Important Policy Notices

For All Members:

• RealCare Privacy Policy
• General Guidelines
• Qualifying Events
• C.A.R. Group Health Plan Administration and Fees

For C.A.R. Group Insurance Program Members:
Thank you for your participation in the C.A.R. Insurance Plan. Below are important policy notices that you should read, print and retain for safekeeping.

2024 CAR Required Notices

• CAR Anthem Required Notices (Combined)
• CAR Kaiser Required Notices (Combined)
• CAR MetLife Required Notices (Combined)

Required Notices Include:

• • HIPAA Notice of Special Enrollment Rights
  • Newborns’ and Mothers’ Health Protection Act
  • Women’s Health & Cancer Rights Act
  • Covered CA Notice
  • Patient Protections Notice
  • No Surprises Act Notice
  • Anthem Creditable Coverage Notice
  • Anthem Non Creditable Coverage Notice
  • Kaiser Creditable Coverage Notice

2024 Medicare/CMS Creditable Coverage Notices

• 2024 Anthem Non Creditable Coverage Notice
• 2024 Anthem Creditable Coverage Notice
• 2024 Kaiser Creditable Coverage Notice

2023 Medicare/CMS Creditable Coverage Notices

• 2023 Anthem Non Creditable Coverage Notice – REVISED
• 2023 Anthem Creditable Coverage Notice – REVISED
• 2023 Kaiser Creditable Coverage Notice

2024 Evidence of Coverage Documents will be uploaded when received from the carriers in January

2023 Kaiser Evidence of Coverage Documents

HSA Plans

• Kaiser Bronze HDHP 7000-0 Evidence of Coverage Northern CA
• Kaiser Bronze HDHP 7000-0 Evidence of Coverage Southern CA
• Kaiser Silver HDHP 2700-25% Evidence of Coverage Northern CA
• Kaiser Silver HDHP 2700-25% Evidence of Coverage Southern CA
• Kaiser Gold HDHP 1600-15% Evidence of Coverage Northern CA
• Kaiser Gold HDHP Gold 1600-15% Evidence of Coverage Southern CA

HMO Plans

• Kaiser Bronze 5400-60 Evidence of Coverage Northern CA
• Kaiser Bronze 5400-60 Evidence of Coverage Southern CA
• Kaiser Bronze 6300-65 Evidence of Coverage Northern CA
• Kaiser Bronze 6300-65 Evidence of Coverage Southern CA
• Kaiser Silver 2800-65 Evidence of Coverage Northern CA
• Kaiser Silver 2800-65 Evidence of Coverage Southern CA
• Kaiser Silver 2300-65 Evidence of Coverage Northern CA
• Kaiser Silver 2300-65 Evidence of Coverage Southern CA
• Kaiser Silver 2500-55 Evidence of Coverage Northern CA
• Kaiser Silver 2500-55 Evidence of Coverage Southern CA
• Kaiser Silver 1900-65 Evidence of Coverage Northern CA
• Kaiser Silver 1900-65 Evidence of Coverage Southern CA
• Kaiser Gold HRA 2250-35 Evidence of Coverage Northern CA
• Kaiser Gold HRA 2250-35 Evidence of Coverage Southern CA
• Kaiser Gold 1000-40 Evidence of Coverage Northern CA
• Kaiser Gold 1000-40 Evidence of Coverage Southern CA
• Kaiser Gold 250-35 Evidence of Coverage Northern CA
• Kaiser Gold 250-35 Evidence of Coverage Southern CA
• Kaiser Gold 0-30 Evidence of Coverage Northern CA
• Kaiser Gold 0-30 Evidence of Coverage Southern CA
• Kaiser Platinum 0-20 Evidence of Coverage Northern CA
• Kaiser Platinum 0-20 Evidence of Coverage Southern CA
• Kaiser Platinum 0-10 Evidence of Coverage Northern CA
• Kaiser Platinum 0-10 Evidence of Coverage Southern CA

2023 Anthem Evidence of Coverage Documents

HSA Plans

• Anthem Bronze PPO 6700-0% 6RG7
• Anthem Bronze PPO 6000-45% 6RJK
• Anthem Silver PPO 2100-30% HSA 6RK0 Self Only
• Anthem Silver PPO 2100-30% HSA 6RJ5 Family
• Anthem Silver PPO 2600-35% HSA 6RG5 Self Only
• Anthem Silver PPO 2600-35% HSA 6RH6 Family

