This document is a brief summary of the benefits and services covered by CommuniCare Advantage. It includes answers to frequently asked questions, important contact information, an overview of benefits and services offered, and information about your rights as a member of CommuniCare Advantage. Key terms and their definitions appear in alphabetical order in the last chapter of the Member Handbook.
Summary of Benefits for 2027
CommuniCare Advantage (HMO D-SNP)
2027 · San Diego
Introduction
A. Disclaimers
This is a summary of health services covered by CommuniCare Advantage for 2027. This is only a summary. Please read the Member Handbook for the full list of benefits. To get a Member Handbook, call Member Services at 1-888-244-4430, TTY users should call 1-855-266-4584, we are available 24 hours a day, 7 days a week. The call is free. You may also obtain a copy of the Member Handbook which is located on our website at www.chgsd.com.
You can get this document for free in other formats, such as large print, braille, or audio. Call Member Services Department at 1-888-244-4430, TTY users should call 1-855-266-4584. We are open to assist you 24 hours a day, 7 days a week. The call is free.
This document is available for free in English, Spanish, Vietnamese, Tagalog, Arabic, Simplified Chinese, Farsi, and Russian.
For more information about Medicare, you can read the Medicare & You handbook. It has a summary of Medicare benefits, rights, and protections and answers to the most frequently asked questions about Medicare. You can get it at the Medicare website (www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days a week. TTY users should call 1-877-486-2048. For more information about Medi-Cal, you can check the California Department of Healthcare Services (DHCS) website (www.dhcs.ca.gov/) or contact the Medi-Cal Office of the Ombudsman at 1-888-452-8609, Monday through Friday, between 8 a.m. and 5 p.m. You can also call the Medicare and Medi-Cal Ombudsperson Program (MMOP), at 1-855-501-3077, Monday through Friday, between 9 a.m. and 5 p.m.
You can make a standing request to get any documents in a language other than English or in an alternate format, such as Braille, CD, audio, or large print; this information will be kept in your file for future mailings and communications so that you do not need to make separate request each time. To make a standing request or if you decide to update your preferred language and/or format please call the Member Services Department at 1-888-244-4430, TTY users should call 1-855-266-4584. We are open to assist you 24 hours a day, 7 days a week. The call is free.
We have free interpreter services to answer any questions that you may have about our health or drug plan. To get an interpreter just call us at 1-888-244-4430. Someone that speaks your language can help you. This is a free service.
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.
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). 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). 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.
B. Frequently asked questions (FAQ)
The following table lists frequently asked questions.
| Frequently Asked Questions | Answers |
|---|---|
| What’s a Medi-Medi Plan? | A Medi-Medi Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. It’s for people age 21 and older. A Medi-Medi Plan is an organization made up of doctors, hospitals, pharmacies, providers of Long-term Services and Supports (LTSS), and other providers. It also has case managers to help you manage all your providers and services and supports. They all work together to provide the care you need. |
| Will I get the same Medicare and Medi-Cal benefits in CommuniCare Advantage that I get now? | You’ll get most of your covered Medicare and Medi-Cal benefits directly from CommuniCare Advantage. You’ll 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 based on your needs, and your doctor and care team’s assessment. You may also get other benefits outside of your health plan the same way you do now, directly from a State or county agency like In-Home Supportive Services (IHSS), specialty mental health and substance use disorder services, or regional center services. When you enroll in CommuniCare Advantage, you and your care team will work together to develop an Individualized Plan of Care to address your health and support needs, reflecting your personal preferences and goals. If you’re taking any Medicare Part D drugs that CommuniCare Advantage doesn’t normally cover, you can get a temporary supply and we’ll help you to transition to another drug or get an exception for CommuniCare Advantage to cover your drug if medically necessary. For more information, call Member Services at the numbers listed at the bottom of this page. |
| Can I use the same doctors I use now? | Often that’s the case. If your providers (including doctors, hospitals, therapists, pharmacies, and other health care providers) work with CommuniCare Advantage and have a contract with us, you can keep going to them.
