available?

The service area for this plan includes: Santa Clara County, CA. You must live in this area to join the plan.

Do you pay a monthly amount (also called a premium) under Anthem Blue Cross Cal MediConnect Plan?

You will not pay any monthly premiums to Anthem Blue Cross Cal MediConnect Plan for your health coverage.

What is prior authorization? Prior authorization means that you must get approval from Anthem Blue Cross Cal MediConnect Plan before you can get a specific service or drug or see an out-of-network provider. Anthem Blue Cross Cal MediConnect Plan may not cover the service or drug if you do not get approval.

If you need urgent or emergency care or out-of-area dialysis services, you do not need to get approval first. Anthem Blue Cross Cal MediConnect Plan can provide you with a list of services or procedures that require you to obtain prior authorization from Anthem Blue Cross Cal MediConnect Plan before the service is provided.

What is a referral? A referral means that your primary care provider must give you approval to see someone that is not your primary care provider. If you dont get approval, Anthem Blue Cross Cal MediConnect Plan may not cover the services. There are certain specialists in which you do not need a referral, such as womens health specialists. For more information on when a referral is necessary, see the Member Handbook.





Answers

What is Extra Help? Extra Help is a Medicare program that helps reduce your prescription drug program costs such as copays. Your prescription drug copays under Anthem Blue Cross Cal MediConnect Plan already include the amount of Extra Help you qualify for. For more information about 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.

Who should you contact if you have questions or need help?

If you have general questions or questions about our plan, services, service area, billing, or Member ID cards, please call Anthem Blue Cross Cal MediConnect Plan Member Services:

CALL 1-855-817-5785

Calls to this number are free. Monday through Friday from 8 a.m. to 8 p.m. Pacific time.

Member Services also has free language interpreter services available for people who do not speak English.

TTY 711

This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.

Calls to this number are free. Monday through Friday from 8 a.m. to 8 p.m. Pacific time.





Answers

Who should you contact if you have questions or need help? (continued)

If you have questions about your health, please call the 24/7 NurseLine:

CALL 1-855-817-5785

Calls to this number are free. 24 hours a day, 7 days a week

TTY 711


Calls to this number are free. 24 hours a day, 7 days a week

If you need immediate behavioral health services, please call the Behavioral Health Crisis Line:

CALL 1-855-817-5785

Calls to this number are free. This service is available 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for people who do not speak English.

TTY 711


Calls to this number are free. 24 hours a day, 7 days a week.




The following chart is a quick overview of what services you may need, your costs and

rules about the benefits.

Health need or problem Services you may need

Your costs for in-network providers

Limitations, exceptions, & benefit information (rules about benefits)

You want to see a doctor

Visits to treat an injury or illness

$0

Wellness visits, such as a physical

$0

Transportation to a doctors office

$0 You are covered for unlimited trips per year to plan-approved locations. Prior authorization may be required.

Specialist care $0 May require referral from your doctor.

Care to keep you from getting sick, such as flu shots

$0 You are covered for an annual flu shot from network providers.

Welcome to Medicare preventive visit (one time only)

$0

You need medical tests Lab tests, such as blood work $0 May require referral from your doctor.

X-rays or other pictures, such as CAT scans

$0 May require referral from your doctor.

Screening tests, such as tests to check for cancer

$0 May require referral from your doctor.

You need drugs to treat your illness or condition

Generic drugs (no brand name)

$0 to $8.35 copay for one month or up to a 93-day supply

There may be limitations on the types of drugs covered. Please see Anthem Blue Cross Cal MediConnect Plans List of Covered Drugs (Drug List) for more information.







Tier 1 Medicare Part D preferred generic drugs: $0 copay

Tier 2 Medicare Part D preferred and non-preferred generic drugs: $0-$8.35 copay

Tier 3 Medi-Cal (state) approved generic prescription drugs: $0 copay

Tier 4 Medi-Cal (state) approved over-the-counter drugs that are covered by Medi-Cal: $0 copay

Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details.

You are also covered for up to a 93-day extended supply of prescription drugs from mail-order or network long-term care pharmacies. You will pay the 31-day supply copay for the 93-day extended supply.








