Since Medicare Advantage (MA) was introduced, the program's popularity continues to grow every year, with the number of enrollees doubling over the past decade. Over 22 million people joined a Medicare Advantage plan in 2019, which accounts for over one-third of all Medicare beneficiaries. This page describes Medicare Advantage plans in California, including how the program works, who is eligible, and how to compare your options.
What Is Medicare Advantage in California?
California Medicare Advantage plans are offered by private insurance companies and are similar to the employer-sponsored group health insurance most Americans are familiar with.
Also known as Medicare Part C, every Advantage plan must provide the same benefits you get with Original Medicare. This includes:
- Medicare Part A, which covers inpatient services received in a hospital or skilled nursing facility (SNF)
- Medicare Part B, which covers outpatient services such as doctor visits, lab work, urgent care, and durable medical equipment (DME)
Original Medicare does not include prescription drug coverage. For that, you need a Medicare Part D plan.
The reason Medicare Advantage has become so popular is that most plans provide more coverage than you get with Original Medicare. For example, around 90 percent of Advantage plans provide prescription drug coverage.
California Medicare Advantage Plans with Prescription Drug Coverage
Medicare Advantage Prescription Drug plans (MA-PD) bundle your Medicare Parts A, B, and D benefits into a single policy. Other common add-on benefits include:
- Routine vision care, including eye exams and prescription lenses
- Routine dental care, such as cleanings and x-rays
- Hearing aids
- Fitness programs like SilverSneakers
Benefits vary widely depending on the plan and provider, so compare your options carefully. (More on that in a moment.)
Who Is Eligible for Medicare Advantage in California?
If you have Medicare Parts A and B, you can sign up for Medicare Part C in California.
American citizens and permanent legal residents who have been here for at least 5 years become eligible for Medicare when they turn 65. Please note that enrollment in Parts A and B is only automatic if you began collecting Social Security benefits at least 4 months before your 65th birthday. Everyone else has to apply for Medicare. You can do that on the Social Security website by clicking here.
Around one-sixth of Medicare beneficiaries qualify due to collecting Railroad Retirement Board (RRB) or Social Security disability benefits for 24 months. Enrollment occurs automatically in your 25th month.
You may also qualify for Medicare if you have amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease) or end-stage renal disease (ESRD).
When Can You Sign Up for a Medicare Advantage Plan in California?
Signing up for a Medicare Advantage plan in California is restricted to specific enrollment periods.
Your Initial Enrollment Period (IEP) begins 3 months before you first become eligible for Medicare. It lasts for a full 7 months. For example, if your 65th birthday or 25th month of collecting RRB or Social Security disability occurs in September, then your IEP starts on June 1 and ends on December 31. However, if your birthday falls on the first of the month, those dates are pushed forward one month (May 1 through November 30 if your birthday is September 1).
If you miss your Initial Enrollment Period and do not qualify for a Special Enrollment Period (SEP), you may sign up for Medicare Part A and/or Part B during the General Enrollment Period. This lasts from January 1 through March 31. Once General Enrollment ends, you then have from April 1 through June 30 to sign up for a Medicare Advantage plan.
The Medicare Annual Enrollment Period (AEP) lasts from October 15 through December 7. It is available to anyone who is currently enrolled in Medicare. During this time, you may make any change you want to your Medicare coverage, including joining an Advantage plan.
If you currently have an MA plan, you may switch to another one or return to Original Medicare during the Medicare Advantage Open Enrollment Period. If making that change means you lose your prescription drug coverage, you may also enroll in a standalone Part D plan at that time.
Please note that you cannot have both an MA-PD plan and a Medicare Part D plan.
Finally, Medicare created Special Enrollment Periods for beneficiaries who experience certain life changes, such as moving or losing their current coverage. There are dozens of ways to qualify for an SEP. Medicare.gov provides the full list of special circumstances here.
Types of Medicare Advantages Plans in California
There are four main types of Medicare Advantage plans in California. The most popular by far are health maintenance organizations (HMOs). These plans use a provider network that may include pretty much any entity that provides healthcare services:
- Nurse practitioners
- Urgent care centers
- Medical clinics
- Durable medical equipment
- Nursing homes
Most HMOs will only cover care received from an in-network provider. However, if you choose an HMO that has a point-of-service (POS) option, you may be able to get out-of-network care. Just know that your out-of-pocket cost will be higher. HMOs also require members to choose a primary care physician who manages their care and provides referrals to specialists.
Preferred provider organizations (PPOs) have networks that are similar to HMOs. However, you may visit an out-of-network provider for a higher cost. In addition, PPOs do not require members to choose a primary doctor or get a referral to see a specialist.
Private fee-for service plans (PFFS) determine how much they'll pay providers. You then cover any remaining amount. Most PFFS plans have a provider network but allow members to go out-of-network for a higher cost.
Special needs plans (SNPs) are limited to Medicare beneficiaries who meet certain criteria. These vary by plan, but generally amount to:
- Having a certain chronic condition, such as diabetes, ESRD, or HIV/AIDS
- Living in an institution, such as a nursing home
- Being eligible for both Medicare and Medicaid
If you meet the plan's criteria, you may join an SNP at any time. Most require members to choose a primary doctor who coordinates care and provides referrals.
How to Choose a Medicare Advantage Plan in California
To get the best plan for your particular needs, you should consider the following four metrics:
- Cost: This may include a yearly deductible, monthly premiums, and copays or coinsurance payable at the time of service.
- Coverage: Benefits vary widely from plan to plan, so look carefully at what the plans offer to be sure you're comparing apples to apples. If it's an MA-PD plan, don't forget to review the drug formulary. This is the list of covered prescription medications. If it doesn't include yours, keep looking until you find a plan that does.
- Network: If you have complex, ongoing medical issues, you probably want to choose an Advantage plan that includes your providers in its network.
- Ratings: Each fall, Medicare releases its ratings of Medicare Advantage and Part D plans to help beneficiaries better compare their options.
Our Find a Plan tool makes comparing Medicare Advantage plans in California easy. Just enter your location information and estimated coverage start date to review the Medicare plan options in your area.
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