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

*Bản miễn phí mà không cần phải ghi danh.

© California Physician’s Service DBA Blue Shield of California 1999-2023. Bảo lưu mọi quyền.

California Physician’s Service DBA Blue Shield of California là một hội viên độc lập của Blue Shield Association.

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

Đối với các Chương trình Medicare Advantage của Blue Shield: Blue Shield of California là một chương trình HMO, HMO D-SNP, PPO và PDP có hợp đồng với Medicare và hợp đồng với Chương trình Medicaid của tiểu bang California. Ghi danh vào Blue Shield of California phụ thuộc vào việc gia hạn hợp đồng.

 
 
Công ty tuân thủ luật pháp tiểu bang và luật dân quyền liên bang hiện hành và không phân biệt đối xử, loại trừ hoặc đối xử khác biệt với mọi người dựa trên chủng tộc, màu da, nguồn gốc quốc gia, nhận dạng nhóm dân tộc, bệnh, thông tin di truyền, tổ tiên, tôn giáo, tình dục, tình trạng hôn nhân, giới tính, nhân dạng giới tính, xu hướng giới tính, độ tuổi, tình trạng khuyết tật tâm thần hoặc khuyết tật thể chất. 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。