(continued)

Brand name drugs $0 to $8.35 copay for one month or up to a 93-day supply

Tier 1 Medicare Part D preferred brand name drugs: $0 copay

Tier 2 Medicare Part D preferred and non-preferred brand name drugs: $0-$8.35 copay

Tier 3 Medi-Cal (state) approved brand name prescription drugs: $0 copay

Tier 4 Medi-Cal (state) approved over-the-counter drugs that are covered by Medi-Cal: $0 copay

There may be limitations on the types of drugs covered. Please see Anthem Blue Cross Cal MediConnect Plans List of Covered Drugs (Drug List) for more information.

You are also covered for up to a 93-day extended supply of prescription drugs from mail-order or network long-term care pharmacies. You will pay the 31-day supply copay for the 93-day extended supply.







Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details.


(continued)

Over-the-counter drugs $0 There may be limitations on the types of drugs covered. Please see Anthem Blue Cross Cal MediConnect Plans List of Covered Drugs (Drug List) for more information.

Medicare Part B prescription drugs

$0 Part B drugs include drugs given by your doctor in his or her office, some oral cancer drugs, and some drugs used with certain medical equipment. Read the Member Handbook for more information on these drugs.

You need therapy after a stroke or accident

Occupational, physical, or speech therapy

$0 Referral from your doctor and prior authorization may be required.

You need emergency care

Emergency room services $0 You are covered for emergency services from any qualified provider, whether you are in the plans service area or away from the service area. No prior authorization is required.







Ambulance services $0 No prior authorization is required for emergency ambulance services. Prior authorization is required for routine ambulance transportation.

Urgent care $0 You are covered for urgently needed services from any qualified provider, whether you are in the plans service area or away from the plans service area. No prior authorization is required.

You need hospital care Hospital stay $0 Referral from your doctor may be required. Prior authorization is required.

Doctor or surgeon care $0 Referral from your doctor may be required. Prior authorization is required.

You need help getting better or have special health needs

Rehabilitation services $0 Referral from your doctor may be required. Prior authorization is required.

Medical equipment for home care

$0 Referral from your doctor may be required. Prior authorization is required.

Skilled nursing care $0 Referral from your doctor may be required. Prior authorization is required.

You need eye care Eye exams $0 Diagnostic eye exams from network providers are covered all year long. Routine eye exams and refractions from network providers are covered once each year.

Glasses or contact lenses $0 Eyeglasses or contact lenses from network providers, up to a maximum total cost of $200, are covered every two years.







You need hearing or auditory services

Hearing screenings $0 One routine hearing screening exam per year from a network provider is covered.

Hearing aids $0 Hearing aids, up to a maximum total cost of $1,510 from network providers, are covered unless you are pregnant or reside in a nursing facility.

You have a chronic condition, such as diabetes or heart disease

Services to help manage your disease

$0 You are covered for self-management training from network providers. Referral from your doctor and prior authorization may be required.

Diabetes supplies and services

$0 Referral from your doctor and prior authorization may be required. Diabetic supplies and services are limited to specific manufacturers.

You have a mental health condition

Mental or behavioral health services


You have a substance abuse problem

Substance abuse services $0 Referral from your doctor and prior authorization may be required.

You need long-term mental health services

Inpatient care for people who need mental health care

$0 Referral from your doctor may be required. Prior authorization is required.

You are covered for medically necessary inpatient psychiatric hospital services in excess of Medicares 190-day lifetime limit at no cost by the local county mental health agency.







You need durable medical equipment (DME)

Wheelchairs $0 Referral from your doctor and prior authorization may be required.

Nebulizers $0 Referral from your doctor and prior authorization may be required.

Crutches $0 Referral from your doctor and prior authorization may be required.

Walkers $0 Referral from your doctor and prior authorization may be required.

Oxygen equipment and supplies


You need help living at home

Meals brought to your home $0 You may be covered for these services if you meet the states eligibility requirements.

Home services, such as cleaning or housekeeping

$0 You may be covered for these services if you meet the states eligibility requirements.

Changes to your home, such as ramps and wheelchair access


Training to help you get paid or unpaid jobs


Home health care services $0 You may be covered for these services if you meet the states eligibility requirements.







Services to help you live on your own


Adult day services or other support services


You need a place to live with people available to help you

Assisted living or other housing services


Nursing home care $0 You may be covered for these services if you meet the states eligibility requirements.

