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Plan Documents (ANOC, EOC and Summary of Benefits)
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Medicare Resources
Member Resource Guide 2022 (English | Spanish | Chinese | Korean | Vietnamese)
Multi-Language Interpreter Services
Wider Circle Termination Notice for HMO C-SNP Plans (English | Spanish | Chinese | Korean | Vietnamese)
Wider Circle Termination Notice for HMO and Dual Plans (English | Spanish | Chinese | Korean | Vietnamese)
Non-Discrimination Notice
Out-of-Network Coverage Rules
Part C Pre-Authorizations, Organizational Determination, Appeals, and Grievances
Privacy Practices for Protected Health Information (PHI)
Provider/Pharmacy Search
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Medicare Plan Ratings / Medicare STAR Ratings 2022 (English | Spanish | Chinese | Korean | Vietnamese)
Winter Newsletters (English | Spanish | Chinese | Korean | Vietnamese)
Spring Newsletters (English | Spanish | Chinese | Korean | Vietnamese)
Summer Newsletters (English | Spanish | Chinese | Korean | Vietnamese)
Fall Newsletter (English | Spanish | Chinese | Korean | Vietnamese)
2022 Over-the-Counter (OTC) Order Form (English | Spanish | Chinese | Korean | Vietnamese)
Appeal Form (English | Spanish | Chinese | Korean | Vietnamese)
Appointment of Representative Form (English | Spanish)
Authorization for Disclosure of Protected Health Information
Enrollment Forms (2022
MedImpact Direct Order Forms (English | Spanish | Chinese | Korean | Vietnamese)
Grievance Form (English | Spanish | Chinese | Korean | Vietnamese)
Authorization Service Request Form (English | Spanish)
Benefit Highlights
2022 Health Risk Assessment (HRA) (English | Spanish | Chinese | Korean | Vietnamese)
To complete an Electronic HRA click here
DeltaCare USA Dental Medicare Fee Schedule | Fee Schedule for Dual Eligibles
Western Dental Medicare Fee Schedule | Fee Schedule for Dual Eligibles
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