Translated forms and documents

The 2021 and 2022 Enrollment Application and other plan documents are available in Chinese, Korean and Spanish for certain plans.

Applications

Full application – Chinese – 2021, PDF opens new window

Full application – Chinese – 2022, PDF opens new window

D-SNP application – Chinese – 2021, PDF opens new window

D-SNP application – Chinese – 2022, PDF opens new window

Plan documents

Transition Letter – 2022, PDF opens new window

Low Income Premium Subsidy – 2022, PDF opens new window

Humana Gold Plus H3533-033 (HMO)

Summary of benefits – Chinese – 2021, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

Summary of benefits – Chinese – 2022, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

Evidence of coverage – Chinese – 2021, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

Evidence of coverage – Chinese – 2022, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

Annual Notice of Change – Chinese – 2022, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

CMS 30533 Plan Star Ratings – 2021, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

CMS 30533 Plan Star Ratings – 2022, Humana Gold Plus HMO H3533-033 (HMO), PDF opens new window

Humana Gold Plus H3533-034 (D-SNP)

Summary of benefits – Chinese – 2022, Humana Gold Plus H3533-034 (D-SNP), PDF opens new window

Evidence of coverage – Chinese – 2022, Humana Gold Plus H3533-034 (D-SNP), PDF opens new window

Annual Notice of Change – Chinese – 2022, Humana Gold Plus H3533-034 (D-SNP), PDF opens new window

CMS 30533 Plan Star Ratings – 2022, Humana Gold Plus H3533-034 (D-SNP), PDF opens new window

Humana Gold Plus H3533-034 (SNP)

Summary of benefits – Chinese – 2022, Humana Gold Plus H3533-034 (SNP), PDF opens new window

Evidence of coverage – Chinese – 2022, Humana Gold Plus H3533-034 (SNP), PDF opens new window

Annual Notice of Change – Chinese – 2022, Humana Gold Plus H3533-034 (SNP), PDF opens new window

CMS 30533 Plan Star Ratings – 2022, Humana Gold Plus H3533-034 (SNP), PDF opens new window

Provider and Pharmacy Directories

H3533NYHS01ACCH21 – 2021, PDF opens new window

H3533NYHS01ACCH22 – 2022, PDF opens new window

H3533NYHS01BCCH21 – 2021, PDF opens new window

H3533NYHS01BCCH22 – 2022, PDF opens new window

H3533NYHS01CCCH21 – 2021, PDF opens new window

H3533NYHS01CCCH22 – 2022, PDF opens new window

H3533NYHS01DCCH21 – 2021, PDF opens new window

H3533NYHS01DCCH22 – 2022, PDF opens new window

Prescription Drug Guides

Chinese Comprehensive HMO – 2021, PDF opens new window

Chinese Comprehensive HMO – 2022, PDF opens new window

Chinese Comprehensive HMO D-SNP – 2022, PDF opens new window

Applications

Full application – Korean – 2021, PDF opens new window

Full application – Korean – 2022, PDF opens new window

D-SNP application – Korean – 2021, PDF opens new window

D-SNP application – Korean – 2022, PDF opens new window

Applications

Full application – Spanish – 2021, PDF opens new window

Full application – Spanish – 2022, PDF opens new window

D-SNP application – Spanish – 2021, PDF opens new window

D-SNP application – Spanish – 2022, PDF opens new window