Specialized Kidney (CKD) Care
C-SNP HMO-POS
Champion Advantage
Medicare Only
Enroll NowCalifornia
Chronic Special Needs Plans for Kidney Diseases
Champion Health Plan offers Champion Advantage and Champion Connect, which all bring together specialized clinical support, medication coverage, and care coordination, designed around the unique needs of members managing kidney disease.Our care teams work directly with your nephrologist and primary care doctor to coordinate dialysis, transplant evaluations, medications, and the full range of preventive services Champion members count on.If you have chronic kidney disease (stage 4 or stage 5), severe loss of kidney function (generally an eGFR of 15–29), kidney failure (generally an eGFR below 15, whether or not dialysis has started), end-stage renal disease requiring dialysis, hemodialysis, peritoneal dialysis, home dialysis, in-center dialysis, kidney transplant recipient (within 36 months following the kidney transplant, when included in Champion Health Plan’s CMS-approved eligibility criteria), Champion Health Plan has a plan built to help you manage your healthcare needs.
Specialized Kidney (CKD) Care plus Medi-Cal Support
C-SNP HMO-POS
Champion Connect
Medicare + Medi-Cal
Enroll NowCalifornia Counties Available
- Imperial County
- Fresno County
- Kern County
- Los Angeles County
- Madera County
- Orange County
- Riverside County
- San Bernardino County
- San Diego County
| Doctor & Care Cost | Champion Advantage | Champion Connect |
|---|---|---|
| Monthly Premium |
In-Network: $0 Out-of-Network: $0 |
In-Network: $0 Out-of-Network: $0 |
| Annual Plan Deductible |
In-Network: No Deductible Out-of-Network: No Deductible |
In-Network: No Plan Deductible Out-of-Network: No Plan Deductible |
| Annual Maximum Out of Pocket (MOOP) |
In-Network: $999 (combined for in-network and out-of-network covered services) Out-of-Network: $999 (combined for in-network and out-of-network covered services) |
In-Network: $9,850 (combined for in-network and out-of-network Medicare-covered services) Out-of-Network: $9,850 (combined for in-network and out-of-network Medicare-covered services) |
| Primary Care Physician |
In-Network: $0 Copay Out-of-Network: $0 Copay |
In-Network: $0 Copay Out-of-Network: $0 Copay |
| Specialists* |
In-Network: $0 Copay Out-of-Network: $0 Copay |
In-Network: 20% of the Cost Out-of-Network: 20% of the Cost |
| Diagnostic Radiology, Labs* |
In-Network: $0 Copay Out-of-Network: $0 Copay |
In-Network: $0 Copay for lab services and X-rays Out-of-Network: $0 Copay for lab services and X-rays |
| Annual Physical Exam |
In-Network: $0 Copay for one exam per year Out-of-Network: $0 Copay for one exam per year |
In-Network: $0 Copay for one exam per year Out-of-Network: $0 Copay for one exam per year |
| Dialysis |
In-Network: $0 Copay Out-of-Network: 20% of the Cost |
In-Network: 20% of the Cost Out-of-Network: 20% of the Cost |
| Urgent Care |
In-Network: $0 Copay Out-of-Network: $0 Copay |
In-Network: $0 Copay Out-of-Network: $0 Copay |
| Emergency Care |
In-Network: $150 Copay Out-of-Network: $150 Copay |
In-Network: $115 Copay Out-of-Network: $115 Copay |
| Worldwide Emergency Care |
Out-of-Network: $0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
Out-of-Network: $0 Copay for up to $100,000 maximum Worldwide benefit limit reimbursable by the plan not to exceed 60% of local Medicare rates. Combined with Worldwide Urgently Needed Care. |
| Inpatient Hospital* |
In-Network: $0 Copay per stay Out-of-Network: Not Covered |
In-Network: $1,736 Deductible per benefit period Out-of-Network: Not Covered |
| Outpatient Hospital* |
In-Network: $100 Copay per visit outpatient hospital services Out-of-Network: $100 Copay per visit outpatient hospital services |
In-Network: 20% of the Cost for outpatient hospital services, surgery in an Ambulatory Surgery Center, and outpatient hospital observation Out-of-Network: 20% of the Cost for outpatient hospital services |
| Plan Benefits | Champion Advantage | Champion Connect |
|---|---|---|
| Healthy Foods / Over-the-Counter Items / Utilities Benefit |
In-Network: $270 Allowance every quarter. Eligible members pay $0 Copay for a debit card to use on over-the-counter items, healthy foods and produce, and assistance with utility costs. Any unused monthly amounts not used within 90 days do not roll over to the next period.^ Out-of-Network: Not Covered |
In-Network: $480 Allowance every quarter. Out-of-Network: Not Covered |
| Transportation |
In-Network: $0 Copay for 40 one-way trips to plan-approved health-related locations, up to 25 miles per trip Out-of-Network: Not Covered |
In-Network: $0 Copay for 60 one-way trips to plan-approved health-related locations, up to 25 miles per trip Out-of-Network: Not Covered |
