D-SNP | Annual Notice of Change

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

ATTENTION: If you need help in your language, call 1-888-244-4430 (TTY users should call 1-855-266-4584 or 711). Aids and services for people with disabilities, like documents in braille and large print, are also available. Call 1-888-244-4430 (TTY: users should call 1-855-266-4584 or 711). These services are free of charge.

العربية (Arabic)
انتباه: إذا كنت بحاجة إلى مساعدة بلغتك، فاتصل على 1-888-244-4430 (TTY: 1-855-266-4584 or 711. كما تتوفر مساعدات وخدمات للأشخاص ذوي الإعاقة، مثل مستندات بطريقة برايل وبالخط الكبير. اتصل على 1-888-244-4430 (TTY: 1-855-266-4584 or 711). هذه الخدمات مجانية.

繁體中文 (Traditional Chinese)
請注意：如果您需要以您的語言提供幫助，請致電 1-888-244-4430 (TTY: 1-855-266-4584 or 711)。我們也提供給殘障人士的協助和服務，例如點字和大字體文件。請致電 1-888-244-4430 (TTY 1-855-266-4584 or 711)。這些服務免費提供。

Español (Spanish)
ATENCIÓN: Si necesita ayuda en su idioma, llame al 1-888-244-4430 (TTY: 1-855-266-4584 or 711). También hay ayudas y servicios para personas con discapacidades, como documentos en braille y en letra grande. Llame al 1-888-244-4430 (TTY: 1-855-266-4584 or 711Estos servicios son gratuitos.

فارسی (Farsi)
توجه: اگر به کمک به زبان خود نیاز دارید، با 1-888-244-4430 (TTY: 711) تماس بگیرید. کمک‌ها و خدماتی برای افراد دارای معلولیت، مانند اسناد بریل و چاپ درشت نیز در دسترس است. با 1-888-244-4430 (TTY: 711) تماس بگیرید. این خدمات رایگان هستند.

한국어 (Korean)
주의: 귀하의 언어로 도움이 필요하신 경우 1-888-244-4430 (TTY: 1-855-266-4584 or 711)번으로 전화하십시오. 점자 및 큰 활자 문서와 같은 장애인을 위한 지원 및 서비스도 제공됩니다. 1-888-244-4430 (TTY: 1-855-266-4584 or 711)번으로 전화하십시오. 이 서비스는 무료입니다.

Русский (Russian)
ВНИМАНИЕ! Если вам нужна помощь на вашем языке, звоните по номеру 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Также предоставляются вспомогательные средства и услуги для людей с ограниченными возможностями, например, документы шрифтом Брайля и крупным шрифтом. Звоните по номеру 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Эти услуги предоставляются бесплатно.

Tiếng Việt (Vietnamese)
CHÚ Ý: Nếu quý vị cần trợ giúp bằng ngôn ngữ của mình, vui lòng gọi số 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Chúng tôi cũng hỗ trợ và cung cấp các dịch vụ cho người khuyết tật, như tài liệu chữ nổi Braille và bản in chữ lớn. Vui lòng gọi số 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Các dịch vụ này đều miễn phí.

Tagalog (Filipino)
PAUNAWA: Kung kailangan mo ng tulong sa iyong wika, tumawag sa 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Mayroon ding mga tulong at serbisyo para sa mga taong may kapansanan, tulad ng mga dokumentong nakasulat sa braille at malalaking titik. Tumawag sa 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Libre ang mga serbisyong ito.

Հայերեն (Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ: Եթե Ձեզ օգնություն է հարկավոր Ձեր լեզվով, զանգահարեք 1-888-244-4430 (TTY: 1-855-266-4584 or 711): Կան նաև օժանդակ միջոցներ ու ծառայություններ հաշմանդամություն ունեցող անձանց համար, օրինակ՝ Բրայլի գրատիպով ու խոշորատառ տպագրված նյութեր։ Զանգահարեք 1-888-244-4430 (TTY: 1-855-266-4584 or 711): Այդ ծառայություններն անվճար են։

ខ្មែរ (Cambodian)
ចំណាំ៖ បើអ្នកត្រូវការជំនួយជាភាសារបស់អ្នក សូមទូរស័ព្ទទៅ 1-888-244-4430 (TTY: 1-855-266-4584 or 711)។ មានជំនួយ និងសេវាសម្រាប់ជនពិការផងដែរ ដូចជាឯកសារជាអក្សរប្រាយ និងអក្សរធំៗ។ សូមទូរស័ព្ទទៅ 1-888-244-4430 (TTY: 1-855-266-4584 or 711)។ សេវាទាំងនេះមានឱ្យដោយឥតគិតថ្លៃ។

