医疗保险和 D-SNP 基础知识

Medicare is a federal health program for people 65 and over. Some people under 65 with certain disabilities can get it too. It has four parts. The main parts are A and B, called Original Medicare. Parts C and D are additional plans from private insurance companies like the Alliance’s TotalCare (HMO D-SNP).

Original Medicare

A 部分 helps pay for services like:

• Inpatient care.
• Skilled nursing facility care (not long-term care).
• Home healthcare (if you’re mostly homebound).
• Hospice care (for people with serious illness near the end of life).

Part B helps pay for:

• 医生来访。
• Lab tests done outside of the hospital.
• Outpatient services and surgeries.
• Preventive health appointments.
• Some medical equipment, like walkers or oxygen tanks.

Additional Plan Options

Part C is also called Medicare Advantage. These plans combine hospital, medical and usually Part D prescription drug coverage, all into one plan. They often provide extra benefits that Original Medicare doesn’t cover.

Part D helps pay for prescription medicines. It can either be combined with a Part C plan or purchased as a separate plan.

全面护理（HMO D-SNP） is a special type of Medicare Advantage plan from the Alliance. It includes Part D drug coverage and is therefore known as an MA-PD plan.

TotalCare is special in another way - it is a plan that is designed especially for people that are enrolled in both Medicaid (Medi-Cal) and Medicare, known as a Dual Eligible Special Needs Plan or “D-SNP.”

Enrollment periods

WHEN CAN I SIGN UP?

Your Initial Enrollment Period (IEP) starts 3 months before you turn 65. You can sign up during that time or during your birthday month. After your birthday month, you’ll have 3 months left to enroll. This gives you a total of 7 months to enroll.

Special Enrollment Period (SEP)

You can sign up for a Medicare Advantage or Part D plan at other times if certain things happen in your life. These may include (but aren’t limited to) changing jobs, moving out of your plan’s service area, moving in or out of a nursing home, or becoming eligible for Medicaid. SEP also applies to people who have been disabled for at least 24 months.

Annual Enrollment Period – October 15 to December 7
This is the time each year to enroll in or change your Medicare Advantage or Part D plan. You can also switch to Original Medicare (Parts A and B) only. Your new coverage begins January 1 of each year.

Open Enrollment Period – January 1 to March 31
This is an extra time each year when you can make one enrollment change to your existing Medicare Advantage plan. You can do one of the following:

• Switch to a different Medicare Advantage plan.
• Drop your Medicare Advantage plan and go back to Original Medicare only. If you do this and need prescription drug coverage, you have until March 31 to add a Medicare Part D (prescription drug) plan.

For more information about Medicare, you can read the Medicare & You handbook. If you don’t have a copy of this booklet, you can access it online at the Medicare website (www.medicare.gov/medicare-and-you) or request a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan for people who qualify for both Medicare and Medicaid. Medicare is a federal health program mainly for people 65 and older. Medicaid is a health program for people with low income. Some states also cover other people, based on their state rules. coordinates your health care and often includes extra benefits that regular Medicare Advantage plans don’t have.

Exclusively Aligned Enrollment (EAE) D-SNPs
The TotalCare plan is a special type of D-SNP called an Exclusively Aligned Enrollment (EAE) D-SNP. “Exclusively aligned enrollment” means that you get both your Medicare and Medicaid benefits from the same organization—in this case, the Alliance.

As a TotalCare member, you will have one plan for both Medicare and Medi-Cal. The value of this type of plan include:

• One plan that manages all your care.
• Extra benefits beyond standard Medicare and Medicaid coverage.
• A single member ID card and member handbook with details about both programs.
• Care coordination and case management through a care coordinator who is your main point of contact.
• Clearer communication for you and your providers.
• Access to specialists who accept both Medicare and Medicaid.

Our goal is to make it easy for you to get the care you need and help you stay healthy and feel your best.