Medicare Advantage Plans in California
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: November 11, 2020
Medicare Advantage plans provide healthcare coverage to eligible Medicare beneficiaries through private insurers. This Medicare Part C option includes the same basic coverage as Original Medicare. It’s essentially the combination of Medicare Parts A and B. However, many Medicare Advantage Plans also include Part D prescription drug coverage. You may also enjoy more services with an Advantage plan, like hearing, vision, or dental. Original Medicare doesn’t have this extra coverage.
- 1 In 2019, there were 220 Medicare Advantage plans in California.
- 2 40% of the total Medicare population in California is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $9,868 per beneficiary in California, which is 2% lower than the national average.
- 4 Available Medicare Advantage plans range from 1 to 90 across California’s 58 counties.
If you’re considering a Medicare Advantage plan, you have a variety of options, but your choices are limited by your required geographical coverage area and the available health insurance providers. If you took advantage of employer-sponsored health coverage in the past, you might recognize some of the plan types that Medicare Advantage offers. Weigh the features, benefits, and disadvantages of each available plan type against your individual needs to choose the plan most suitable for you.
Medicare Advantage Plans in California
Types of Medicare Advantage Plans
There are three types of Medicare Advantage plans to choose from in California currently. A fourth coverage option — the Private Fee-for-Service (PFFS) Plan — is no longer available here. Of the remaining three, two promote in-network health care for top savings and comprehensive care. The third plan option is designed to give people with special conditions and healthcare needs managed care that focuses on their specific disease and medical requirements.
Health Maintenance Organizations (HMO)
With an HMO plan, you receive medical services within an approved network of providers and facilities. HMO healthcare coverage is wide-ranging, including preventative care, lab work, in-patient and out-patient medical care, and other essential medical services. Some HMO plans also offer dental coverage, prescription drugs, and other optional services.
HMO plans require participants to choose primary care providers (PCP) who manage their health care. If you need to see a specialist or other medical professionals outside of your PCP’s area of expertise, you must get a referral from your PCP. Out-of-network medical services are typically not covered. Some exceptions may apply. You can also check for a Point-of-Service option, so you can see providers outside your network for a discounted cost. While popular in California, HMOs aren’t available throughout the entire state.
Preferred Provider Organizations (PPO)
Similar to HMOs, PPO plans support in-network care. However, you can also see providers outside of your approved network. You just pay a higher co-payment for out-of-network visits. You can also avoid the PCP referral system. With a PPO, you don’t need to choose a primary care provider.
Moreover, in most cases, you can schedule appointments with specialists directly. Check with the individual PPO plan for specific rules. As of 2020, local PPO’s are available in more than a third of California’s 58 counties. Prescription drug coverage is included with all these local plans.
Special Needs Plans (SNP)
As they are named, SNPs are tailored to participants who have special medical needs due to certain diseases or chronic medical conditions (C-SNPs). Some examples include alcohol dependence, cancer, cardiovascular disease, HIV/AIDS, ESRD, and neurological disorders. Each plan is designed for the specific condition that the participants suffer from and typically offer more services than does Original Medicare.
Nursing home residents and other patients living in institutions, as well as people who need at-home nursing care, are eligible for I-SNPs. Low-income participants who qualify for both Medi-Cal and Medicare may opt for a D-SNP. Prescription drug coverage must be included in all SNPs.
Private Fee-For-Service Plans (PFFS)
Note that California’s Medicare Advantage program no longer includes Fee-for-Service plans.
The PFFS option dispenses with the provider network system that HMOs and PPOs favor. Instead, participants are simply limited to providers and facilities who choose to accept PFFS Medicare Advantage coverage. These providers must be approved by Medicare and agree to the PFFS terms of service and payment conditions. The private insurers, who have contracted with Medicare to offer these plans, set the payment rates and plan premiums. PCPs and referrals are not required. When available, these plans were most frequently used in rural areas of California.
Enrollment & Eligibility for Medicare Advantage Plans in California
To participate in a California Medicare Advantage plan, you must meet age, income, health condition, Social Security status, and other eligibility criteria. Plus, there are time constraints for when you are allowed to enroll or change plans.
To qualify for a California Medicare Advantage plan, you must meet the following minimum requirements.
- You are at least 65 or permanently disabled and receiving Social Security or Railroad Retirement Board benefits, or you have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Individuals receiving disability insurance must do so for 24 months in order to qualify for Medicare.
- You’re a citizen or have been a legal permanent resident for no less than five years.
- You must be enrolled in both Parts A and B of Original Medicare.
- You cannot be enrolled in Medigap insurance.
- You reside in the service area of the plan you want.
- If you have ESRD, you may not enroll in an HMO or PPO. However, you may qualify for an SNP.
- To enroll in an SNP, you must belong to a qualified group.