हिन्दी (Hindi)
ध्यान दें: अगर आपको अपनी भाषा में सहायता की आवश्यकता है तो 1-888-244-4430 (TTY: 711) पर कॉल करें। अशक्तता वाले लोगों के लिए ब्रेल और बड़े अक्षरों में दस्तावेज़ जैसी सेवाएं भी उपलब्ध हैं। कृपया 1-888-244-4430 (TTY: 711) पर कॉल करें। ये सेवाएं नि:शुल्क हैं।

Hmoob (Hmong)
CEEB TOOM: Yog koj xav tau kev pab txhais koj hom lus, hu rau 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Muaj cov kev pab thiab kev pab cuam rau cov neeg xiam oob khab, xws li ntawv luam ua ntawv loj thiab ntawv Braille. Hu rau 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Cov kev pab cuam no yog dawb.

日本語 (Japanese)
注意: 日本語での支援が必要な場合は、1-888-244-4430 (TTY: 1-855-266-4584 or 711) にお電話ください。 点字や大きな文字で書かれた書類など、障害をお持ちの方のための支援やサービスも提供しています。 1-888-244-4430 (TTY: 1-855-266-4584 or 711) にお電話ください。これらのサービスは無料です。

ພາສາລາວ (Laotian)
ປະກາດ: ຖ້າທ່ານຕ້ອງການຄວາມຊ່ວຍເຫຼືອໃນພາສາຂອງທ່ານ, ໃຫ້ໂທຫາ 1-888-244-4430 (TTY: 1-855-266-4584 or 711). ຍັງມີການຊ່ວຍເຫຼືອແລະການບໍລິການສໍາລັບຜູ້ພິການ, ເຊັ່ນເອກະສານທີ່ພິມໂດຍອັກສອນບາຣ໌ລ ແລະພິມໂຕໃຫຍ່. ໂທ 1-888-244-4430 (TTY: 1-855-266-4584 or 711). ການບໍລິການເຫຼົ່ານີ້ໃຫ້ຟຣີ.

Mien
LONGC HNYOUV JANGX LONGX OC: Beiv taux meih qiemx longc mienh tengx faan benx meih nyei waac nor douc waac daaih lorx taux 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Liouh lorx jauv-louc tengx aengx caux nzie gong bun taux ninh mbuo wuaaic fangx mienh, beiv taux longc benx nzangc-pokc bun hluo mbiutc aengx caux aamz mborqv benx domh sou se mbenc nzoih bun longc. Douc waac daaih lorx 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Naaiv deix nzie weih gong-bou jauv-louc se benx wang-henh tengx mv zuqc cuotv nyaanh oc.

ਪੰਜਾਬੀ (Punjabi)
ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਹਾਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਵਿੱਚ ਮਦਦ ਦੀ ਲੋੜ ਹੈ, ਤਾਂ 1-888-244-4430 (TTY: 1-855-266-4584 or 711) 'ਤੇ ਕਾਲ ਕਰੋ। ਅਸੀਂ ਉਪਲਬਧ ਕਰਵਾਉਂਦੇ ਹਾਂ ਸਹਾਇਤਾ ਅਤੇ ਸੇਵਾਵਾਂ ਜੋ ਕਿ ਅਪਾਹਜ ਵਿਅਕਤੀਆਂ ਲਈ ਹਨ, ਜਿਵੇਂ ਕਿ ਬ੍ਰੇਲ ਅਤੇ ਵੱਡੇ ਅੱਖਰਾਂ ਵਾਲੇ ਦਸਤਾਵੇਜ਼। ਕਿਰਪਾ ਕਰਕੇ 1-888-244-4430 (TTY: 1-855-266-4584 or 711) 'ਤੇ ਕਾਲ ਕਰੋ। ਇਹ ਸੇਵਾਵਾਂ ਮੁਫ਼ਤ ਹਨ।

ภาษาไทย (Thai)
โปรดทราบ: หากคุณต้องการความช่วยเหลือเป็นภาษาของคุณ กรุณาโทร 1-888-244-4430 (TTY: 1-855-266-4584 or 711). มีบริการช่วยเหลือและบริการสำหรับผู้พิการ เช่น เอกสารอักษรเบรลล์และตัวพิมพ์ขนาดใหญ่ กรุณาโทร 1-888-244-4430 (TTY: 1-855-266-4584 or 711). บริการเหล่านี้ฟรี

Українська (Ukrainian)
УВАГА! Якщо вам потрібна допомога вашою мовою, зателефонуйте за номером 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Також надаються допоміжні засоби та послуги для людей з інвалідністю, наприклад документи шрифтом Брайля або великим шрифтом. Зателефонуйте за номером 1-888-244-4430 (TTY: 1-855-266-4584 or 711). Ці послуги є безкоштовними.