Your caregiver needs some time off

Respite care $0 You may be covered for these services if you meet the states eligibility requirements.




Other services that Anthem Blue Cross Cal MediConnect Plan covers

This is not a complete list. Call Member Services or read the Member Handbook to find out about other covered services.

Other services covered by Anthem Blue Cross Cal MediConnect Plan


Routine Podiatry $0 copay for routine podiatry services:

Covered for up to one visit every three months

Referral from your doctor is required

Exclusions and limitations apply to Medical and Surgical Services

Routine Transportation $0 copay

Covered for unlimited trips per year to plan-approved locations

Prior authorization may be required

Health Club/Fitness Class Membership $0 copay; includes exercise and strength classes through an approved vendor

Incontinence Cream and Diapers $0 copay

Acupuncture $0 copay

Limited to two outpatient services per calendar month, delivered by approved providers

Authorization rules apply for additional medically necessary visits

Tobacco Cessation Counseling for Pregnant Women

$0 copay; referral from your doctor and prior authorization may be required.

Respite Care Services $0 copay; referral from your doctor and prior authorization may be required.

Institution for Mental Disease Services for Individuals 65 or Older

$0 copay

You may be covered for these services if you meet the state's eligibility requirements.

Referral from your doctor and prior authorization may be required.






Nursing Facility Resident: Chiropractic Care & Foot Care

$0 copay



Nursing Facility Resident: Vision & Dental $0 copay



Nursing Facility Resident: Acupuncture

$0 copay



Personal Emergency Response System (PERS)

$0 copay

You may be covered for these services if you meet the States eligibility requirements.


Nursing Facility Resident: Hearing Exams and Hearing Aids

$0 copay



Multi-Senior Services Program (MSSP) $0 copay


Multi-Senior Services Program (MSSP) services are limited to a maximum allowable amount each year per MMSP discretion.






Medical Transport $0 copay; referral from your doctor and prior authorization may be required.

Nutritional Counseling $0 copay for nutritional consultations; referral from your doctor and prior authorization may be required.

Meal Delivery $0 copay

You may qualify for this service after discharge from the hospital if you:

Are homebound, at-risk

Have trouble preparing food and dont have anyone to help you in your home)

Prior authorization may be required.

Covers up to 2 meals per day for 7 days of meals/planning.




Benefits covered outside of Anthem Blue Cross Cal MediConnect Plan

This is not a complete list. Call Member Services to find out about other services not covered by Anthem Blue Cross Cal

MediConnect Plan but available through Medicare or Medi-Cal.

Other services covered by Medicare

or Medi-Cal Your costs

Some hospice care services $0

California Community Transitions (CCT) pre-transition coordination services and post-transition services

$0

Certain dental services, including cleanings, fillings, and complete dentures

Services that are covered under the Medi-Cal Dental Program are not chargeable to you. However, you are responsible for your share of cost amount, if applicable. You are responsible for paying for services not covered by your plan or by Medi-Cal.




Services that Anthem Blue Cross Cal MediConnect Plan, Medicare, and Medi-Cal do not cover

This is not a complete list. Call Member Services to find out about other excluded services.

Services not covered by Anthem Blue Cross Cal MediConnect Plan, Medicare, or Medi-Cal

Services considered not reasonable and necessary, according to the standards of Medicare and Medi-Cal, unless these services are listed by our plan as covered services.

Experimental medical and surgical treatment, items, and drugs, unless covered by Medicare or under a Medicare-approved clinical research study or by our plan

Experimental treatment and items are those that are not generally accepted by the medical community.

See your Member Handbook for more information on clinical research studies.

Surgical treatment for morbid obesity, except when it is medically needed and Medicare pays for it

A private room in a hospital, except when it is medically needed

Services not covered by Anthem Blue Cross Cal MediConnect Plan, Medicare, or Medi-Cal

Private duty nurses

Personal items in your room at a hospital or a nursing facility, such as a telephone or a television

Full-time nursing care in your home

Homemaker services (includes basic household assistance like light cleaning or making meals), except those covered by Medi-Cal

Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically needed

Cosmetic surgery or other cosmetic work, unless it is needed because of an accidental injury or to improve a part of the body that is not shaped right.

The plan will pay for reconstruction of a breast after a mastectomy and for treating the other breast to match it.