To find out if your doctors are in the plan’s network, call Member Services at 1-888-244-4430, TTY users should call 1-855-266-4584 or read CommuniCare Advantage’s Provider and Pharmacy Directory on the plan’s website at www.chgsd.com. If CommuniCare Advantage is new for you, we’ll work with you to develop an Individualized Plan of Care to address your needs. |
| What’s a CommuniCare Advantage case manager? | A CommuniCare Advantage case manager is one main person for you to contact. This person helps to manage all your providers and services and make sure you get what you need. |
| What are Long-term Services and Supports (LTSS)? | Long-term Services and Supports (LTSS) are help for people who need assistance to do everyday tasks like bathing, toileting, 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. In some cases, a county or other agency may administer these services, and your case manager or care team will work with that agency. |
| What’s a Multipurpose Senior Services Program (MSSP)? | A MSSP provides on-going care coordination with health care providers beyond what your health plan already provides and can connect you to other needed community services and resources. This program helps you get services that help you live independently in your home. |
| What happens if I need a service but no one in CommuniCare Advantage’s network can provide it? | Most services will be provided by our network providers. If you need a service that can’t be provided within our network, CommuniCare Advantage will pay for the cost of an out-of-network provider. |
| Where’s CommuniCare Advantage available? | The service area for this plan includes: San Diego, California. You must live in this area to join the plan. |
| What’s prior authorization? | Prior authorization means an approval from CommuniCare Advantage to seek services outside of our network or to get services not routinely covered by our network before you get the services. CommuniCare Advantage may not cover the service, procedure, item, or drug if you don’t get prior authorization. If you need urgent or emergency care or out-of-area dialysis services, you don't need to get prior authorization first. CommuniCare Advantage can provide you or your provider with a list of services or procedures that require you to get prior authorization from CommuniCare Advantage before the service is provided. If you have questions about whether prior authorization is required for specific services, procedures, items, or drugs, call Member Services at the numbers listed at the bottom of this page for help. |
| What’s a referral? | A referral means that your primary care provider (PCP) must give you approval to go to someone that’s not your PCP. A referral is different than a prior authorization. If you don’t get a referral from your PCP, CommuniCare Advantage may not cover the services. CommuniCare Advantage can provide you with a list of services that require you to get a referral from your PCP before the service is provided. Refer to the Member Handbook to learn more about when you’ll need to get a referral from your PCP. |
| Do I pay a monthly amount (also called a premium) under CommuniCare Advantage? | No. Because you have Medi-Cal, you won’t pay any monthly premiums, including your Medicare Part B premium, for your health coverage. |
| Do I pay a deductible as a member of CommuniCare Advantage? | No. You don’t pay deductibles in CommuniCare Advantage. |
| What’s the maximum out-of-pocket amount that I’ll pay for medical services as a member of CommuniCare Advantage? | There’s no cost-sharing for medical services in CommuniCare Advantage, so your annual out-of-pocket costs will be $0. |
C. List of covered services
The following table is a quick overview of what services you may need, your costs, and rules about the benefits.
| Health need or concern | Services you may need | Your costs for in-network providers | Limitations, exceptions, & benefit information (rules about benefits) |
|---|---|---|---|
| You need hospital care | Hospital stay | $0 | Authorization rules may apply |
| Doctor or surgeon care | $0 | Authorization rules may apply | |
| Outpatient hospital services, including observation | $0 | Authorization rules may apply | |
| Ambulatory surgical center (ASC) services | $0 | Authorization rules may apply | |
| You want a doctor | Visits to treat an injury or illness | $0 | Authorization rules may apply |
| Specialist care | $0 | Authorization rules may apply | |
| Wellness visits, such as a physical | $0 | Authorization rules may apply | |
| Care to keep you from getting sick, such as flu shots and screenings to check for cancer | $0 | Authorization rules may apply | |
| “Welcome to Medicare” (preventive visit one time only) | $0 | Authorization rules may apply | |
| You need emergency care | Emergency room services | $0 | You may get emergency room services Out of Network and without prior authorizations. |
| Urgent care | $0 | You may get emergency room services Out of Network and without prior authorizations. | |
| You need medical tests | Diagnostic radiology services (for example, X-rays or other imaging services, such as CAT scans or MRIs) | $0 | Authorization rules may apply |
| Lab tests and diagnostic procedures, such as blood work | $0 | Authorization rules may apply | |
| You need hearing/auditory services | Hearing screenings | $0 | Authorization rules may apply |
| Hearing aids | $0 | Authorization rules may apply | |
