L.A. Care Health Plan Medicare Advantage (HMO SNP)

L.A. Care Health Plan Medicare Advantage is a plan designed for people eligible for both Medicare and Medi-Cal. This plan includes Medicare coverage and Part D Prescription Coverage.

We take care of it all:

• L.A. Care Health Plan Health Navigators coordinate your Medi-Cal and Medicare benefits for you. You don’t have to worry about what is covered and what is not.
• 24-hour customer service. If you have concerns or questions, call one number and L.A. Care Health Plan can assist you.
• You can request to have a representative contact you to provide additional information.
• In-home appointments with an L.A. Care Health Plan representative are available to assist you with the enrollment process.

What Are the Plan Benefits for 2013?

• Monthly premium: $0
• Doctor visits, including specialists: $0
• Dental services: 
  $0 co-payment for preventive benefits:
  - No limit for oral exam(s) every year
  - Up to 2 cleanings every year
  - Up to 2 fluoride treatments every year
  - Up to 1 series of bitewing dental X-ray(s) 2 times a year
  - Up to 1 complete series of full mouth X-ray(s) every 3 years

  $0 co-payment for restorative benefits:
  - Fillings
  - Crowns
  - Root canals
  - Scaling and root planing (deep cleaning) 1 time every 2 years

  $0 co-payment for the following prosthodontics (dentures):
  - Complete and partial dentures (including routine post-delivery care) 1 time every 5 years
  - Denture adjustments and repairs

  $0 co-payment for the following oral surgery benefits:
  - Extractions

• Vision services: $0 copay for 1 routine eye exam every year, $200 eyewear allowance every year
• Worldwide emergency services coverage: $10,000 annual limit for emergencies outside the U.S.
• Routine transportation (non-emergency): $0 for 28 one-way trips per year
• Prescription drugs*:
• - Generic Drugs:  Typically $1.15 copay per prescription
  - Brand-Name Drugs: Typically $3.50 copay per prescription
  Prescription drug copays up to the Initial Coverage Limit ($4,750). When you (or those paying on your behalf) have  spent a total of $4,750 in out-of-costs within the calendar year, you will move from the Initial Coverage Stage to the Catastrophic Coverage Stage, the plan will pay for the most of the cost of your drugs for the rest of the year. You must use network pharmacies to access your prescription drug benefits, except under non-routine circumstances, and quantity limitations and restrictions may apply.

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

National Coverage Determination (NCDs)

 National Coverage Determinations (NCDs)information can be found here.

Availability of Medicare Subsidy Information

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
• Your State Medicaid Office

Contact Us

Current members: 1-888-522-1298 (TTY/TDD 1-866-522-2731) for questions related to L.A. Care Health Plan Medicare Advantage. L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

Prospective members: 1-888-522-1298, (TTY/TDD 1-866-522-2731) for questions related to L.A. Care Health Plan Medicare Advantage. L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

For questions related to the Medicare Part D Prescription Drug program, current and prospective members should call 1-888-522-1298, (TTY/TDD 1-866-522-2731).

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.medicare.gov.

Fax: 213-438-5712

Write or visit:

L.A. Care Health Plan
Member Services Department
1055 W 7th Street
Los Angeles, CA  90017

L.A. Care Health Plan Nurse Advice Line: 1-800-249-3619 (TTY/TDD 1-800-854-7784). The L.A. Care Health Plan Nurse Advice Line is available for members 24 hours a day, 7 days a week.

Medicare Complaint Form

You may submit feedback about your Medicare Advantage health plan directly to Medicare. By clicking on this link you will be leaving L.A. Care Health Plan website and will de directed to the CMS Model Electronic Complaint Form. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-(800)-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048, 24 hours a day/7 days a week. You may also visit the Medicare website at http://www.medicare.gov.

You may also visit the Office of the Medicare Ombudsman (OMO): The Medicare Beneficiary Ombudsman can help you with complaints, grievances, and requests for information. To be directed to the Office of the Medicare Ombudsman, please click on the following link: Office of the Medicare Ombudsman.

Disclaimer Information

L.A. Care Health Plan is a Coordinated Care Plan with a Medicare contract and a contract with the California Medicaid program. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medi-Cal or by another third party. Individuals must have both Part A and Part B to enroll. You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-plan providers, neither Medicare nor L.A. Care Health Plan will be responsible for costs. You must use network pharmacies to fill your prescriptions, except under non-routine circumstances when you cannot reasonably use network pharmacies. Limitations, copayments, and restrictions may apply.

L.A. Care Health Plan has been approved by the National Committee for Quality Assurance (NCQA), a non-profit organization dedicated to improving health care quality until December 31, 2014.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information about benefits, coverage conditions or limitations, please call our Member Services Department at 1-888-522-1298 (TTY/TDD 1-866-522-2731). L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays. Benefits, formulary, pharmacy network, premium and/or copayments may change on January 1, 2014.

This information is available for free in other languages. Please contact our customer service number at 1-888-522-1298 for additional information. TTY/TDD users should call 1-866-522-2731. We are available 24 hours a day, 7 days a week (including holidays).

Esta información está disponible de forma gratuita en otros idiomas. Por favor, comuníqiese con el departamento de servicios para los miembros al 1-888-522-1298 para obtener información adicional. Los usuarios de TTY deben llamar al 1-866-522-2731. Estamos disponibles las 24 horas del día, los 7 días a la semana, (incluso los días festivos). 

Plan member materials are available in a different language or format, including large print, audio, and Braille or upon request.

Los materiales para miembros del plan están disponibles en otros idiomas o formatos como letra grande, audio, y braille a su solicitud.

Potential for Contract Termination

Medicare (the Centers for Medicare & Medicaid Services) must approve L.A. Care Health Plan Medicare Advantage each year. You can continue to get Medicare coverage as a member of our Plan only as long as we choose to continue to offer the Plan for the year in question and the Centers for Medicare & Medicaid Services renews its approval of the Plan. Even if L.A. Care leaves the program, you will not lose Medicare Coverage. If L.A. Care decides not to continue for an additional calendar year, we must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.