CommuniCare Advantage (HMO D-SNP) is an HMO D-SNP health plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in CommuniCare Advantage depends on contract renewal.

It’s important to review your coverage now to make sure it will still meet your needs next year. If it doesn’t meet your needs, you may be able to leave our plan. Refer to Section D for more information on changes to your benefits for next year.

If you choose to leave our plan, your membership will end on the last day of the month in which your request was made. You’ll still be in the Medicare and Medi-Cal programs as long as you’re eligible.

If you leave our plan, you can get information about your:

• Medicare options in the table in Section E2.

• Medi-Cal options and services in Section E2.

• CommuniCare Advantage is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to members.

• When this Annual Notice of Change says “we,” “us,” “our,” or “our plan,” it means the Medicare Medi-Cal Plan.

• Check if there are any changes to our benefits and costs that may affect you.

  • Are there any changes that affect the services you use?

  • Review benefit and cost changes to make sure they’ll work for you next year.

  • Refer to Section D1 for information about benefit and cost changes for our plan.

  • Check if there are any changes to our drug coverage that may affect you.

  • Will your drugs be covered? Are they in a different cost-sharing tier? Can you use the same pharmacies? Will there be any changes such as prior authorization, step therapy, or quantity limits?

  • Review changes to make sure our drug coverage will wor for you next year.

  • Refer to Section D2 for information about changes to our drug coverage.

  • Your drug costs may have risen since last year.

  • Talk to your doctor about lower cost alternatives that may be available for you; this may save you in annual out-of-pocket costs throughout the year.

  • Keep in mind that your plan benefits determine exactly how much your own drug costs may change.

• Check if your providers and pharmacies will be in our network next year.

  • Are your doctors, including your specialists, in our network? What about your pharmacy? What about the hospitals or other providers you use?

  • Refer to Section C for information about our Provider and Pharmacy Directory.

• Think about your overall costs in the plan.

  • How much will you spend out-of-pocket for the services and drugs you use regularly?

  • How do the total costs compare to other coverage options?

• Think about whether you’re happy with our plan.

Amounts you pay for your drugs depends on which pharmacy you use. Our plan has a network of pharmacies. In most cases, your prescriptions are covered only if they’re filled at one of our network pharmacies. Our network includes pharmacies with preferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharing offered by other network pharmacies for some drugs.

Our provider and pharmacy network has changed for 2027.

Please review the 2027 Provider and Pharmacy Directory to find out if your providers (primary care provider, specialists, hospitals, etc.) or pharmacy are in our network. An updated Provider and Pharmacy Directory is located on our website at www.chgsd.com. You may also call Member Services at the numbers at the bottom of the page for updated provider information or to ask us to mail you a Provider and Pharmacy Directory.

It’s important that you know that we may also make changes to our network during the year. If your provider leaves our plan, you have certain rights and protections. For more information, refer to Chapter 3 of your Member Handbook or call Member Services at the number at the bottom of the page for help.

We’re changing our coverage for certain medical services and what you pay for these covered medical services next year. The table below describes these changes.

Changes to our Drug List

Our List of Covered Drugs is also called the Formulary or Drug List. A copy of our Drug List is posted online at www.chgsd.com.

We made changes to our Drug List, which could include removing or adding drugs, changing drugs we cover, and changes to the restrictions that apply to our coverage for certain drugs or moving them to a different cost-sharing tier.

Review the Drug List to make sure your drugs will be covered next year and to find out if there are any restrictions or if your drug has been moved to a different cost-sharing tier.

Most of the changes in the Drug List are new for the beginning of each year. However, we might make other changes that are allowed by Medicare and/or the state that will affect you during the calendar year. We update our online Drug List at least monthly to provide the most up to date list of drugs. If we make a change that will affect a drug you’re taking, we’ll send you a notice about the change.

If you’re affected by a change in drug coverage, we encourage you to:

• Work with your doctor (or other prescriber) to find a different drug that we cover.