| Dental Services* |
In-Network: $0 Copay for Preventive Dental Services and Medicare-covered dental services Out-of-Network: $0 Copay for Medicare-covered dental services |
In-Network: $0 Copay for Preventive Dental Services and Medicare-covered dental services Out-of-Network: $0 Copay for Medicare-covered dental services |
| Routine Eye Exam |
In-Network: $0 Copay for one exam and one refraction every year Out-of-Network: Not Covered |
In-Network: $0 Copay for one exam every year Out-of-Network: Not Covered |
| Vision Eyewear (frames/lenses/contacts) |
In-Network: $350 Allowance every year Out-of-Network: Not Covered |
In-Network: $350 Allowance every year Out-of-Network: Not Covered |
| Routine Hearing Exam |
In-Network: $0 Copay for one exam and one fitting/evaluation every year Out-of-Network: Not Covered |
In-Network: $0 Copay for one exam and one fitting/evaluation every year Out-of-Network: Not Covered |
| Hearing Aid |
In-Network: $149 Copay per TruHearing Advanced hearing aid (all models), up to 2 aids every 3 years Out-of-Network: Not Covered |
In-Network: $149 Copay per TruHearing Advanced hearing aid (all models), up to 2 aids every 3 years Out-of-Network: Not Covered |
| Respite |
In-Network: $0 Copay for up to 12 four-hour sessions per year with Helper Bees Out-of-Network: Not Covered |
In-Network: $0 Copay for up to 12 four-hour sessions per year with Helper Bees Out-of-Network: Not Covered |
| Personal Emergency Response System (PERS) |
In-Network: $0 Copay Out-of-Network: Not Covered |
In-Network: $0 Copay Out-of-Network: Not Covered |
| Prescription Drug Costs | Champion Advantage | Champion Connect |
|---|---|---|
| Tier 1 - Preferred Generics (Participating Retail Pharmacy) |
In-Network: $0 Copay |
In-Network: $0 Copay |
| Tier 1 - Preferred Generics (Mail Order) |
In-Network: $0 Copay |
In-Network: $0 Copay |
| Tier 2 - Non-Preferred Generics (Participating Retail Pharmacy) |
In-Network: $5 Copay |
In-Network: $0 Copay |
| Tier 2 - Non-Preferred Generics (Mail Order) |
In-Network: $10 Copay |
In-Network: $0 Copay |
| Tier 3 - Preferred Brand (Participating Retail Pharmacy) |
In-Network: $47 Copay |
In-Network: 25% of the Cost |
| Tier 3 - Preferred Brand (Mail Order) |
In-Network: $94 Copay |
In-Network: 25% of the Cost |
| Tier 4 - Non-Preferred Brands (Participating Retail Pharmacy) |
In-Network: $100 Copay |
In-Network: 25% of the Cost |
| Tier 4 - Non-Preferred Brands (Mail Order) |
In-Network: $200 Copay |
In-Network: 25% of the Cost |
| Tier 5 - Specialty Drugs (Participating Retail Pharmacy) |
In-Network: 33% of the Cost |
In-Network: 25% of the Cost |
| Tier 5 - Specialty Drugs (Mail Order) |
In-Network: A 100-day supply is not available in Tier 5 |
In-Network: A 100-day supply is not available in Tier 5 |
| Tier 6 - Select Care (Participating Retail Pharmacy) |
In-Network: $0 Copay |
In-Network: $0 Copay |
| Tier 6 - Select Care (Mail Order) |
In-Network: $0 Copay |
In-Network: $0 Copay |
| Insulin |
In-Network: At retail pharmacy locations, you won’t pay more than $20 for a one-month supply or $60 for a three-month supply of each insulin product covered by our plan on Tiers 2, 3, and 4. You will not pay more than $20 for a one-month supply of insulin on Tier 5. For mail order, you won’t pay more than $40 for a three month supply of each insulin product covered by our plan on Tiers 2, 3, and 4. Long term supplies of insulins in Tier 5 are not available through mail order. |
In-Network: You won’t pay more than $35 for a one-month supply or $105 for a three-month supply of each insulin product covered by our plan on Tiers 3 and 4 and no more than $35 for a one-month supply of insulin on Tier 5, even if you haven’t paid your deductible. |
| Plan Resources | Champion Advantage | Champion Connect |
|---|---|---|
| Summary of Benefits | Download | Download |
| Annual Notice of Change (ANOC) | Download | Download |
| Over-the-Counter Catalog | Download | Download |
| Healthy Foods Catalog | Download | Download |
| Dental Fee Schedule | Download | Download |
| Clinical Criteria | Download | Download |
| Verification of Chronic Condition Form | Download | Download |
| Health Risk Assessment Form | Download | Download |
| Enrollment Form | Download | Download |
| Evidence of Coverage (EOC) | Download | Download |
| Enrollment Kit | Download | Download |
*As a Point-of-Service (POS) plan, you can use providers outside of the plan’s network but you may have an additional cost. If you use an out-of-network provider that is not participating in Medicare, neither Medicare nor Champion Advantage and Champion Connect (HMO-POS C-SNP) will pay for those services. Make sure your provider participates in Medicare.