Other criteria may apply depending on the plan you choose and the private insurance provider that’s offering the coverage.
You can only enroll in a California Medical Advantage plan during your initial coverage period (ICEP), the annual election period (AEP), or the general enrollment period (GEP). A Medicare Advantage (MA) open enrollment period applies if you are already a Medicare Advantage plan participant seeking to change plans.
- ICEP: The seven month period around your 65th birthday, including the three months before your birthday month, the month of your birthday, and the three months after.
- AEP: Annual period between October 15 and December 7
- GEP: Annual period between January 1 and March 31
- GEP Part B enrollees: If you already have Part A but never had Part B, you can enroll in Part B between January 1 and March 31. You may then enroll in a Medicare Advantage plan between April 1 and June 1.
- MA Open Enrollment: You can switch from an MA plan to another MA plan or to Original Medicare during the annual GEP period between January 1 and March 31.
- Special Election Periods (SEPs): Various specific circumstances may allow you to leave an existing MA plan or enroll in a new MA plan.
During the Open Enrollment Period (OEP) the following can occur:
- Anyone who has (or is signing up for) Medicare Parts A or B can join or drop a Part D prescription drug plan.
- Anyone with Original Medicare (Parts A & B) can switch to a Medicare Advantage plan.
- Anyone with Medicare Advantage can drop it and switch back to just Original Medicare (Parts A & B).
- Anyone with Medicare Advantage can switch to a new Medicare Advantage plan.
- Anyone with a Part D prescription drug plan can switch to a new Part D prescription drug plan.
Prescription Drug Coverage
Medicare Part D plans provide prescription drug coverage. This is an important part of your medical care, especially if you have a chronic condition requiring medication management. Each plan has its own formulary that specifies which drugs are covered. However, they must meet Medicare drug coverage standards, at a minimum.
Plans with formulary tiers charge differing levels of copayments for each drug tier. In those arrangements, generic drugs are the least expensive. Preferred brand-name drugs follow generics, and then non-preferred brand-name medicines come into play. Some providers offer a specialty tier for expensive medication at the highest copay amount. Many Medicare Advantage plans include Part D coverage (MA-PDs). Check the plan details before enrolling. In California, this coverage is required with SNPs. Note that you may not add a stand-alone Part D plan to a Medical Advantage Plan.
Medicare Advantage Resources in California
Choosing the right Medicare plan can feel overwhelming. There is a lot of available information, but the data is often complicated and confusing. It may also seem as though the rules and available plans are always changing. But reliable and qualified resources can simplify the process and help you make an educated decision.
The following state and county organizations and nonprofits provide helpful Medicare Advantage information, support, counseling, and links to make the process go more smoothly for you.
California Department of Aging
The California DOA sponsors Medicare Counseling through the Health Insurance Counseling and Advocacy Program (HICAP) at the county level. You can locate community resources through Area Agencies on Aging online by selecting your county on an interactive map or by calling 1-800-510-2020.
You can also get legal help for your Medicare issues. To take advantage of these services, you must either be almost eligible for Medicare or already eligible due to age or disability. HICAP counselors also deliver periodic educational conferences and presentations on Medicare for people of all ages.
Contact Information: Website | 1-800-434-0222
California Department of Insurance
The state DOI website is a valuable resource for Original Medicare and Medicare Advantage information. The site includes links to pertinent information and contact numbers for the various federal and state Medicare departments. This resource is designed to provide helpful information for California seniors looking for health coverage.
Contact Information: Website | 1-800-633-4227
California Health Advocates
CHA is a non-profit dedicated to Medicare education and advocacy. Learn more about Medicare in California for you or your family members with their fact sheets and Medicare topics pages. Plus, you can stay abreast of changes to Medicare with the CHA Medicare Basics news feed. Blog and news posts update Californians on updates, legal changes, and programs that can help you understand Medicare programs and plans and make you aware of available state and local resources.
Individual articles on this section of the CHA website include information about timely Medicare topics, links to more material, and contact information for the pertinent organizations, when applicable. You can also link to other relevant news feeds on this site, like the Medicare Advantage, Medicare & Disabilities, and Medicare Billings, Claims & Appeals blogs.
Contact Information: Website | 916-231-5110
Center for Health Care Rights
Los Angeles County Medicare beneficiaries can turn to this California Center for legal help, counseling, and advocacy in addressing Medicare issues and problems. This non-profit helps seniors over 65 and Medicare beneficiaries who live in the County of LA. You can seek counseling over the phone or in-person. Call their hotline at 1-800-824-0780 to schedule an appointment. They offer services in many languages. The website also provides informative links, publications, and event notifications.
Contact Information: Website | 213-383-4519
- Sources [-]
https://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans Last accessed April 2021
https://cahealthadvocates.org/the-basics/special-election-periods-seps-for-parts-c-d/ Last accessed April 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.