You need dental care (continued on next page) You need dental care (continued from previous page) | Dental check-ups and preventive care | $0 | Medi-Cal covers dental check-ups and preventive care. Services that are covered under the Medi-Cal Dental Program are not chargeable to you. However, you are responsible for your share of the cost amount, if applicable. You are responsible for paying for services not covered by your plan or by the Medi-Cal Dental Program. Authorization rules may apply. For more information regarding the Medi-Cal Dental Program visit https://dental.dhcs.ca.gov |
| Restorative and emergency dental care | $0 | Medi-Cal covers dental check-ups and preventive care. Services that are covered under the Medi-Cal Dental Program are not chargeable to you. However, you are responsible for your share of the cost amount, if applicable. You are responsible for paying for services not covered by your plan or by the Medi-Cal Dental Program. Authorization rules may apply. For more information regarding the Medi-Cal Dental Program visit https://dental.dhcs.ca.gov/ $2,500 maximum per calendar year can be used for Partial or Full Dentures and/or Dental Implants. | |
| Preventive Dental - Supplemental Benefit | $0 | Medi-Cal covers dental check-ups and preventive care. | |
| You need eye care | Eye exams | $0 | Authorization rules may apply |
| Glasses or contact lenses | $0 | Authorization rules may apply | |
| Other vision care | $0 | Authorization rules may apply | |
You need mental health services (continued on next page) You need mental health services (continued from previouspage) | Mental health services | $0 | Your plan covers and is not limited to:
You are also eligible to receive services through the County Specialty Mental Health Plan by calling 1-888-724-7240. |
| Inpatient and outpatient care and community-based services for people who need mental health services | $0 | Your plan covers and is not limited to:
You are also eligible to receive services through the County Specialty Mental Health Plan by calling 1-888-724-7240. | |
| You need substance use disorder services | Substance use disorder services | $0 | Your plan covers but is not limited to alcohol and drug screening, assessment, brief interventions, and referral to treatment (SABIRT), Medication Assisted Treatment (MAT) in a Medical Facility and, Opiate Treatment. Medicare Medi-Cal recipients are also eligible to receive services from the County Drug Organized Medi-Cal Delivery system (DMCS-ODS) for Substance Use Disorder services for more information please call 1-888-724-7240. |
| You need a place to live with people available to help you | Skilled nursing care | $0 | Authorization rules may apply |
| Nursing home care | $0 | Authorization rules may apply | |
| Adult Foster Care and Group Adult Foster Care | $0 | Authorization rules may apply | |
| You need therapy after a stroke or accident | Occupational, physical, or speech therapy | $0 | Authorization rules may apply |
| You need help getting to health services | Ambulance services | $0 | Authorization rules may apply |
| Emergency transportation | $0 | Authorization is not required for emergency transportation. | |
| Transportation to medical appointments and services | $0 | Authorization rules may apply. Transportation may include bus and trolley passes, mileage reimbursements, and/or door-to-door transportation. | |
| You need drugs to treat your illness or condition | Medicare Part B drugs | $0 | Part B drugs include drugs given by your doctor in their 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 drugs to treat your illness or condition (continued on the next page) | Medicare Part D drugs Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Tier Tier 6: Select Care Drugs | Tier 1: $0-$5.80 for a 31-supply Tier 2: $0-$5.80 for a 31-supply Tier 3: $0-$14.40 for a 31-supply Tier 4: $0-$14.40 for a 31-supply Tier 5: $0-$14.40 for a 31-supply Tier 6: $0-$5.80 for a 31-supply Copays for drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. | There may be limitations on the types of drugs covered. Please refer to CommuniCare Advantage’s List of Covered Drugs (Drug List) for more information. Once you or others on your behalf pay $2,400 you’ve reached the catastrophic coverage stage and you pay $0 for all your Medicare drugs. Read the Member Handbook for more information on this stage. For some drugs, you can get a long-term supply (also called an “extended supply”) when you fill your prescription. If your medication is in Tier 1, 2, 3, or 4, you can get up to a 93-day supply. If your medication is in Tier 6, you can get up to a 100-day supply. Tier 5 medications do not qualify for a long-term supply. These medications can only be filled at a retail pharmacy for up to a 31-day supply. You will pay the same copay for a long-term supply as you would for a one-month supply. Tier 1, 2, 3, 4, and 6 medications are available at participating retail pharmacies or through mail order. |
| You need drugs to treat your illness or condition (continued from previous page) | Over-the-counter (OTC) drugs | $0 | There may be limitations on the types of drugs covered. Please refer to CommuniCare Advantage’s List of Covered Drugs (Drug List) for more information. Non-prescription over-the-counter drugs are limited to $130 per quarter, not to exceed $520.00 per benefit year, including tax. Any unused balance does not carry over to the next quarter. |
