If you’re enrolled in Original Medicare, Part A and Part B, in California, you may choose to receive your health coverage through Medicare Advantage (Medicare Part C). Under Medicare Advantage, you receive your health benefits through a Medicare health plan instead of Original Medicare, the federally administered program; these plans are available through Medicare-approved private insurance companies. Your coverage choices will depend on the California zip code you live in and on the specific health insurance plan you enroll in.
How Medicare Advantage works in California
Medicare Advantage is required to offer at least the same hospitalization and medical benefits as Original Medicare, Part A and Part B, with the exception of hospice care. Medicare Advantage plans in California may offer additional benefits, like routine vision and dental, hearing, and wellness programs. Many plans, known as Medicare Advantage Prescription Drug plans, also cover prescription medications.
As a Medicare beneficiary in California, you must first be enrolled in Original Medicare, Part A and Part B, to be eligible for Medicare Part C. You’re first eligible to enroll during your seven-month Initial Enrollment Period (IEP), which begins three months before you turn 65, includes your birthday month, and ends three months after that month. If you qualify for Medicare because of disability, you can enroll in Medicare at any age; your IEP in this case would be three months before the 25th month of Social Security or Railroad Retirement disability months and would last seven months. Failure to sign up for Original Medicare during this seven-month span may result in a late-enrollment penalty for as long as you remain enrolled in Medicare. You may enroll in Original Medicare at a later date, during the annual General Enrollment Period, which runs from January 1 to March 31, but you may have to pay a late-enrollment penalty. Keep in mind that you may delay Medicare Part A and/or Part B in certain situations (for example, if you have group coverage because you’re working). You may enroll later on with a Special Enrollment Period when that coverage ends or you stop working; in this situation, you generally wouldn’t have to pay a late-enrollment penalty.
Once you’re enrolled in Part A and Part B, you may be eligible for Medicare Advantage in California if you live in the service area of a plan and don’t have end-stage renal disease (with some exceptions). You’re first eligible to enroll in Medicare Part C during your Initial Coverage Election Period (ICEP), which generally takes place during the same seven-month period as your Initial Enrollment Period for Part B. If you delay Part B, your ICEP is the three month period before your Part B coverage starts.
If you didn’t enroll in a Medicare Advantage plan when you were first eligible or decide you want to switch to Medicare Part C later on, you can do so during certain times of the year. In California and the rest of the United States, you can enroll in or change plans during the Annual Election Period, also called the Fall Open Enrollment, which runs from October 15 to December 7. Your new coverage goes into effect on January 1 of the following year. During this time, you can sign up for Medicare Part C coverage for the first time, change Medicare Advantage plans, or disenroll from your Medicare Advantage plan to return to Original Medicare. If you’re enrolled in Original Medicare, you can use this period to make changes to your Medicare prescription drug coverage by enrolling in, switching plans, or disenrolling from a stand-alone Medicare Prescription Drug Plan.
As a California Medicare beneficiary, you may be eligible to switch Medicare plans during Special Election Periods (SEPs). If you go through certain life-changing events, like losing your current coverage, or moving to a new address where your old plan may not be available, you may be allowed to switch Medicare Advantage plans during a Special Election Period. These periods vary according to the reason you’re eligible for an SEP.
If you decide to leave Medicare Advantage and switch back to Original Medicare, Part A and Part B, you can do so during the Medicare Advantage Open Enrollment Period, which runs annually from January 1 to March 31 each year in California and the rest of the United States. During this period, you can also enroll in a Medicare Prescription Drug Plan or switch from one Medicare Advantage plan to another.
Types of Medicare Advantage plans in California
There are various Medicare Advantage plans available in California. Here’s a look at the main types of existing health plans:
- Health Maintenance Organizations (HMOs): Under an HMO, you’re required to visit doctors, health-care providers, and hospitals included in your plan’s network; you’re generally not covered if you go out of network unless it’s for emergency or urgent care. You may also have to get a referral from your primary care doctor to receive coverage for specialist services.
- HMO Point-of-Service (HMO-POS): More flexible than an HMO, an HMO-POS plan lets you sometimes go out-of-network for certain health services, but generally at a higher cost.
- Preferred Provider Organization (PPO*): A PPO offers even more flexibility than an HMO-POS plan, letting beneficiaries choose doctors, health-care providers, and hospitals outside of the plan’s network, but again at a higher cost. If you use providers in the plan’s preferred provider network, your copayments and coinsurance costs may be lower.
- Private Fee-for-Service (PFFS): These types of Medicare Advantage plans generally reserve the right to decide how much they will pay for your doctor, health-care provider, and hospital visits. PFFS plans also determine your share of each covered medical service. You can generally see any doctor who will agree to contract with the plan and accept its payment terms, but you’ll need to do this on a case-by-case basis and not all providers will agree to treat you.
- Medical Savings Account (MSA): An MSA plan combines a high deductible with a savings account that beneficiaries use to pay for their health-care expenses. You can use the money that the plan deposits into your account, tax-free, before you reach the plan’s deductible.
- Special Needs Plan (SNP): A Medicare SNP limits enrollment to people with special health needs, which includes those living in institutions, people with certain chronic or disabling conditions, and people who qualify for both Medicare and Medicaid. SNPs offer coverage tailored to suit those specific needs. Some of the chronic conditions that Medicare SNPs target include patients with HIV/AIDS, congestive heart failure, and diabetes, among others.
- Medicare Advantage Prescription Drug (MAPD) plan: An MAPD plan combines health and prescription drug coverage (also available under stand-alone Medicare Prescription Drug Plans if you have Original Medicare) into a single insurance plan. Most of the above types of plans can be Medicare Advantage Prescription Drug plans, with the exception of MSA plans, which never cover prescription drugs.
Comparing Medicare Advantage plans available in California
As a Medicare beneficiary, it’s important for you to compare all your available options when enrolling in a Medicare Advantage plan in California.
The availability and cost of Medicare Advantage plans generally varies depending on your state and county of residence. It’s common for premiums of a Medicare Advantage plan with the same coverage and benefits to vary between different counties within the state of California. You may find that some Medicare Advantage plans in California offer premiums as low as $0; however, always keep in mind that you must continue paying your Medicare Part B premiums, even if your Medicare Advantage plan has a $0 premium, in order to keep your Part B coverage.
Some Medicare Advantage plans may offer additional benefits beyond what is included in Original Medicare, Part A and Part B, so you will need to determine exactly what kind of coverage you may require, plus whether or not you want prescription drug coverage with your Medicare Advantage plan through a Medicare Advantage Prescription Drug plan. With all these options available in California, you can see why it can be important to compare plan options with the benefits and costs best suited for your personal health needs.
To start comparing Medicare Advantage plan options in California today, enter your zip code into the plan finder tool on this page for a customized list of plan options available in your area. You can also enter your prescription drug needs to further customize your search and cost estimates.
For further information about other types of Medicare insurance plans in California, see:
Hopefully, you now have a better idea of how Medicare Advantage works in California and what some of your coverage choices may be. To get help finding the Medicare plan option that may work best for your health needs, contact us today to speak with a licensed insurance agent by calling the phone number on this page.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover an out-of-network service, you or your provider are encouraged to ask the plan for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.