- In 2019, there were 220 Medicare Advantage Plans available in California.
- 40% of the total Medicare population in California was enrolled in Medicare Advantage Plans as of 2018.
- In 2018, Original Medicare spent an average of $9,868 per beneficiary in California, which is 2% lower than the national average.
- Available Medicare Advantage Plans range from one to 90 across California’s 58 counties.
Medicare-approved private health insurance companies administer Medicare Advantage Plans. Depending on your health care needs, this may be the more economical option. These plans usually cover more than Original Medicare and have annual out-of-pocket limits, which Original Medicare lacks.
Medicare Advantage Plans in California
Types of Medicare Advantage Plans
California’s Medicare Advantage program is made up of several types of plans to accommodate varying budgets and health care needs. All of these plans offer the same benefits as Original Medicare and may feature provider networks and have rules regarding choosing a primary care provider and getting referrals to see specialists.
Health Maintenance Organizations (HMO)
HMO plans have provider networks that you must get your care from to have services covered by your insurance. While there are a few exceptions, such as out-of-area dialysis and emergency care, HMOs generally don’t pay towards any health care costs you incur when you go to an out-of-network doctor or hospital. With this plan, you’re usually required to choose a primary doctor and get referrals to see specialists. To get the most from your coverage and prevent denied claims, always follow the plan’s rules, such as getting prior approval for certain screenings and services.
Preferred Provider Organizations (PPO)
PPO plans are similar to HMOs in having network providers. However, you have the flexibility to go out-of-network and still have a portion of your expenses covered, although you pay less for services if you use the doctors, specialists, and hospitals in the plan’s network. Most plans don’t require you to choose a primary care physician or get a referral to see a specialist.
Private Fee-For-Service Plans (PFFS)
PFFS plans have specific payment terms for the total cost of the health care services you receive, including what the plan pays for a covered service and what you pay. If you have this type of plan, you can go to any health care provider who agrees to these payment terms. Some PFFS plans have network providers that agree to always treat members, and going to these providers is typically the most economical option. You don’t need to choose a primary care doctor or get a referral to see a specialist.
Special Needs Plans (SNP)
SNPs limit their enrollment to people who meet certain conditions and tailor their benefits, provider networks, and drug formularies accordingly. For example, some SNPs are for those with certain chronic conditions and cover doctors and specialists who specialize in managing that condition. Other SNPs are for those who are dual-eligible for Medicare and Medicaid and have provider networks that accept payment from both programs. Most SNPs require you to choose a primary care doctor and get referrals to see specialists.
Enrollment and eligibility for Medicare Advantage Plans in California
To be eligible to join a Medicare Advantage Plan, you must be at least 65 years old or have a disability that qualifies you for Original Medicare Parts A and B. You must live within the service area of the plan you choose. If you live in California for half of the year and in another state for the other half, find out if the plan you choose covers you in both places.
There are scheduled enrollment periods in which you can join a Medicare Advantage Plan, switch to a different plan or back to Original Medicare, or drop your coverage altogether.
- Initial Enrollment Period: This period opens up when you first become eligible for Medicare and runs for seven months, including the three months before your 65th birthday, the month of your birthday, and the three months following.
- Open Enrollment Period: This period runs from October 15 to December 7. During this period, you can enroll in a Medicare Advantage plan or switch between plans, and any changes you make to your coverage will take effect on January 1.
- Medicare Advantage Open Enrollment Period: This period goes from January 1 to March 31 and is exclusively for those enrolled in Medicare Advantage. During this time, you can switch to another Medicare Advantage Plan or back to Original Medicare one time.
Special enrollment periods open when certain events happen in your life, such as moving or losing your insurance coverage for any reason.
Prescription drug coverage
Even if you don’t take a prescribed medication when you first sign up for Original Medicare, you should consider prescription drug coverage, called Part D, to avoid late enrollment fees. All SNPs and most HMO, PPO, and PFFS plans include some type of drug coverage. If you want prescription drug coverage and you’re signing up for an HMO and PPO Plan, make sure that it’s included in the plan you select. You won’t be allowed to add Part D to these plan types. If you have a PFFS Plan that doesn’t cover prescription drugs, you can typically add Part D coverage for an additional premium.
Medicare Advantage Resources in California
As you’re shopping around for the right Medicare Advantage Plan for your health care needs, it helps to receive guidance and advice from experts who understand the program and process. California has several organizations where you can talk to trained counselors who help you get the most from your Medicare benefits.
Health Insurance Counseling and Advocacy Program
HICAP provides a wide array of services to those who are eligible or will soon be eligible for Medicare. Through this statewide program, you can get information on how to sign up for a Medicare Advantage Plan, find out which plans are available in your region, and get answers to any questions you may have about your prescription drug coverage or cost-sharing responsibilities. It’s staffed with trained counselors who provide free one-on-one consultations regarding health insurance-related issues and Medicare and who can assist you with understanding your medical bills or resolving billing problems.
Contact Information: Website | 800-434-0222
California Department of Insurance
The California Department of Insurance has a Seniors Information Center where you can get up-to-date information on health care coverage options, Medicare, Medicare Supplement Insurance and Medicare Advantage Plans, prescription drug coverage, and Medi-Cal. The website has an information guide that outlines your rights when signing up for an insurance policy. It includes a database of government, private, and nonprofit agencies that provide information on Medicare-related issues, including a directory of local HICAP counselors.
Contact Information: Website | 800-927-4357
County of Los Angeles Workforce Development, Aging and Community Services
WDACS is the Area Agency on Aging in Los Angeles County. It’s one of nearly three dozen AAAs in the state and receives federal funds to administer a variety of programs to seniors aged 60 and over. The agency serves as your single point of contact for getting assistance through HICAP. Volunteer counselors are typically stationed at agency-operated senior centers throughout the region. They are available to help you compare available Medicare Advantage Plans, organize your medical bills, and resolve denied claims.
Contact Information: Website | 213-738-2600
Bet Tzedek Legal Services
Bet Tzedek Legal Services is funded in part through the federal Older Americans Act to provide free civil legal services to those aged 60 and over in the Los Angeles area. Its team can help you access public benefits that you’re eligible for, including Medicare. The agency helps to address Medicare fraud and scams, denied coverage, or canceled policies.
Contact Information: Website | 323-939-0506
Learn More from Our Sources
- Medicare | Medicare Advantage Plans
- KFF |Enrollees as a Percentage of Total Medicare Population
- Forbes | Medicare’s Out-Of-Pocket Maximum Limit: How Much Will It Cost You?
- Medicare | Health Maintenance Organization (HMO)
- Medicare | Preferred Provider Organization (PPO)
- Medicare | Private Fee-for-Service (PFFS)
- Medicare | Special Needs Plans (SNP)
- Medicare | Who Can Join a Medicare Advantage Plan?
- Medicare | Joining a Health or Drug Plan
- Medicare | Special Circumstances (Special Enrollment Periods)
- Medicare | Part D Late Enrollment Penalty
- Medicare | How to Get Prescription Drug Coverage