Medicare is the federally backed health insurance program for older Americans who turn 65. Those who have disabilities or specific illnesses may also qualify at a younger age. New enrollees can choose Original Medicare, which is administered by the federal government, or Medicare Advantage, which is offered via private health insurance companies. Medicare Advantage is also known as Medicare Part C or referred to as MA, and plans must follow federal guidelines.

For those who become Medicare-eligible, it’s a good idea to review all options, including Medicare Advantage plans offered in their state. Often, MA plans may have additional coverages that aren’t offered by Original Medicare. While plans vary by county, all California residents have at least several options from which to choose.

What You Should Know About Medicare Advantage Plans in California

  • California has the second most MA plans in the nation: In California, there are 458 plans available in 2022; only Florida has more.
  • Coverage varies by provider: Medicare Advantage Plans are provided by private insurance companies, which can set their own prices and offer different additional benefits.
  • Location dependant: Medicare Advantage Plan availability depends on where you live.

Is Medicare Advantage Right for You?

You have choices in Medicare coverage. While you can opt to stick with Original Medicare, a Medicare Advantage Plan – also known as Part C – may be a better alternative for you.

Original Medicare Medicare Advantage Plans
Original Medicare covers your Part A hospital insurance and Part B medical insurance. Medicare Advantage Plans combine Part A, Part B, and additional benefits.
You can add Part D prescription drug coverage. Prescription drug coverage is usually included.
You’re able to use any medical provider in the U.S. that accepts Medicare. You’ll usually need to use doctors in your plan’s network.
You can buy supplemental coverage to manage out-of-pocket costs, including your coinsurance. Your Medicare Advantage Plan may have lower out-of-pocket costs than Original Medicare.
Vision, hearing, dental, and other benefits aren’t covered. Your plan may offer additional benefits, including vision, hearing, and dental.
Note:

  • You can’t have both a Medicare Advantage Plan and a Medicare Supplement Plan.
  • You must be enrolled in Medicare Parts A and B to join a Medicare Advantage Plan.

How to Compare Medicare Advantage Plans in California

With 458 Medicare Advantage Plans available in California, you likely have several options in your area. To help you choose the best plan for you, consider what is most important to you before selecting a plan. There are several factors to keep in mind:

  • Monthly premium: This is how much you pay for coverage monthly, regardless of the care you receive. You may need to pay your plan’s premium in addition to the Medicare Part B premium, although some plans have $0 premiums or help pay for your Part B premium.
  • Plan network: You may need to use doctors and providers who are within a plan’s network. Before choosing a Medicare Advantage Plan, think about the doctors and facilities (including pharmacies) you prefer to use, then check if the plan offers coverage at those locations. Some plans may provide out-of-network coverage, but this usually comes at a higher cost.
  • Deductible: Your deductible is the amount you must pay before your insurance plan starts helping cover the costs. Medicare Advantage Plans set their deductibles, and these may change only once per year on January 1.
  • Copayments and coinsurance: Copayments or coinsurance are how much you pay for each service or doctor’s visit, such as $20 per doctor visit. Each Medicare Advantage Plan sets its copayment or coinsurance amount that can differ from what you would pay through Original Medicare.
  • Out-of-pocket maximum: Each Medicare Advantage Plan sets a yearly limit on the maximum amount you’d be responsible for paying for services covered by Medicare. Once you reach this limit, you won’t have to pay anything for the services you receive covered by Part A and Part B in that year.
  • Additional coverage: Most Medicare Advantage Plans also provide prescription drug coverage and often include additional benefits that Original Medicare won’t cover, such as vision, dental, and hearing. Plans may provide even more benefits, like discounted gym membership or transportation to doctor’s visits. Medicare Advantage Plans can also tailor their benefits to the specific needs of particular chronically ill beneficiaries.

About Medicare Advantage Plans in California

With 43% of eligible California residents opting for a Medicare Advantage Plan, it’s more popular in the Golden State than anywhere else in the nation. California offers the second most MA plans in the nation.

Number of Medicare Advantage Plans available Medicare Advantage Plan types available Medicare Advantage Plans rated 3.5 or higher by NCQA
458
  • Local HMO
  • Local PPO
  • Aetna Health of California Inc.
  • Aetna Life Insurance Company (California)
  • Blue Shield of California
  • Chinese Community Health Plan
  • Easy Choice Health Plan, Inc.
  • Health Net of California, Inc.
  • Inter Valley Health Plan
  • Kaiser Foundation Health Plan Inc. (Northern California)
  • Kaiser Foundation Health Plan Inc. (Southern California)
  • SCAN Health Plan
  • Sierra Health and Life Insurance Company, Inc. (AZ, CA, NV)
  • Stanford Health Care Advantage
  • UnitedHealthcare Insurance Company (AZ, CA, NV)
  • UnitedHealthcare of California – Medicare

Understanding Medicare Advantage Plan Types:

  • HMO: Health Maintenance Organization plans generally provide coverage only at in-network providers except in medical emergencies. You usually need to have a primary care physician who can give you a referral to see specialists. Most HMO plans include prescription drug coverage.
  • HMO-POS: HMO-POS plans are HMO plans with a Point of Service benefit for out-of-network providers. In these plans, you may be able to use out-of-network providers for certain services but may pay more for your care if you do.
  • PPO: Preferred Provider Organization plans have a network of healthcare providers and facilities where your care will cost less. You can use out-of-network providers as well, but your care will cost more. You usually do not need a primary care doctor to get referrals to see specialists or receive treatment. Most PPO plans include prescription drug coverage.
  • PFFS: Private Fee-for-Service plans allow you to use any Medicare-approved provider. Some PFFS plans have networks of providers where you can receive lower-cost care. You don’t need referrals to see specialists in PFFS plans, but prescription drugs are not always covered.
  • SNPs: Special Needs Plans are for beneficiaries with specific diseases or characteristics. These plans tailor benefits and providers to the special needs of the group they serve. You are generally limited to the network of providers the plan offers and need a primary care doctor and get referrals to specialists. All SNP plans include prescription drug coverage.

