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C-SNP | Summary of Benefits

Community y Más (HMO C-SNP) · Plan Year 2027

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Summary of Benefits for 2027

Community y Más (HMO C-SNP)

2027 · San Diego

Introduction

Introduction

2027 Summary of Benefits

Community y Más (HMO C-SNP)

January 1, 2027 - December 31, 2027

H6248, Plan 001

Our service area includes the following counties in California: San Diego

Member Services can be reached via:

PHONE

1-800-232-3133

24 hours a day, 7 days a week

TTY1-855-266-4584
(This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.)
WEBSITEwww.chgsd.com
MAIL

Community Health Group

Member Services Department

2420 Fenton Street Suite 100

Chula Vista, CA 91914

This document gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2027. This is an important legal document. Please keep it in a safe place.

Please contact Member Services if you would like this information in large print, braille, and/or audio.

Member Services also has free language interpretation services available for people who do not speak English.

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call Member Services at 1-800-232-3133, TTY users should call 1-855-266-4584, we are open 24 hours a day, 7 days a week to assist you, the call is free.

ATENCIÓN: Si usted habla español, los servicios de asistencia de idiomas, están disponibles para usted de manera gratuita. Llame a Servicio al Cliente al 1-800-232-3133, estamos disponibles para ayudarle las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-855-266-4584. La llamada a es gratis.

CHÚ Ý: Nếu bạn nói tiếng việt, các dịch vụ trợ giúp ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi Dịch Vụ Khách Hàng theo số 1-800-232-3133, chúng tôi mở cửa 24 giờ một ngày, 7 ngày một tuần để giúp bạn. Người dùng TTY nên gọi 1-855- 266-4584. Cuộc gọi miễn phí.

PANSININ: Kung nagsasalita ka ng tagalog, ang mga serbisyo sa tulong ng wika, nang libre, ay magagamit mo. Tawagan ang Member Services sa 1-800-232-3133, bukas kami ng 24 oras sa isang araw, 7 araw sa isang 2ingo upang tulungan ka. Ang mga gumagamit ng TTY ay dapat tumawag sa 1- 855-266-4584. Ang tawag ay libre.

请注意：如果您讲中文，可为您免费提供语言协助服务。请联系会员服务处，免费电话： 1-800-232-3133，听障专线：1-855-266-4584，服务时间：每周 7 天、每天 24 小时。 通话 免费。

ة تنبيه: إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية متاحة لك بدون أي مقابل. اتصل بالرقم.الهاتف النصي:-1-855-266-4584) . الاتصال مجاني1-800-232-3133 (

توجه: اگر به زبان فارسی صحبت می‌کنید، خدمات کمک زبانی، به صورت رایگان، در اختیار شماست. با 1-800-232-3313 (پیام‌نگار: 1-855-266-4584) تماس بگیرید. تماس با این شماره‌ها رایگان است.

DISCLAIMERS

DISCLAIMERS

Important notice.

When this booklet says “we,” “us,” or “our,” it means Community Health Group. When it says “plan” or “our plan,” it means Community y Más.

Important notice.

Community y Más is an HMO C-SNP health plan with a Medicare contract. Enrollment in this plan depends on contract renewal.

Important notice.

This is a summary of health services covered by our plan. The benefit information provided does not list every service that we cover, limitation, or exclusion. To get a complete list of covered services, please call Member Services at 1-800-232-3133 (TTY users, please call 1-855-266-4584) to request the Evidence of Coverage, or access it online at www.chgsd.com.

Important notice.

Community y Más has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You can see our plan’s Provider/Pharmacy Directories and Evidence of Coverage at www.chgsd.com. Or call us and we will send you a copy of the directory.

Important notice.

Except in emergency situations, if you use providers that are not in our network, we may not pay for the services you receive. Generally, you must use network pharmacies to fill your prescriptions for covered Part D drugs. You may need a referral and/or authorization to get some types of care.

Important notice.

Our plan's provider and pharmacy directories are available on our website at www.chgsd.com. Please contact us to request paper copies of the directories.

Important notice.

For coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 7 days a week, 24 hours a day. TTY users, please call 1-877-486-2048.