Regular dental care, such as cleanings, fillings, or dentures

Dental care required to treat illness or injury may be covered as inpatient or outpatient care.

Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines except those covered by Medi-Cal




Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease

Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease

Radial keratotomy, LASIK surgery, vision therapy and other low-vision aids

The plan will pay for glasses after cataract surgery.

Reversal of sterilization procedures and nonprescription contraceptive supplies

Naturopath services (the use of natural or alternative treatments) except acupuncture services covered by Medi-Cal

Services provided to veterans in Veterans Affairs (VA) facilities

When a veteran gets emergency services at a VA hospital and the VA cost-sharing is more than the cost-sharing under our plan, we will reimburse the veteran for the difference.

Members are still responsible for their cost-sharing amounts.

The plan will not cover the excluded services listed above. Even if you receive the services at an emergency room, the services are still not covered.




Your rights as a member of the plan

As a member of Anthem Blue Cross Cal MediConnect Plan, you have certain rights. You can exercise these rights without

being punished. You can also use these rights without losing your health care services. We will tell you about your rights at

least once a year. For more information on your rights, please read the Member Handbook. Your rights include, but are not

limited to, the following:

You have a right to respect, fairness and dignity. This includes the right to:

Get covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay, or ability to speak English

Get information in other formats (e.g., large print, braille, and/or audio)

Be free from any form of physical restraint or seclusion

Not be billed by network providers

Have your questions and concerns answered completely and courteously

You have the right to get information about your health care. This includes information on treatment

and your treatment options. This information should

be in a format you can understand. These rights

include getting information on:

Description of the services we cover

How to get services

How much services will cost you

Names of health care providers and care managers

You have the right to make decisions about your care, including refusing treatment. This includes

the right to:

Choose a Primary Care Provider (PCP) and you can change your PCP at any time

See a womens health care provider without a referral

Get your covered services and drugs quickly

Know about all treatment options, no matter what they cost or whether they are covered

Refuse treatment, even if your doctor advises against it

Stop taking medicine

Ask for a second opinion. Anthem Blue Cross Cal MediConnect Plan will pay for the cost of your second opinion visit.

Create and apply an advance directive, such as a will or health care proxy.




You have the right to timely access to care that does not have any communication or physical

access barriers. This includes the right to:

Get medical care timely

Get in and out of a health care providers office. This means barrier free access for people with disabilities, in accordance with the Americans with Disabilities Act

Have interpreters to help you communicate with your doctors and your health plan. Call Member Services at 1-855-817-5785 (TTY 711) if you need help with this service

You have the right to seek emergency and urgent care when you need it. This means you have the

right to:

Get emergency services, 24 hours a day, seven days a week, without prior approval in an emergency

See an out of network urgent or emergency care provider, when necessary

You have a right to confidentiality and privacy. This includes the right to:

Ask for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected

Have your personal health information kept private

You have the right to make complaints about your covered services or care. This includes the right to:

File a complaint or grievance against us or our providers. You also have the right to appeal certain decisions made by us or our providers

Ask for an Independent Medical Review of Medi-Cal services or items that are medical in nature from the California Department of Managed Health Care

Ask for a state fair hearing from the State of California

Get a detailed reason for why services were denied

For more information about your rights, you can read the Anthem Blue Cross Cal MediConnect Plan Member Handbook. If you

have questions, you can also call Anthem Blue Cross Cal MediConnect Plan Member Services.




If you have a complaint or think we should cover something we denied

If you have a complaint or think Anthem Blue Cross Cal MediConnect Plan should cover something we denied, call

Anthem Blue Cross Cal MediConnect Plan at 1-855-817-5785 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m.

Pacific time. You may be able to appeal our decision.

For questions about complaints and appeals, you can read Chapter 9 of the Anthem Blue Cross Cal MediConnect Plan

Member Handbook. You can also call Anthem Blue Cross Cal MediConnect Plan Member Services.

You can also submit appeals and grievances in writing:

Mail to:

Medicare Complaints, Appeals and Grievances

4361 Irwin Simpson Road

Mail location OH0205-A537

Mason, OH 45040

Fax your appeal to 1-888-458-1406.

If you suspect fraud

Most health care professionals and organizations that provide services are honest. Unfortunately, there may be some who

are dishonest.

