Medicare Advantage Plan
L.A. Care Health Plan Medicare Advantage (HMO SNP)
Are You Eligible for Both Medi-Cal and Medicare?
If you are a person dually eligible for Medi-Cal and Medicare or a caring relative or friend who is helping someone in search of a health plan with better Medicare benefits, L.A. Care Health Plan may have the plan you are looking for.
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.
- Monthly premium: $0
- Doctor visits, including specialists: $0
$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:
- 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:
- 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
- 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-pocket costs within the calendar year, you will move from the Initial Coverage Stage to the Catastrophic Coverage Stage, the plan will pay for 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.
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 (PDF) and Evidence of Coverage (PDF).
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).
How Do I Apply?
L.A. Care Health Plan can help you determine your eligibility status and can even help you with your application. Simply call 1-888-522-1298 (TTY/TDD 1-866-522-2731) today! L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week (including holidays).
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.
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, comuníquese 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.
Click on the links below to:
- Learn How to Enroll
- Find a Doctor or Hospital
- Learn How to Choose and See a Doctor
- Learn about Part D & Prescription Drugs
- See our Medicare Advantage Plan Benefits & Services
- Access Member Resources and other Helpful Information
- Learn How to Report a Problem