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Understand Medicare Part C in California

Medicare Advantage Plans offer a few key differences that distinguish them from Parts A and B of the Original Medicare system managed by the federal government. While Part A pays for inpatient care at a hospital and Part B covers services and supplies used to treat or prevent medical conditions, Medicare Advantage Plans come with a few added benefits. Plans are required to offer the same level of care as Original Medicare and may include additional health care benefits, such as prescription drug coverage, routine hearing, vision, and dental exams, and fitness club memberships:

  • In 2022, there are 458 Medicare Advantage Plans available in California
  • 95% of the total Medicare population in California has access to a Medicare Advantage Plan with a $0 monthly premium in 2022
  • In 2022, the average monthly premium for a Medicare Advantage Plan in California is $18.12, a decrease from $19.69 in 2021
  • Thirty-two Medicare Advantage Plans offer innovative benefits, such as wellness and health care planning, reduced cost-sharing, and rewards and incentives programs in 2022

Designed to be an all-in-one solution, Medicare Advantage Plans are offered by Medicare-approved private insurance companies. There are several types of Medicare Advantage Plans available, depending on your insurance provider and location. Learn the differences between these plans and how they affect your coverage so that you can make the right choice for your medical situation.

Medicare Advantage Plans in California

Compare ratings of some of California’s Medicare Advantage Plan providers:

Medicare Advantage Plans in California
Insurance company Medicare rating A.M. Best rating BBB rating NCQA rating J.D. Power ranking
Aetna 4 stars A A+ 2.5 to 4.5 stars Fifth out of 10
Anthem Blue Cross Blue Shield 4 to 4.5 stars A+ A+ Not rated Sixth out of 10
Cigna 4 stars A- Not rated 2.5 to 4.5 stars Seventh out of 10
Humana 4 stars A- A+ 1.5 to 4.5 stars Third out of 10
Kaiser 5 A A- 4.5 to 5 stars First out of 10
UnitedHealthcare 3.5 stars A- A- 4 stars Fourth out of 10

What Medicare Advantage Plans cover

Medicare Advantage Plans cover benefits from Original Medicare Part A (hospital insurance), Part B (medical insurance), usually Part D (prescription drug coverage), and sometimes additional benefits that Original Medicare doesn’t cover.  Each Medicare Advantage Plan insurer sets the rules about how you receive and pay for these benefits.

Hospital and skilled nursing facility inpatient care Home health care Prescription drug coverage (if included in your plan)
Medically necessary outpatient services, such as:

  • Doctor’s visits
  • Ambulance services
  • Emergency and urgent care
  • Durable medical equipment (DME)
  • Mental health care
  • Prescription drugs that you cannot self-administer
  • X-rays
  • Laboratory tests
 Preventive services, such as:

  • Vaccinations
  • Cancer screenings
  • Diabetes screenings
  • Depression screenings
 Additional benefits (depending on your plan), such as:

  • Routine vision exams with allowance for glasses
  • Routine dental exams
  • Hearing exams with allowance for hearing aids
  • Fitness and wellness programs and discounts
  • Transportation to medically necessary care
  • Over-the-counter (OTC) drugs

Types of Medicare Advantage Plans in California

There are four types of plans available in California’s Medicare Advantage program: Health maintenance organization (HMO), preferred provider organization (PPO), private fee-for-service (PFFS), and special needs plan (SNP). Each offers a different level of flexibility in your network of care providers and varies in price. All Medicare Advantage Plans provide the same coverage as Original Medicare, but additional benefits may come with an increased premium.

HMOs HMOs typically require that you receive all services from in network providers:

  • You must have a primary care physician (PCP), referrals for specialists, and prior authorizations for treatments and some prescriptions.
  • Drug coverage usually is included. You aren’t able to purchase standalone drug coverage.
  • Lower costs if you stay in network.
PPOs PPOs include a preferred network of providers, but you have the option of choosing doctors or hospitals from outside of the network for a higher cost.

  • You don’t need to choose a primary care doctor or referrals for specialists.
  • Drug coverage is usually included.
  • You aren’t able to purchase stand-alone drug coverage.
  • Higher premium and out-of-network costs.
PFFS Plans PFFS plans don’t require a primary care physician or referrals for specialists:

  • You can go to any Medicare-approved health care provider or facility that accepts the plan’s payment terms and agrees to treat you.
  • May include drug coverage, or you can purchase a standalone drug plan.
  • Higher cost if you choose a provider that doesn’t agree to the plan’s terms.
SNPs SNPs are only for people with specific conditions and characteristics, and include care coordination and targeted benefits tailored to meet your specific needs:

  • You need a PCP and referrals to specialists.
  • Drug coverage is always included.
  • If you’re eligible, you can join an SNP at any time.