| You need help getting better or have special health needs | Rehabilitation services | $0 | Authorization rules may apply |
| Medical equipment for home care | $0 | Authorization rules may apply | |
| Dialysis services | $0 | Authorization rules may apply | |
| You need foot care | Podiatry services | $0 | Authorization rules may apply |
| Orthotic services | $0 | Authorization rules may apply | |
You need durable medical equipment (DME) Note: This isn’t a complete list of covered DME. For a complete list, contact Member Services or refer to Chapter 4 of the Member Handbook. | Wheelchairs, crutches, and walkers | $0 | Authorization rules may apply |
| Nebulizers | $0 | Authorization rules may apply | |
| Oxygen equipment and supplies | $0 | Authorization rules may apply | |
| You need help living at home (continued on the next page) | Home health services | $0 | Authorization rules may apply |
| Home services, such as cleaning or housekeeping, or home modifications such as grab bars | $0 | $800 maximum benefit per calendar year for home modifications for grab bars. For information about In Home Supportive Services (IHSS) call 1-800-510-2020. Authorization rules may apply. | |
| Adult day health, Community Based Adult Services (CBAS), or other support services | $0 | Authorization rules may apply. Please visit your PCP for a referral. | |
| Day habilitation services | $0 | Authorization rules may apply | |
| You need help living at home (continued) | Services to help you live on your own (home health care services or personal care attendant services) | $0 | For information about In-Home Supportive Services (IHSS) call 1-800-510-2020. For information about Home Health Services call us at 1-888-244-4430.Authorization rules may apply. |
| Additional services | Chiropractic services | $0 | Authorization rules may apply |
| Fitness Membership | $0 | Get a free basic membership at participating 24 Hour Fitness locations | |
| Diabetes supplies and services | $0 | Authorization rules may apply | |
| Prosthetic services | $0 | Authorization rules may apply | |
| Radiation therapy | $0 | Authorization rules may apply | |
| Services to help manage your disease | $0 | Authorization rules may apply | |
| California Integrated Care Management (CICM) | $0 | Upon enrollment into the Plan, you will automatically be enrolled in the California Integrated Care Management program and assigned a CHG Case Manager. |
The above summary of benefits is provided for informational purposes only and isn’t a complete list of benefits. For a complete list and more information about your benefits, you can read the CommuniCare Advantage Member Handbook. If you don’t have a Member Handbook, call CommuniCare Advantage Member Services at the numbers listed at the bottom of this page to get one. If you have questions, you can also call Member Services or visit www.chgsd.com.
D. Benefits covered outside of CommuniCare Advantage
There are some services that you can get that aren’t covered by CommuniCare Advantage but are covered by Medicare, Medi-Cal, or a State or county agency. This isn’t a complete list. Call Member Services at the numbers listed at the bottom of this page to find out about these services.
| Other services covered by Medicare, Medi-Cal, or a State Agency | Your costs |
|---|---|
| For In-Home Supportive Services (IHSS), contact at 1-800-339-4661 or visit the website at www.sandiegocounty.gov/content/sdc/hhsa/programs/ais/Services/InHomeSupportive-Services. | Cost will be determined by the agency providing the services |
For Specialty Mental Health services, contact the County Specialty Mental Health Plan at 1-888-724-7240 or visit the website at www.sandiegocounty.gov/hhsa/programs/bhs. For Substance Use Disorder services, contact the County Drug Organized Medi-Cal Delivery system (DMCS-ODS) at 1-888-724-7240 or visit the website at www.sandiegocounty.gov/hhsa/programs/bhs. | Cost will be determined by the agency providing the services |
| For waiver programs, contact the Assisted Living Waiver (ALW) program or the Multipurpose Senior Services Program (MSSP) at 1-866-351-7722 or visit the website at www.sandiegocounty.gov/content/sdc/hhsa/programs/aisl | Cost will be determined by the agency providing the services |
The San Diego Regional Center provides assessments to establish eligibility for services and develops Individual Program Plans (IPP) or Individual Family Service Plans (IFSP) for eligible individuals. Service coordinators secure necessary services through community agencies, referrals, or purchases. Available services include day programs, behavioral training, respite, and more. For San Diego Regional Center Services please call 1-858-576-2996 or visit the website at www.sdrc.org. | Cost will be determined by the agency providing the services |
Certain dental services
| $0 |
| Certain hospice care services covered outside of CommuniCare Advantage | $0 |
| Psychosocial rehabilitation | Cost will be determined by the agency providing the services |
| Targeted case management | Cost will be determined by the agency providing the services |
| Rest home room and board | Cost will be determined by the agency providing the services |
E. Services that CommuniCare Advantage, Medicare, and Medi-Cal don’t cover
This isn’t a complete list. Call Member Services at the numbers listed at the bottom of this page to find out about other excluded services.