Enrollment and Eligibility for Medicare Advantage Plans in California

You’re eligible for Medicare when you turn 65 or if you’re younger and have a qualifying disability. A qualifying disability means at least one of the following applies:

  • You’ve received Social Security Disability Insurance or Railroad Board Disability Annuity for 24 months
  • You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease
  • You have End-Stage Renal Disease

When you become eligible for Medicare, you are also eligible for Medicare Advantage Plans. There are specific times of the year when you can enroll for the first time in a Medicare Advantage Plan: during your Initial Enrollment Period and the Open Enrollment Period.

  • Your IEP begins three months before the month you turn 65 and extends for three months after the month you turn 65. During this period, you can enroll in a Medicare Advantage Plan. If you join before the month you turn 65, your coverage will begin the first day of the month you turn 65. If you enroll in the three months after turning 65, your coverage will begin the first day of the month after you enroll.
  • If you miss your IEP, you can sign up for Medicare during the General Enrollment Period from January 1 to March 31.
  • After you enroll in Medicare, you can enroll in or make changes to your Medicare Advantage Plan coverage during the Medicare OEP from October 15 and December 7 of each year. During this time, you can change from Original Medicare to Medicare Advantage, switch to a different Medicare Advantage Plan, or change from Medicare Advantage back to Original Medicare.

Medicare Advantage Open Enrollment occurs between January 1 and March 31 of each year. This period is only for beneficiaries already in a Medicare Advantage Plan, and you can change plans or switch to Original Medicare. You cannot switch from Original Medicare to Medicare Advantage during Medicare Advantage Open Enrollment.

There are exceptions to these enrollment periods called Special Enrollment Periods. Certain events or circumstances may make you eligible to change your Medicare Advantage Plan outside of the open enrollment periods, such as if you move outside of your existing plan’s service area or to a location with new plan options you didn’t have before. If you think you may qualify for a Special Enrollment Period, call 1-800-MEDICARE and explain your situation.

Medicare Enrollment Periods

Enrollment period When it happens Medicare plans you can choose What you can do
Initial Enrollment Period Three months before you turn 65, the month you turn 65, and three months after Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Sign up for Medicare Part A and Part B. Complete your Part B enrollment to avoid a late enrollment penalty.
General Enrollment Period January 1 to March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan. If you enroll in Medicare during this period, your MAP enrollment is April through June. Sign up for Medicare if you missed your IEP
Open Enrollment Period October 15 to December 7 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Join, switch, or drop a plan
Medicare Advantage Open Enrollment Period January 1 to March 31 Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan If you’re enrolled in a Medicare Advantage Plan, you can change your plan or switch to Original Medicare
Special Enrollment Period When you have a qualifying event Medicare Part A, Part B, Part D, Medigap, or Medicare Advantage Plan Make changes to your plan

California Medicare Advantage Plans With Prescription Drug Coverage

Most Medicare Advantage HMO and PPO plans and all SNP plans provide prescription drug coverage like you would get from Medicare Part D. Some PFFS plans may provide prescription drug coverage, but not all do. Evaluate a plan’s prescription drug coverage when deciding which California Medicare Advantage Plan to use.

Prescription drug coverage may vary by cost, coverage, and convenience among Medicare Advantage Plans. Your monthly premium may include a premium for the drug coverage in the plan. There is usually a copayment or coinsurance amount that you have to pay for each prescription after you reach your annual deductible.

Some plans use different cost tiers with different costs for different drugs. For instance, you may pay less for generic drugs than brand-name drugs or less for brand-name drugs within different tiers. If your plan uses tiers, the formulary will list all covered drugs and their tiers. Verify your preferred or local pharmacies are included in the plan’s network.

Getting Help with Medicare Advantage Plans

California-wide Medicare Advantage Resources

Resource Contact How they help
CA.gov – Department of Health Care Services Phone: (888) 452-8609

email: [email protected]

The mission of DHCS is to provide Californians with access to affordable, integrated, high-quality health care, including medical, dental, mental health, substance use treatment services and long-term care
California Department of Insurance Phone: 800-927-4357 CDI enforces the insurance laws of California and has authority over how insurers and licensees conduct business in California
California Health Advocates Phone: 800-434-0222 California Health Advocates is the leading Medicare advocacy and education non-profit in California

Local Medicare Advantage Resources

Resource Contact How they help
LACounty.gov – Department of Public Social Services Phone: 866-613-3777 A guide to services available to residents of LA county
OaklandCA.gov – Medicare and the Annual Enrollment Period Phone: 510-615-5566 This site offers an overview of eligibility, costs, benefits, and changes in Medicare Parts A and B
San Francisco Health Service System Phone: 800-541-2266 A guide to services available to residents of San Francisco

Federal Medicare Advantage Resources

Resource Contact How they help
American Hospital Association – Medicare Advantage Phone: 800-424-4301 AHA ensures that members’ perspectives and needs are heard and addressed in national health policy development, legislative and regulatory debates, and judicial matters
CMS.gov – Medicare Advantage Applications N/A A guide to managing Medicare eligibility and enrollment
Medicare.gov – Medicare Advantage Plans Phone: 800-633-4227 This is the main website for applying for (or making changes to) your Medicare coverage
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Tammy Burns
Insurance and health care consultant

Tammy Burns is an experienced health insurance advisor. She is ACA-certified for health insurance and other ancillary, life, and annuity products.

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