ELIGIBILITY

ELIGIBILITY

Community y Más is a Medicare Advantage “Special Needs Plan” or “SNP,” which means its benefits, providers, and drug formularies are tailored to best meet the needs of people with specific medical conditions or characteristics.

Our plan is designed specifically for people who have certain medical conditions.

In order to join Community y Más, you must:

  • Be enrolled in Medicare Parts

    A (hospital insurance),

    B (medical insurance), and

    D (prescription drug insurance)

  • Have Cardiovascular Disorders, Chronic Heart Failure, and/or Diabetes

PREMIUMS AND DEDUCTIBLES

PREMIUMS AND DEDUCTIBLES

Extra Help is a Medicare program that helps people with limited incomes and resources reduce their Medicare Part D prescription drug costs such as premiums, deductibles, and copayments. Extra Help is also called the “Low-Income Subsidy,” or “LIS.” Your prescription drug copayments under our plan already include the amount of Extra Help you qualify for. For more information about Extra Help, contact your local Social Security Office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. These calls are free.

Health Insurance TermDefinitionYour costsLimitations, exceptions, and other information
Plan PremiumPremium is the amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.There is no plan premiumYou must continue to pay your Medicare Part B premium unless your Part B premium is paid for you by Medicaid or another third party.
DeductibleDeductible is the amount you pay during a coverage period for covered health care services before your plan begins to pay.There are no deductibles 
Maximum Out-of-Pocket (MOOP) ResponsibilityOut-of-Pocket Limit is the most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit, the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs.$1,500Your out-of-pocket limit does not include amounts you pay for Part D prescription drug costs.
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

Overview

Please note that services marked with an * are supplemental benefits covered by our plan.

MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need hospital care

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Inpatient Hospital Coverage$0 to $75Our plan covers unlimited days in an acute inpatient hospital.
Outpatient Hospital Coverage, including Observation Services$75 per dayReferral and authorization required
Ambulatory Surgery Center (ASC)$0Referral and authorization required
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need to see a doctor

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Primary Care Provider (PCP) Visit$0 
Specialist Visit$0Referral and authorization required
Preventive Care, such as screenings, vaccinations, and wellness visits$0Referral and/or authorization may be required for some preventive care services.
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need immediate medical attention

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Emergency Care$140 per visit

If you are admitted to the hospital within 24 hours, your copayment is waived.

Emergency/Urgent care services are covered worldwide up to $50,000 per year.

Urgently Needed Services$0 to $140Emergency/Urgent care services are covered worldwide up to $50,000 per year.
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need medical tests

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Diagnostic Tests and Procedures$0 
Lab Services$0 
Diagnostic Radiology, such as MRIs and CT scans$0 to $75Authorization required
Therapeutic Radiology, such as radiation treatment for cancer$0Authorization required
X-Rays$0Authorization required
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need hearing/audiological services

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Hearing Services (Diagnostic Hearing and Balance Evaluations)$0 
Routine Hearing Exam*$0We cover one routine hearing exam per year.
Hearing Aid Fitting/Evaluation*$0We cover one hearing aid fitting/evaluation every year.
Hearing Aids*$0We pay up to $750, every three (3) years for hearing aids for both ears combined.
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need dental care

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)

Medicare Part A Dental Services

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. However, Medicare currently pays for dental services in a limited number of circumstances, specifically when that service is an integral part of specific treatment of a beneficiary's primary medical condition. Some examples include reconstruction of the jaw following fracture or injury, tooth extractions done in preparation for radiation treatment for cancer involving the jaw, or oral exams preceding kidney transplantation.

$0Like Medicare Part A (hospital insurance), we cover certain dental services that you get when you're in a hospital and hospital stays if you need to have emergency or complicated dental procedures.
Dental Services$0$2,000.00 maximum per calendar year for services received in San Diego county through a First Dental Health network provider managed by Centrix. Member may use receive 2 oral exams, 2 dental X-Rays, 2 cleanings per year. The $2,000.00 amount can be used towards dentures or implants.
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need vision care

Services you may need

Costs you pay for

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Medicare Part B Eye Health Services$0Like Medicare Part B (medical insurance), we cover certain exams and treatments for specific conditions.
Eyewear for Specific Conditions$0We cover one pair of eyeglasses or contact lenses after each cataract surgery that implants an intraocular lens.
Routine Eye Exam*$0We cover one routine eye exam per year
Eyewear*$0We cover up to $300 per year for contact lenses and/or eyeglasses (lenses and frames) through a Vision Service Plan provider in San Diego county.
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need mental health services