If you think a doctor, hospital, or other pharmacy is doing something wrong, please contact us.

Call us at Anthem Blue Cross Cal MediConnect Plan Member Services. Phone numbers are on the cover of this summary.

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

You can also visit www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx for more information.

http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx

H6229_16_28361_I 08/05/2016 ACADMEM-0353-16

Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) complies with applicable Federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age, or disability in its health programs and activities. Anthem Blue Cross Cal MediConnect Plan provides free aids and services to people with disabilities to communicate effectively with us and provides free language services to people whose primary language is not English such as qualified interpreters and information written in other languages. These services can be obtained by calling the customer service number on the back of your member ID card. If you believe that Anthem Blue Cross Cal MediConnect Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with the Compliance Coordinator: Medicare Complaints, Appeals & Grievances:

Mailstop: OH0205-A537

4361 Irwin Simpson Road Mason, OH 45040 Fax: 1-888-458-1406 If you need help filing a grievance, the Compliance Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services; 200 Independence Ave. SW; Room 509F, HHH Building; Washington, D.C. 20201; 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html

H6229_17_28645_U CMS Accepted 09/05/2016 ACADMKT-0151-16

Multi-language Interpreter Services Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-817-5785 (TTY 711). Spanish: ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-855-817-5785 (TTY 711). Albanian: KUJDES: Nse flitni shqip, pr ju ka n dispozicion shrbime t asistencs gjuhsore, pa pages. Telefononi n 1-855-817-5785 (TTY 711).

Amharic: : 1-855-817-5785 ( 711).

Arabic:

: . (.711) 1-855-817-5785

Armenian: ,

: 1-855-817-5785 (TTY () 711) Assyrian:

:

. 5785-817-855-1

(TTY 711)

Bassa: D n k dy gbo: j k m s-w-po-ny j n, n, wuu k k po-po n m gbo kpa. 1-855-817-5785 (TTY 711)

Bengali: , , 1-855-817-5785 (TTY 711)

Chinese: 1-855-817-5785TTY 711

Dinka: PI KENE: Na ye jam n Thuja, ke kuny yen kc waar thook at kuka lu yk abac ke cn wnh cuat piny. Yup 1-855-817-5785 (TTY 711) Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1-855-817-5785 (TTY 711). Farsi:

: (TTY 711) 5785-817-855-1 . .

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Yoruba: AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-855-817-5785 (TTY 711). Anthem Blue Cross Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Anthem Blue Cross is the trade name for Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Anthem Blue Cross Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Anthem Blue Cross is the trade name for Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

H6229_18_33043_R CMS Approved 09/21/2017 ACADMKT-0186-17

Have questions?

Call us toll free at 1-855-817-5785 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. Pacific time or visit mss.anthem.com/CAmmp.

http://mss.anthem.com/CAmmp

Summary of Benefits Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)The following chart lists frequently asked questions.The following chart is a quick overview of what services you may need, your costs and rules about the benefits.Other services that Anthem Blue Cross Cal MediConnect Plan coversBenefits covered outside of Anthem Blue Cross Cal MediConnect PlanServices that Anthem Blue Cross Cal MediConnect Plan, Medicare, and Medi-Cal do not coverServices not covered by Anthem Blue Cross Cal MediConnect Plan, Medicare, or Medi-CalServices not covered by Anthem Blue Cross Cal MediConnect Plan, Medicare, or Medi-Cal

Your rights as a member of the planIf you have a complaint or think we should cover something we deniedIf you suspect fraudMulti-language Interpreter Services Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)English:Spanish:Albanian:Amharic:Arabic:Armenian:Assyrian:Bassa:Bengali:Chinese:Dinka:Dutch:Farsi:French:German:Greek:Gujarati:Haitian:Hindi:Hmong:Igbo:Ilocano:Indonesian:Italian:Japanese:Khmer:Kirundi:Korean:Nepali:Oromo:Pennsylvania Dutch:Polish:Portuguese:Punjabi:Romanian:Russian:Samoan:Serbian:Swahili:Tagalog:Thai:Ukrainian:Urdu:Vietnamese:Yiddish:Yoruba:

summary of benefits - anthem€¦ · anthem blue cross cal mediconnect plan: summary of benefits ....

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