When to sign up for Medicare Advantage Plans in California

If you want to enroll in a California Medicare Advantage Plan, you need to be enrolled in Medicare Part A and Part B, and you cannot be enrolled in Medigap. Enrollment is available to seniors 65 and older and those with a qualifying disability.

Your disability typically qualifies if you’ve received at least 24 Social Security or Railroad Retirement Board (RRB) Disability Insurance payments. You can also enroll in Medicare Advantage Plans if you have End-Stage Renal Disease (ESRD) or amyotrophic lateral sclerosis (ALS).

There are three periods when you can enroll:

  • The first is the Initial Coverage Election Period when you first become eligible. This period includes the three months before your 65th birthday, the month of your birthday, and the three months following. If you have a disability, this period will occur three months before or after your 25th month of receiving benefits.
  • The Annual Election Period runs from October 15 to December 7. During this period, you can switch from Original Medicare to a Medicare Advantage Plan. If you’re already enrolled in Medicare Advantage, you can switch between plans during this period.
  • The Open Enrollment Period takes place between January 1 and March 31. You can switch between Medicare Advantage Plans or go back to Original Medicare during this period.

Medicare provides special enrollment periods for unusual life circumstances, such as losing your job (and health coverage) and moving out of the area your insurance carrier services.

How to Choose a Medicare Advantage Plan in California

Consider these factors as you compare Medicare Advantage Plans available in your area:

Monthly premium This is in addition to your Part B monthly premium. so it affects your monthly cash flow. You pay whether or not you access your benefits. You should have access to at least one zero premium plan with drug coverage in your area.
Provider network Check to make sure your doctors, hospitals, and pharmacies are in network to keep costs as low as possible.
Out-of-pocket max This is the most you’ll spend ― not including your premium, deductible, and drug costs ― for Medicare-covered services as long as you follow the plan’s rules for in and out of network coverage.
Deductibles, coinsurance & copays Also known as cost-sharing, these expenses apply when you access your benefits. Check to see what your plan charges for doctor’s visits, services, treatments, and prescription drugs.
Drug coverage/formulary See if your drugs are on the plan’s formulary and how much they cost each time you fill a prescription. You may want to talk with your doctor about a generic or alternative version of a drug you need.
Additional benefits Consider which additional benefits are important to you. Most plans require you to use network providers and may charge extra premiums for more comprehensive coverage.

Medicare Advantage Resources in California

If you’re feeling confused by the multitude of plan options available, getting in touch with trained, unbiased counselors can be a good first step. California is home to several organizations that can help you make an informed decision.

 

California Association of Area Agencies on Aging  Website | (916) 443-2800 California Association of Area Agencies on Aging can connect you with one of its regional agencies, all of which provide a comprehensive selection of services for the region’s older adults. The agencies have programs designed to help seniors 60 and older maintain their health and independence, including resources to guide you through the Medicare enrollment process, and the counselors will help you understand the available benefits fully.
California Department on Aging  Website | 800-434-0222 The Department offers HICAP Medicare counseling services to help you navigate the program and Medicare Advantage plans.
California Health Advocates Website | 916-231-5114 California Health Advocates provides information about Medicare, including Part D prescription coverage, and how to access financial aid. .
Health Services Advisory Group  Website | 818-409-9229 or 415-897-2400 If you already have Medicare, you can turn to the Health Services Advisory Group with any complaints about quality of care, delays in care, or other issues.
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Tammy Burns
Insurance and health care consultant

Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.

Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.

author-img
Tammy Burns
Insurance and health care consultant

Tammy Burns is an experienced health insurance advisor. She earned her nursing degree in 1990 from Jacksonville State University, obtained her insurance billing and coding certification in 1995, and holds a health and life insurance license in Alabama, Georgia, Iowa, Mississippi, and Tennessee. Burns is Affordable Care Act (ACA)-certified for health insurance and other ancillary, life, and annuity products. She maintains an active nursing license and practices private-duty nursing.

Burns’ background as a nurse, insurance biller and coder, and insurance consultant includes infectious disease, oncology, gynecology, phlebotomy, post operative, family medicine, geriatrics, home health, hospice, human resources, management, billing, coding, claims, fixed annuities, group and individual health and life products, and Medicare. She’s always been driven by a desire to help people, spending more than 25 years as a practicing nurse in hospitals, private doctors’ offices, home health, and hospice. As a nurse, Burns supported patients filing insurance claims with Medicare, Medicaid, and private insurance companies as well as responding to billing questions from confused patients.

Seeing firsthand how unsuspecting patients are frequently confused by an overly complex system they don’t understand led Burns to become an insurance agent and health care consultant, now helping people understand the medical system. Since becoming an insurance agent in 2013, she has worked with some of the largest and most reputable insurance carriers and agencies in the nation, and she has built a large and loyal clientele by way of her commitment to transparency and personalized service.

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