Services you may need

Costs you pay for

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Inpatient services in a psychiatric hospital$0 to $75We cover unlimited days per year in an inpatient psychiatric facility.
Outpatient Therapy$0Referral and authorization required
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need rehabilitation or therapy services

Services you may need

Costs you pay for

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Skilled Nursing Facility (SNF) care

$0 copay for days 1 through 20

$200 copay per day for days 21 through 100

* These are 2026 cost-sharing amounts and may change for 2027. We will provide updated rates as soon as they are released.

We cover up to 100 days in a SNF. A 3-day qualifying stay in a hospital is not required.

Referral and authorization required

Physical, Occupational, and/or Speech Therapy$0Referral and authorization required
MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need transportation

Services you may need

Costs you pay for

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Ambulance$150 copayment per tripAuthorization is required for non-emergency services.
Routine Transportation$0

We cover up to 24 plan-approved one-way trips by taxi to health-related locations.

Referral and authorization required

MEDICARE-COVERED HEALTH SERVICES AND YOUR COSTS

If you need outpatient prescription drugs (i.e., medicine you would get in a doctor’s office or in an outpatient hospital setting)

Services you may need

Costs you pay for

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Medicare Part B Drugs

You pay a 0% to 20% coinsurance for Medicare-covered Part B prescription drugs.

You won’t pay more than $35 for a one-month supply of each Part B insulin product covered by our plan.

Like Medicare Part B (medical insurance), we cover a limited number of outpatient prescription drugs under certain conditions, such as those you get at a doctor's office or in a hospital outpatient setting.

Authorization required

PRESCRIPTION DRUG STAGES AND YOUR COSTS

PRESCRIPTION DRUG STAGES AND YOUR COSTS

Health Insurance TermDefinitionYour costsLimitations, exceptions, and other information
Deductible (Stage 1)Deductible is the amount you pay during a coverage period (usually one year) for prescription drugs before your plan begins to pay.During this stage, you pay $0 cost sharing for drugs on Tier 1 and Tier 6, $9 per drug per month cost sharing for drugs on Tier 2 and the full cost of drugs on Tier 3, Tier 4 and Tier 5 until you’ve reached the yearly deductible.You stay in this stage until you’ve reached the yearly deductible of $700.

Initial Coverage Phase

(Stage 2)

Initial Coverage Phase is the stage that begins when you fill your first prescription and ends when your year-to-date total prescription drug costs reach the phase threshold.During this stage, we pay our share of the cost of your drugs, and you pay your share of the cost.

You stay in this stage until your year-to-date total drug costs (costs paid by both you and our plan) total $2,400

Cost sharing is based on your level of Extra Help.

Catastrophic Coverage

(Stage 3)

Catastrophic Coverage is a phase designed to protect you from having to pay very high out-of-pocket costs for prescription drugs. It usually begins after you have spent a pre-determined amount on your health care.During this stage, you pay $0 covered Part D drugs (i.e., we will pay the full cost of your covered Part D drugs).You enter this stage when your total year-to-date out-of-pocket costs are more than $2,400
PRESCRIPTION DRUG TIERS AND YOUR COSTS

PRESCRIPTION DRUG TIERS AND YOUR COSTS

If you need prescription drugs during the Initial Coverage Phase (Stage 2)

Prescription Drug Tier

Your cost for a

one (1)-month supply at a retail pharmacy

(in-network pharmacy)

Your cost for a

three (3)-month supply at a retail pharmacy

(in-network pharmacy)

Your cost for a

three (3)-month supply through our mail-order pharmacy

Tier 1: Preferred Generic Drugs$0$0$0
Tier 2: Generic Drugs$9 copayment$27 copayment$27 copayment
Tier 3: Preferred Brand Drugs

$47 copayment

You pay no more than $35 per month supply of each covered insulin product on this tier.

$141 copayment

You pay no more than $105 per 3-month supply of each covered insulin product on this tier.

$141 copayment

You pay no more than $105 per 3-month supply of each covered insulin product on this tier.

