Blue Shield提供

2025年Medicare Advantage雙重特殊需求計劃文件

All your Blue Shield of California Medicare Advantage Dual Special Needs Plan documents – including the enrollment form, enrollment checklist, language assistance notice, and Medicare Star Ratings – are listed on this page. 

You can use plan documents to help you understand your plan.

  • Evidence of Coverage (EOC) describes in detail the healthcare benefits covered by your plan.
  • Member handbook describes in detail the healthcare benefits covered by your plan.
  • Summary of Benefits (SOB) is a simplified document that outlines your health benefits and coverage. 
  • Annual Notice of Changes (ANOC) is a summary of any changes in the costs and coverage of your plan, effective each January 1.

For information on members and Blue Shield of California’s rights and responsibilities upon disenrollment, please refer to Chapter 10 in your member handbook linked below.

Blue Shield TotalDual Plan (HMO D-SNP)和Blue Shield Inspire (HMO D-SNP)

Member handbook

English (PDF, X KB) / Español (PDF, X KB), Arabic (PDF,  X KB), Armenian (PDF,  X KB), Chinese (Simplified) (PDF,  X KB), Chinese (Traditional) (PDF,  X KB), Farsi (PDF,  X KB), Khmer (PDF, X KB), Korean (PDF,  X KB), Russian (PDF,  X KB), Tagalog (PDF,  X KB), Vietnamese (PDF,  X KB)

Evidence of Coverage (EOC): 
English (PDF, 5.3 MB) / Español (PDF, 4 MB), Arabic (PDF, 2.8 MB, Armenian (PDF, 5.3 MB), Chinese (Simplified) (PDF,  4.2 MB), Chinese (Traditional) (PDF,  4.7 MB), Farsi (PDF, 4.5 KB), Khmer (PDF, 6.9 MB), Korean (PDF, 6.5 MB), Russian (PDF, 5.4 MB), Tagalog (PDF,  4.1 MB), Vietnamese (PDF,  5.4 MB)

Summary of Benefits (SOB)
English (PDF, X KB) / Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB)  Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X KB)   Korean (PDF,  X KB) Russian (PDF,  X KB)  Tagalog (PDF,  X KB)  Vietnamese (PDF,  X KB)

Annual Notice of Changes
English (PDF, X KB) / Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB)  Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X KB)   Korean (PDF,  X KB) Russian (PDF,  X KB)  Tagalog (PDF,  X KB)  Vietnamese (PDF,  X KB)

Enrollment form  English
(PDF, X KB) / Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB)  Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X KB)   Korean (PDF,  X KB) Russian (PDF,  X KB)  Tagalog (PDF,  X KB)  Vietnamese (PDF,  X KB)

Pre-enrollment checklist
English English (PDF, X KB) / Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB)  Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X KB)   Korean (PDF,  X KB) Russian (PDF,  X KB)  Tagalog (PDF,  X KB)  Vietnamese (PDF,  X KB)

Model of Care Evaluation Summary of Findings 
English (PDF, X KB) / Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB)  Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X KB)   Korean (PDF,  X KB) Russian (PDF,  X KB)  Tagalog (PDF,  X KB)  Vietnamese (PDF,  X KB)


 

Member Handbook

English (PDF, X KB) / Español (PDF, X KB) 

Evidence of Coverage (EOC): 
English (PDF, 5.3 MB) / Español (PDF, 4 MB), Arabic (PDF, 2.8 MB, Armenian (PDF, 5.3 MB), Chinese (Simplified) (PDF,  4.2 MB), Chinese (Traditional) (PDF,  4.7 MB), Farsi (PDF, 4.5 KB), Khmer (PDF, 6.9 MB), Korean (PDF, 6.5 MB), Russian (PDF, 5.4 MB), Tagalog (PDF,  4.1 MB), Vietnamese (PDF,  5.4 MB)

Summary of Benefits (SOB)
English (PDF, X KB) / Español (PDF, X KB) 

Annual Notice of Changes
English (PDF, X KB) / Español (PDF, x MB ) 

Pre-enrollment Checklist
English (PDF, X MB  ) / Español (PDF, X MB  ) Arabic (PDF,  X  ) Armenian (PDF,  X  )  Chinese (Simplified) (PDF,  X  ) Chinese (Traditional) (PDF,  X  ) Farsi (PDF,  X  ) Khmer (PDF, X MB)   Korean (PDF,  X  ) Russian (PDF,  X  )  Tagalog (PDF,  X  )  Vietnamese (PDF,  X  )

