Blue Shield offers

2025 Medicare Advantage Dual Special Needs Plan documents

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.

  • 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) and 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)

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) 

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) 

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)

 


 

Nondiscrimination notices, Language assistance notices, and Blue Shield MA-PD star ratings

Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice
English (PDF, X KB) / Español (PDF, X KB)   

Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Notice of availability of language assistance services and auxiliary aids and services (Notice of Availability)
English (PDF, X KB)


 

Blue Shield Inspire (HMO D-SNP) and Blue Shield TotalDual Plan (HMO D-SNP) Medicare Star Ratings* 
English (PDF, X MB) / Español (PDF, X MB) Arabic (PDF,  X KB) Armenian (PDF,  X KB)  Chinese (Simplified) (PDF,  KB) Chinese (Traditional) (PDF,  X KB) Farsi (PDF,  X KB) Khmer (PDF, X MB)   Korean (PDF, X KB) Russian <(PDF,  X KB)  Tagalog (PDF,  XB)  Vietnamese (PDF,  X KB)


 

*Every year, Medicare evaluates plans based on a 5-star rating system.

Please refer to our list of compatible browsers when downloading or viewing PDF documents.

You can also log into your online account and go to the Benefits section on your member dashboard.

If you want help understanding your documents, please call:

  • Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Customer Service at (800) 452-4413 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.
  • For help in your language, please review the Multi-Language Notice and the Nondiscrimination Notice located for download on this page.

Blue Shield offer Blue Shield TotalDual plan (HMO  D-SNP) to new members in Los Angeles and San Diego counties. Our D-SNP plans in Merced, Orange, San Bernardino, San Joaquin, and Stanislaus counties are closed to new enrollment.

H2819_24_441A_C
Page last updated: 10/1/2024

*가입 의무 없이 받아볼 수 있는 무료 사본입니다.

© California Physician’s Service DBA Blue Shield of California 1999-2023. 모든 권리 보유.

California Physician’s Service DBA Blue Shield of California는 Blue Shield Association의 독립 회원사입니다.

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

Blue Shield Medicare Advantage Plan의 경우: Blue Shield of California는 Medicare 계약 및 캘리포니아 주 Medicaid 프로그램과 계약을 맺은 HMO, HMO D-SNP, PPO 및 PDP플랜입니다. Blue Shield of California 가입은 계약 갱신에 따릅니다.

 
 
회사는 적용되는 주법 및 연방 인권법을 준수하며 인종, 피부색, 출신 국가, 민족 집단 식별, 의학적 상태, 유전자 정보, 조상, 종교, 성, 결혼 여부, 성별, 성적 주체성, 성적 취향, 연령 정신 장애 또는 신체 장애를 기준으로 차별하거나 사람들을 배제하거나, 또는 그들을 다르게 대우하지 않습니다. La compañía cumple con las leyes de derechos civiles federales y estatales aplicables, y no discrimina, ni excluye ni trata de manera diferente a las personas por su raza, color, país de origen, identificación con determinado grupo étnico, condición médica, información genética, ascendencia, religión, sexo, estado civil, género, identidad de género, orientación sexual, edad, ni discapacidad física ni mental. 本公司遵守適用的州法律和聯邦民權法律，並且不會以種族、膚色、原國籍、族群認同、醫療狀況、遺傳資訊、血統、宗教、性別、婚姻狀況、性別認同、性取向、年齡、精神殘疾或身體殘疾而進行歧視、排斥或區別對待他人。