Tier 4: Non-Preferred Brand Name Drugs

30% coinsurance

You pay no more than $35 per month supply of each covered insulin product on this tier.

30% coinsurance

You pay no more than $105 per 3-month supply of each covered insulin product on this tier

30% coinsurance

You pay no more than $105 per 3-month supply of each covered insulin product on this tier

Tier 5: Specialty Tier

25% coinsurance

You pay no more than $35 per month supply of each covered insulin product on this tier.

Three (3)-month supply is not available for this Tier.Three (3)-month supply through Mail order is not available for this Tier.
Tier 6: Select Care Drugs$0$0$0

Limitation, exceptions, and other information:

  • If you reside in a long-term care facility, you receive one (1)-month supplies of drugs and pay the same as at a retail pharmacy.

  • You may get drugs from an out-of-network pharmacy, but you may pay more than you pay at an in-network pharmacy.

ADDITIONAL HEALTH SERVICES AND YOUR COSTS

ADDITIONAL HEALTH SERVICES AND YOUR COSTS

If you need additional services

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Acupuncture for chronic low back pain$0 per visit for up to 12 visits per year maximum.

Medicare-covered acupuncture is only covered under certain circumstances.

Referral and authorization required

Acupuncture (Routine)*$0

We cover up 12 treatments every year.

Referral and authorization required

Cardiac and Pulmonary Rehabilitation Services$0

We cover Medicare-covered services.

Referral and authorization required

Chiropractic Care$0 for manual manipulation of the spine to correct a subluxation, which is when one or more of the bones of your spine move out of position

We cover Medicare-covered services.

Referral and authorization required

Chiropractic Care (Routine)*$0

We cover up to 12 routine chiropractic visits per year.

Referral and authorization required

Diabetes Supplies and Services$0

We cover Medicare-covered diabetic supplies and therapeutic shoes or inserts.

Authorization required

Diabetes Self- Management Training$0 
Dialysis$0 
Durable Medical Equipment (DME)15% coinsuranceAuthorization required

If you need additional services (continued)

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)
Home and Bathroom Safety Devices and Modifications and In-home Safety Inspection*$0

We cover up to $800 per year towards the cost and installation of safety devices to prevent injuries in the bathroom (example: grab bars)

We cover an in-home inspection conducted by a qualified health professional to identify the need for safety devices.

Referral and authorization required

Hospice$0

Hospice is covered outside our plan.

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Please contact Member Services for more details.

Kidney Disease Education Services$0 
Meals*$0

Inpatient post-discharge meal benefit: eligible Medicare members receive 28 home delivered meals following each discharge from an inpatient stay at a hospital, skilled nursing facility, or in a rehab facility from a CHG approved provider.

Home delivered meals-chronic condition management program: eligible Medicare members receive 14 meals each week, for 12 weeks. This includes the 28 meals post each discharge. Eligible conditions to receive the chronic meals benefit include CHF, CAD, and Diabetes.

Referral and authorization required

Nutritional/Dietary Benefit*$0

We cover unlimited nutrition/dietary individual and group counseling sessions.

Referral and authorization required

Fitness Benefit*$0

We cover basic membership at 24 Hour Fitness Centers.

Referral and authorization required

Opioid Treatment Services$0Referral and authorization required
Outpatient Substance Abuse Services$0 per individual or group sessionReferral and authorization required
Over-the-Counter (OTC) Items*$0

You may purchase up to $145 every three months of certain OTC items in the OTC Catalog provided by the Plan or Debit Card. The $145 includes tax. $580 maximum per year.

Unused amounts cannot be carried over from quarter to quarter.

Podiatry Services$0

We cover Medicare-covered services.

Referral and authorization required

If you need additional services (continued)

Services you may need

Costs you pay for using

in-network providers

Limitations, exceptions, and other benefit information (rules about benefits)

Prosthetic Devices,

such as braces and artificial limbs

15% coinsuranceAuthorization required
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services$0

We cover Medicare-covered services.

Referral and authorization required

Telehealth Services*$0

We offer the following additional services via telehealth:

  • individual and group sessions for mental health services

  • individual and group sessions for psychiatric services

  • individual and group sessions for outpatient substance abuse

Worldwide Emergency/Urgent Care*$140 copayment per visitYou are covered for up to $50,000 per year for worldwide emergency/urgent care.