Model of Care Evaluation Summary of Findings
English (PDF, X MB  ) / Español (PDF, X KB ) Arabic (PDF,  X  ) Armenian (PDF,  X  )  Chinese (Simplified) (PDF,  X  ) Chinese (Traditional) (PDF,  X  ) Farsi (PDF,  X  ) Khmer (PDF, X MB)   Korean (PDF,  X  ) Russian (PDF,  X  )  Tagalog (PDF,  X  )  Vietnamese (PDF,  X  )


 

Member Handbook

English (PDF, X KB) / Español (PDF, X KB) 

Evidence of Coverage (EOC): 
English (PDF, 5.3 MB) / Español (PDF, 4 MB), Arabic (PDF, 2.8 MB, Armenian (PDF, 5.3 MB), Chinese (Simplified) (PDF,  4.2 MB), Chinese (Traditional) (PDF,  4.7 MB), Farsi (PDF, 4.5 KB), Khmer (PDF, 6.9 MB), Korean (PDF, 6.5 MB), Russian (PDF, 5.4 MB), Tagalog (PDF,  4.1 MB), Vietnamese (PDF,  5.4 MB)

Summary of Benefits (SOB)
English (PDF, X KB)/ Español (PDF, X KB)

Annual Notice of Changes
English (PDF, X KB)/ Español (PDF, X KB)

Enrollment Form
English (PDF, X KB)/ Español (PDF, X KB)

Pre-enrollment Checklist
English (PDF, X KB)/ Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB) Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X MB) Korean (PDF,  X KB)Russian (PDF,  X KB) Tagalog (PDF,  X KB) Vietnamese (PDF,  X KB)

Model of Care Evaluation Summary of Findings
English (PDF, X KB) / Español (PDF, X KB) Arabic (PDF,  X KB) Armenian (PDF,  X KB) Chinese (Simplified) (PDF,  X KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X MB)  Korean (PDF,  X KB) Russian (PDF,  X KB) Tagalog (PDF,  X KB) Vietnamese (PDF,  X KB)

 


 

禁止歧視聲明、語言協助通知和Blue Shield MA-PD星級評等

Blue Shield Medicare Advantage處方藥計劃禁止歧視聲明
英文(PDF, X KB)/西班牙文(PDF, X KB)

Blue Shield TotalDual Plan (HMO D-SNP)和Blue Shield Inspire (HMO D-SNP)語言協助服務可用性和輔助工具和服務（可用性通知）
英文(PDF, X KB)


 

Blue Shield Inspire (HMO D-SNP)和Blue Shield TotalDual Plan (HMO D-SNP) Medicare星級評等*
英文(PDF, X MB)/西班牙文(PDF, X MB) 阿拉伯文(PDF, X KB) 亞美尼亞文(PDF, X KB) 簡體中文(PDF, X KB) 繁體中文(PDF, X KB) 波斯文(PDF, X KB) 高棉文(PDF, X MB) 韓文(PDF, X KB) 俄文(PDF, X KB) 阿加祿文(PDF, XB) 越南文(PDF, X KB)


 

*每年，Medicare都會根據一個5星級評等系統評估計劃。

下載或檢視PDF文件時，請參閱我們的相容瀏覽器清單。

您也可以登入您的網上帳戶，前往會員儀表板的「各項福利」部份。

如果您在瞭解文件方面需要幫助，請致電

  • Blue Shield TotalDual Plan (HMO D-SNP)和Blue Shield Inspire (HMO D-SNP) 客戶服務部：(800) 452-4413（聽障和語障專線(TTY)：711），服務時間為每週七天，上午8時到晚上8時。
  • 如需您所使用語言的協助，請查看本頁面供下載的多語言通知和禁止歧視聲明。

Blue Shield為洛杉磯和聖地牙哥縣的新會員提供Blue Shield TotalDual Plan (HMO D-SNP)計劃。我們在默賽德縣、橙縣、聖貝納迪諾縣、聖華金縣和斯坦尼斯勞斯縣的D-SNP計劃已停止接受新參保。

H2819_24_441A_C
頁面最後更新日期：2024年10月1日

*免費數位副本，無需參保。

† Blue Shield Medicare顧問於4月1日至9月30日期間提供服務：平日服務時間為上午8時至下午8時，10月1日至3月31日：服務時間為每週七天，上午8時至下午8時。

© California Physician’s Service DBA Blue Shield of California 1999-2024.保留所有權利。

California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California 601 12th Street, Oakland, CA 94607.

如為Blue Shield Medicare Advantage計劃：Blue Shield of California是與Medicare簽約的HMO、HMO D-SNP、PPO和PDP計劃，並且與California State Medicaid Program簽有合約。能否參保Blue Shield of California視合約是否續約而定。

 
 
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