| Services CommuniCare Advantage, Medicare, and Medi-Cal don’t cover | |
|---|---|
| Services considered not “reasonable and medically necessary”, according to Medicare and Medi-Cal standards unless we list these as covered services. | Not a covered benefit |
| Experimental medical and surgical treatments, items, and drugs, unless Medicare, a Medicare-approved clinical research study, or our plan covers them. | Not a covered benefit |
| Surgical treatment for morbid obesity, except when medically necessary and Medicare pays for it. | Not a covered benefit |
| A private room in a hospital, except when medically necessary. | Not a covered benefit |
| Private duty nurses. | Not a covered benefit |
| Personal items in your room at a hospital or a nursing facility, such as a telephone or television. | Not a covered benefit |
| Full-time nursing care in your home. | Not a covered benefit |
| Fees charged by your immediate relatives or members of your household. | Not a covered benefit |
| 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 necessary. | Not a covered benefit |
F. Your rights as a member of the plan
As a member of CommuniCare Advantage, 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’ll 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 aren’t limited to, the following:
You have a right to respect, fairness, and dignity. This includes the right to:
Get covered services without concern about medical condition, health status, receipt of health services, claims experience, medical history, disability (including mental impairment), marital status, age, sex, sexual orientation, national origin, race, color, religion, creed, or public assistance
Get information in other languages and formats (for example, large print, braille, or audio) free of charge
Be free from any form of physical restraint or seclusion
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 language and format you can understand. This includes the right to get information on:
Description of the services we cover
How to get services
How much services will cost you
Names of health care providers
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 change your PCP at any time during the year
Use a women’s 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’re covered
Refuse treatment, even if your health care provider advises against it
Stop taking medicine, even if your health care provider advises against it
Ask for a second opinion. CommuniCare Advantage will pay for the cost of your second opinion visit
Make your health care wishes known in an advance directive
You have the right to timely access to care that doesn’t have any communication or physical access barriers. This includes the right to:
Get timely medical care
Get in and out of a health care provider’s office. This means barrier-free access for people with disabilities, in accordance with the Americans with Disabilities Act
Have interpreters to help with communication with your health care providers and your health plan
You have the right to seek emergency and urgent care when you need it. This means you have the right to:
Get emergency services without prior authorization in an emergency
Use 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 file a complaint or appeal a denied, delayed, or modified service. Please see section G below. This includes the right to:
File a complaint or grievance against us or our providers
Appeal certain decisions made by us or our providers
File a complaint with the California Department of Managed Health Care (DMHC) through a toll-free phone number (1-888-466-2219), or a TDD line (1-877-688-9891) for the hearing and speech impaired. The DMHC website (www.dmhc.ca.gov/) has complaint forms, Independent Medical Review (IMR) application forms, and instructions available online.
Ask DMHC for an IMR of Medi-Cal services or items that are medical in nature
Ask for a State Hearing
Get a detailed reason for why services were denied and ask for free copies of all the information used to make the decision
For more information about your rights, you can read the Member Handbook. If you have questions, you can call CommuniCare Advantage Member Services at the numbers listed at the bottom of this page.
You can also call the Medicare and Medi-Cal Ombudsperson Program (MMOP) at 1-855-501-3077, Monday through Friday, between 9 a.m. and 5 p.m., or the Medi-Cal Office of the Ombudsman at 1-888-452-8609, Monday through Friday, between 8 a.m. and 5 p.m.
G. How to file a complaint or appeal a denied, delayed, or modified service
If you have a complaint or think CommuniCare Advantage improperly denied, delayed, or modified a service, call Member Services at the numbers listed at the bottom of this page. You may also submit a complaint in writing to:
Community Health Group
Attention: Grievances and Appeals Supervisor
2420 Fenton Street, Suite 100
Chula Vista, CA 91914
You may be able to appeal our decision.
For questions about complaints and appeals, you can read Chapter 9 of the Member Handbook. You can also call CommuniCare Advantage Member Services at the numbers listed at the bottom of this page.
Help from the California Department of Managed Health Care
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.
H. What to do 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 CommuniCare Advantage Member Services. Phone numbers at the numbers listed at the bottom of this page.
Or, call the Medi-Cal Customer Service Center at 1-800-541-5555. TTY users may call 1-800-430-7077.
Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048. You can call these numbers for free.
You can also call the Department of Health Care Services (DHCS) Medi-Cal Fraud Hotline at 1-800-822-6222.
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