  • You can call Member Services at the numbers at the bottom of the page or contact your case manager to ask for a List of Covered Drugs that treat the same condition.

  • This list can help your provider find a covered drug that might work for you.

• Ask us to cover a temporary supply of the drug.

  • In some situations, we cover a temporary supply of the drug during the first 90 days of the calendar year.

  • This temporary supply is for up to 31 days. (To learn more about when you can get a temporary supply and how to ask for one, refer to Chapter 5 of your Member Handbook.)

  • When you get a temporary supply of a drug, talk with your doctor about what to do when your temporary supply runs out. You can either switch to a different drug our plan covers or ask us to make an exception for you and cover your current drug.

For example, if you take a brand name drug or biological product that’s being replaced by a generic or biosimilar version, you may not get notice of the change 30 days in advance, or before you get a month’s supply of the brand name drug or biological product. You might get information on the specific change after the change is already made.

Some of these drug types may be new to you. For definitions of drug types, please go to Chapter 12 of your Member Handbook. The Food and Drug Administration (FDA) also provides consumer information on drugs. Go to the FDA website: www.fda.gov/drugs/biosimilars/multimedia-education-materials-biosimilars#For%20Patients. You can also call Member Services at the number at the bottom of the page or ask your health care provider, prescriber, or pharmacist for more information.

Changes to drug costs

There are two payment stages for your Medicare Part D drug coverage under our plan. How much you pay depends on your level of Extra Help and which stage you’re in when you get a prescription filled or refilled. These are the two stages:

The Initial Coverage Stage ends when your total out-of-pocket costs for drugs reaches $2,400. At that point, the Catastrophic Coverage Stage begins. Our plan covers all of your drug costs from then until the end of the year. Refer to Chapter 6 of your Member Handbook for more information on how much you’ll pay for drugs.

Under the Manufacturer Discount Program, drug manufacturers pay a portion of our plan’s full cost for covered Part D brand name drugs and biologics during the Initial Coverage Stage and the Catastrophic Coverage Stage. Discounts paid by manufacturers under the Manufacturer Discount program don’t count toward out-of-pocket costs.

During the Initial Coverage Stage, our plan pays a share of the cost of your covered drugs, and you pay your share. Your share is called the copay. The copay depends on what cost-sharing tier the drug is in and where you get it. You pay a copay each time you fill a prescription. If your covered drug costs less than the copay, you pay the lower price.

We moved some of the drugs on our Drug List to a lower or higher drug tier. If your drugs move from tier to tier, this could affect your copay. To find out if your drugs are in a different tier, look them up in our Drug List.

The following table shows your costs for a one-month supply filled at a network pharmacy with standard copays in each of our six drug tiers. These amounts apply only during the time when you’re in the Initial Coverage Stage.

Most adult Part D vaccines are covered at no cost to you. For information about the costs for a long-term supply; or at a network pharmacy that offers preferred cost-sharing; or for mail-order prescriptions go to Chapter 6, Section D of your Member Handbook.

The Initial Coverage Stage ends when your total out-of-pocket costs reach $2,400. At that point the Catastrophic Coverage Stage begins. The plan covers all of your drug costs from then until the end of the year. Refer to Chapter 6 of your Member Handbook for more information about how much you pay for drugs.

When you reach the out-of-pocket limit $2,400 for your drugs, the Catastrophic Coverage Stage begins and you pay nothing for your covered drugs. You stay in the Catastrophic Coverage Stage until the end of the calendar year.

For more information about your costs in the Catastrophic Coverage stage, refer to Chapter 6.

We hope to keep you as a plan member. You don’t have to do anything to stay in our plan. Unless you sign up for a different Medicare plan or change to Original Medicare, you’ll automatically stay enrolled as a member of our plan for 2027.

Most people with Medicare can end their membership during certain times of the year.

In addition, you may end your membership in our plan during the following periods:

• The Open Enrollment Period, which lasts from October 15 to December 7. If you choose a new plan during this period, your membership in our plan ends on December 31 and your membership in the new plan starts on January 1.

• The Medicare Advantage (MA) Open Enrollment Period, which lasts from January 1 to March 31. If you choose a new plan during this period, your membership in the new plan starts the first day of the next month.

• Because you have Medi-Cal, you have some choices to end your membership in our plan including any month of the year.

