L.A. Care Health Plan Medicare Advantage HMO

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 2010?

• Monthly premium: $0
• Doctor visits, including specialists*: $0
• Dental services (routine)*: $0 for the following services:
  1 oral exam every 6 months
  1 cleaning every 6 months
  1 flouride treatment every 6 months
  1 X-ray every 3 years
• Dental services (comprehensive)*: Additional copays apply (based on service)
• Vision services*: $0 copay for routine eye exam every year, $100 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
• Routine podiatry services*: $0 for 6 visits per year
• Prescription drugs*:
  $0 copay for generic drugs (Tier 1) and $3.30 copay (typically) per prescription for brand-name drugs (Tier 2) up to Initial Coverage Limit ($2,830)
  $1.10 copay (typically) per prescription for generic drugs (Tier 1) and $3.30 copay (typically) per prescription for brand-name drugs (Tier 2) during the Coverage Gap (between $2,831 and $4,550)

*Copayments may vary depending on your low-income subsidy level.

Types of Benefits that Are Not Covered

For a list of the types of benefits that the Plan does not cover, see Chapter 4, Section 3 and Chapter 5, Section 8 in the Evidence of Coverage (PDF). These Sections describe some services, items, and drugs that aren’t covered under any conditions and some that are excluded only under specific conditions.

What Are the Eligibility Requirements?

You are eligible for membership in our Plan as long as you live in our geographic service area of Los Angeles County:

• and you are entitled to Medicare Part A
• and you are enrolled in Medicare Part B
• and you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a Plan that we offer, or you were a member of a different Plan that was terminated
• and you have Full Medi-Cal benefits, with no Share of Cost.

Beneficiaries who are eligible to join L.A. Care Health Plan Medicare Advantage may enroll at any time.

Please reference section "Helpful Information & Forms" for additional detail, including links to the L.A. Care Health Plan Medicare Advantage current Summary of Benefits and Evidence of Coverage.

Additional information about benefits, cost-sharing, any applicable conditions and limitations can be found in Chapters 3 to 7 in the Evidence of Coverage (PDF).

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: 1-888-839-9909 (TTY 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: 1-888-4LA-CARE (1-888-452-2273), (TTY 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 1-888-839-9909, (TTY 1-866-522-2731)

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY 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
555 West Fifth Street
Los Angeles, CA  90013

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

Disclaimer Information

L.A. Care Health Plan is a Medicare Advantage organization with a Medicare contract. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medi-Cal or by another third party. 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.

Plan member materials are available in other formats (like braille, large type, audio) upon request.

For full information on L.A. Care Health Plan Medicare Advantage benefits, please call our Member Services department at 1-888-839-9909 (TTY 1-866-522-2731). L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

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.