PPO Plans

• Anthem Bronze PPO 70-6600-35% 6RFV
• Anthem Bronze PPO 40-6200-40% 6RJN
• Anthem Silver PPO 55-2500-45% 6RFY
• Anthem Silver PPO 50-2200-40% 6RK6
• Anthem Silver PPO 55-1950-35% 6RJ0
• Anthem Silver PPO 45-1750-40% 6RGX
• Anthem Gold PPO 35-1000-20% 6RH1
• Anthem Gold PPO 30-750-20% 6RGS
• Anthem Gold PPO 30-500-20% 6RG9
• Anthem Gold PPO 25-30% 6RFN
• Anthem Platinum PPO 15-250-10% 6RG6
• Anthem Platinum PPO 15-40-10% 6RH4

HMO Plans

• Anthem Silver HMO 55 6RJG
• Anthem Gold HMO 35 6RHZ

MetLife Dental and Vision Evidence of Coverage

• MetLife VALUE Dental Plan
• MetLife SELECT Dental Plan
• MetLife CHOICE Dental Plan
• MetLife Enhanced Vision Plan
• MetLife Basic Vision Plan

MetLife Life and AD&D Insurance Certificates

• MetLife Voluntary AD&D
• MetLife Term Life and AD&D

Summary of Benefits & Coverage (SBC)

2024 Anthem Blue Cross Plans

HSA Plans

• Anthem Bronze PPO 6000_45% w_HSA PrevRx SBC 9KGF
• Anthem Bronze PPO 6700_0% w_HSA PrevRx SBC 9KG9
• Anthem Silver PPO HSA_H 2100_3200_4200 30% PrevRx SBC 9B29
• Anthem Silver PPO HSA_H 2100_3200_4200 30% PrevRx SBC 9B35
• Anthem Silver PPO HSA_H 2600_3200_5200 35% PrevRx SBC 9KFG
• Anthem Silver PPO HSA_H 2600_3200_5200 35% PrevRx SBC 9KGL

PPO Plans

• Anthem Bronze PPO 40_6200_40% SBC 9KG2
• Anthem Bronze PPO 70_6600_35% SBC 9B1W
• Anthem Silver PPO 45_1750_40% SBC 9KFJ
• Anthem Silver PPO 50_2200_40% SBC 9B2Q
• Anthem Silver PPO 55_1950_35% SBC 9KGQ
• Anthem Silver PPO 55_2500_45% SBC 9B1X
• Anthem Gold PPO 25_30% SBC 9B25
• Anthem Gold PPO 30_500_20% SBC 9KF1
• Anthem Gold PPO 30_750_20% SBC 9KFK
• Anthem Gold PPO 35_1000_20% SBC 9KFU
• Anthem Platinum PPO 15_40_10% SBC 9B2V
• Anthem Platinum PPO 15_250_10% SBC 9B20

HMO Plans

• Anthem Gold HMO 35_CA_HMO_Small Group_9B2J
• Anthem Silver HMO 55_CA_HMO_Small Group_9B2Y

2024 Kaiser Permanente Plans 

HSA Plans

• 2024 Bronze 60 HDHP HMO 7050-0% SBC
• 2024 Silver 70 HDHP HMO 2850-25% SBC
• 2024 Gold 80 HDHP HMO 1750-15% SBC

HMO Plans

• 2024 Bronze 60 HMO 6300-60 SBC
• 2024 Bronze 60 HMO 5400-60 SBC
• 2024 Silver 70 HMO 2950-65 SBC
• 2024 Silver 70 HMO 2500-55 SBC
• 2024 Silver 70 HMO 2300-65 SBC
• 2024 Silver 70 HMO 1900-65 SBC
• 2024 Gold 80 HRA HMO 2250-35 SBC
• 2024 Gold 80 HMO 1000-40 SBC
• 2024 Gold 80 HMO 250-35 SBC
• 2024 Gold 80 HMO 0-35 SBC
• 2024 Platinum 90 HMO 250-30 SBC
• 2024 Platinum 90 HMO 0-20 SBC
• 2024 Platinum 90 HMO 0-10 SBC

If you have any questions about your health plan or would like a copy of these documents mailed to you, please call RealCare at (800) 939-8088, Option 2