There may be other situations when you’re eligible to make a change to your enrollment. For example, when:

• you moved out of our service area,

• your eligibility for Medi-Cal or Extra Help changed, or

• you recently moved into or currently receiving care in an institution (like a skilled nursing facility or a long-term care hospital). If you recently moved out of an institution, you can change plans or change to Original Medicare for two full months after the month you move out.

Your Medicare services

You have three options for getting your Medicare services listed below any month of the year. You have an additional option listed below during certain times of the year including the Open Enrollment Period and the Medicare Advantage Open Enrollment Period or other situations described in Section E2. By choosing one of these options, you automatically end your membership in our plan.

Your Medi-Cal services

For questions about how to choose a Medi-Cal plan or get your Medi-Cal services after you leave our plan, contact Health Care Options at 1-800-430-4263, Monday – Friday from 8 a.m. to 6 p.m. TTY users should call 1-800-430-7077. Ask how joining another plan or returning to Original Medicare affects how you get your Medi-Cal coverage.

We’re here to help if you have any questions. Call Member Services at the numbers at the bottom of the page during the days and hours of operation listed. These calls are toll-free.

Read your Member Handbook

Your Member Handbook is a legal, detailed description of our plan’s benefits. It has details about benefits and costs for 2027. It explains your rights and the rules to follow to get services and drugs we cover.

The Member Handbook for 2027 will be available by October 15. You can also review the separately mailed Member Handbook to find out if other benefit or cost changes affect you. An up-to-date copy of the Member Handbook is available on our website at www.chgsd.com. You may also call Member Services at the numbers at the bottom of the page to ask us to mail you a Member Handbook for 2027

Our website

You can visit our website at www.chgsd.com. As a reminder, our website has the most up-to-date information about our provider and pharmacy network (Provider and Pharmacy Directory) and our Drug List (List of Covered Drugs).

You can also call the State Health Insurance Assistance Program (SHIP). In California, the SHIP is called the Health Insurance Counseling and Advocacy Program (HICAP). HICAP counselors can help you understand your plan choices and answer questions about switching plans. HICAP isn’t connected with us or with any insurance company or health plan. HICAP has trained counselors in every county, and services are free. HICAP’s phone number is 1-800-434-0222. For more information or to find a local HICAP office in your area, please visit www.aging.ca.gov/Programs_and_Services/Medicare_Counseling/.

The Medicare Medi-Cal Ombudsman Program can help you if you have a problem with our plan. The ombudsman’s services are free and available in all languages. The Medicare Medi-Cal Ombudsman Program:

• can answer questions if you have a problem or complaint and can help you understand what to do.

• makes sure you have information related to your rights and protections and how you can get your concerns resolved.

• isn’t connected with us or with any insurance company or health plan. The phone number for the Medicare Medi-Cal Ombudsman Program is 1-855-501-3077.

To get information directly from Medicare;

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

• chat live at www.Medicare.gov/talk-to-someone

• write to Medicare at PO Box 1270, Lawrence, KS 66044.

Medicare’s Website

You can visit the Medicare website (www.medicare.gov). If you choose to disenroll from our plan and enroll in another Medicare plan, the Medicare website has information about costs, coverage, and quality ratings to help you compare plans.

You can find information about Medicare plans available in your area by using Medicare Plan Finder on Medicare’s website. (For information about plans, refer to www.medicare.gov and click on “Find plans.”)

Medicare & You 2027

You can read the Medicare & You 2027 handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. This handbook is also available in Spanish, Chinese, and Vietnamese.

If you don’t have a copy of this booklet, you can get it at the Medicare website (www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf) or by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1‑877‑486‑2048.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-244-4430 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's internet website www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

Refer to Chapter 9, Section F4 of your Member Handbook for more information.

The Medicare Prescription Payment Plan is a payment option that may help you manage your out-of-pocket costs for drugs covered by our plan by spreading them across the calendar year (January-December) as monthly payments. Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage plan with drug coverage) can use this payment option. If you’re participating in the Medicare Prescription Payment Plan and stay in the same Part D plan, you don’t need to do anything to continue participating in 2027.This payment option might help you manage your expenses, but it doesn’t save you money or lower your total out-of-pocket drug costs.

“Extra Help” from Medicare and help from your state’s pharmaceutical assistance program (SPAP) and the AIDS Drug Assistance Program (ADAP), for those who qualify, is more advantageous than participation in the Medicare Prescription Payment Plan. To learn more about this program, please contact us at the phone number at the bottom of this page or visit www.medicare.gov.

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