2027 Medicare Advantage Dual Special Needs Plan documents
Your Blue Shield of California Medicare Advantage Dual Special Needs Plan documents are listed on this page. Here are a few key documents to help you understand your plan:
- Member Handbook explains the healthcare benefits covered by your plan.
- Summary of Benefits (SOB) is a simplified document that goes over your health benefits and coverage.
- Annual Notice of Changes (ANOC) tells you about any changes to your plan’s costs and coverage that start on January 1 of each year.
To learn about your rights, responsibilities, and what happens if you leave the plan, read Chapter 10 in your member handbook linked below.
Blue Shield Medicare + Medi-Cal Plan (HMO D-SNP)
Blue Shield Medicare + Medi-Cal Plan (HMO D-SNP) – Los Angeles and San Diego counties
Member Handbook
English (PDF, 42 KB) / Español (PDF, 42 KB) / Arabic (PDF, 42 KB) / Armenian (PDF, 42 KB) / Chinese (Simplified) (PDF, 42 KB) / Chinese (Traditional) (PDF, 42 KB) / Farsi (PDF, 42 KB) / Khmer (PDF, 42 KB) / Korean (PDF, 42 KB) / Russian (PDF, 42 KB) / Tagalog (PDF, 42 KB) / Vietnamese (PDF, 42 KB)
Summary of Benefits (SOB)
English (PDF, 1.4 MB) / Español (PDF, 2.1 MB) / Arabic (PDF, 1.9 MB) / Armenian (PDF, 2.1 MB) / Chinese (Simplified) (PDF, 1.9 MB) / Chinese (Traditional) (PDF, 1.7 MB) / Farsi (PDF, 1.7 MB) / Khmer (PDF, 7.3 MB) / Korean (PDF, 1.3 MB) / Russian (PDF, 1.6 MB) / Tagalog (PDF, 2 MB) / Vietnamese (PDF, 1.7 MB)
Annual Notice of Changes
English (PDF, 2 MB) / Español (PDF, 1.7 MB) / Arabic (PDF, 1.9 MB) / Armenian (PDF, 1.9 MB) / Chinese (Simplified) (PDF, 1.4 MB) / Chinese (Traditional) (PDF, 1.7 MB) / Farsi (PDF, 2.4 MB) / Khmer (PDF, 1 MB) / Korean (PDF, 1.5 MB) / Russian (PDF, 1.6 MB) / Tagalog (PDF, 1.3 MB) / Vietnamese (PDF, 3.5 MB)
Attestation for Food and Produce Special Supplemental Benefit for the Chronically Ill (SSBCI)
This plan has a Special Supplemental Benefit for the Chronically Ill (SSBCI) called Food and Produce. To use this benefit, you must meet the plan’s rules for being “chronically ill.” Not everyone will qualify. We will tell you if you need a note from your doctor to show you meet these rules.
English (PDF, 133 KB) / Español (PDF, 42 KB) / Chinese (Simplified) (PDF, 42 KB) / Chinese (Traditional) (PDF, 42 KB) / Korean (PDF, 42 KB)
Enrollment Form
English (PDF, 166 KB / Español (PDF, 42 KB) / Arabic (PDF, 42 KB) / Armenian (PDF, 42 KB) / Chinese (Simplified) (PDF, 42 KB) / Chinese (Traditional) (PDF, 42 KB) / Farsi (PDF, 42 KB) / Khmer (PDF, 42 KB) / Korean (PDF, 42 KB) / Russian (PDF, 42 KB) / Tagalog (PDF, 42 KB) / Vietnamese (PDF, 42 KB)
Pre-enrollment Checklist
English (PDF, 279 KB) / Español (PDF, 152 KB) / Arabic (PDF, 249 KB) / Armenian (PDF, 193 KB) / Chinese (Simplified) (PDF, 246 KB) / Chinese (Traditional) (PDF, 256 KB) / Farsi (PDF, 253 KB) / Khmer (PDF, 188 KB) / Korean (PDF, 218 KB) / Russian (PDF, 245 KB) / Tagalog (PDF, 163 KB) / Vietnamese (PDF, 339 KB)
Model of Care Evaluation Summary of Findings
English (PDF, 214 KB) / Español (PDF, 189 KB) / Arabic (PDF, 233 KB) / Armenian (PDF, 217 KB) / Chinese (Simplified) (PDF, 332 KB) / Chinese (Traditional) (PDF, 341 KB) / Farsi (PDF, 233 KB) / Khmer (PDF, 186 KB) / Korean (PDF, 345 KB) / Russian (PDF, 216 KB) / Tagalog (PDF, 227 KB) / Vietnamese (PDF, 232 KB)
Dental Guide
English (PDF, 472 KB) / Español (PDF, 428 KB)
Nondiscrimination notices, Notice of Availability of Language Services and Auxiliary Aids and Services and Blue Shield MA-PD star ratings
Nondiscrimination and Notice of Availability of Language Services and Auxiliary Aids and Services
Nondiscrimination notice:
English (PDF, 559 KB) / Español (PDF, 629 KB) / Arabic (PDF, 821 KB) / Armenian (PDF, 747 KB) / Chinese (Simplified) (PDF, 1.1 MB) / Chinese (Traditional) (PDF, 695 KB) / Farsi (PDF, 776 KB) / Khmer (PDF, 832 MB) / Korean (PDF, 781 KB) / Russian (PDF, 755 KB) / Tagalog (PDF, 706 KB) / Vietnamese (PDF, 783 KB)
Notice of Availability of Language Services and Auxiliary Aids and Services:
English (PDF, 2 MB)
Blue Shield MA-PD Star ratings
Blue Shield Medicare + Medi-Cal Plan (HMO D-SNP) Medicare Star Ratings¹
English (PDF, 190 KB)
Español (PDF, 188 KB)
Arabic (PDF, 276 KB)
Armenian (PDF, 212 KB)
Chinese (Simplified) (PDF, 272 KB)
Chinese (Traditional) (PDF, 266 KB)
Farsi (PDF, 275 KB)
Khmer (PDF, 220 KB)
Korean (PDF, 295 KB)
Russian (PDF, 266 KB)
Tagalog (PDF, 185 KB)
Vietnamese (PDF, 341 KB)
1Every year, Medicare evaluates plans based on a 5-star rating system.
Please see 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 of California Dual Special Needs Plans Customer Service at (800) 452-4413 (TTY: 711), 8 a.m. to 8 p.m., Pacific Time, seven days a week.
For help in your language, please review the Notice of Availability of Language Services and Auxiliary Aids and Services and the Nondiscrimination Notice located for download on this page.
Blue Shield offers Blue Shield Medicare + Medi-Cal Plan (HMO D-SNP) to new members in Los Angeles and San Diego counties.
Blue Shield of California is an HMO D-SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.
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Page last updated: 10/05/2026