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Medicare Advantage

Do California Medicare Advantage Plans confuse you? We can help!

Medicare Advantage Plans

Medicare Advantage Plans, or Medicare Part C, are private plans that are regulated by CMS and approved to take the place of Medicare parts A and B. Some plans also include the Part D drug coverage plans.

The two most common types of MAPD, or Medicare Advantage Prescription Drug plans are HMO and PPO plans. The primary difference between the two types of plans is that the HMO Medicare Advantage tends to have a more restrictive network, but a lower out of pocket cost and lower premium, in general. With a PPO Medicare Advantage plan, you generally have a less restrictive network, and can go out of network for care in a non-emergency situation, however they tend to cost slightly more because they are less restrictive.

Medicare Advantage Added Benefits

Medicare Advantage Plans in California offer many benefits that you do not get with Original Medicare, often times at a very low cost or no additional premium. They can do this because the federal government compensates them for providing the coverage, per member, and pays a large majority of the premium for you, and they keep costs down by tighter control of their network. Because of this, they may also include added benefits that you would not get with Medicare alone, such as:

  • Out of pocket maximums
  • Set copay amounts
  • Medicare Dental Benefits
  • Vision Coverage
  • Discounts on Services

As you can clearly see, these plans can offer more than Medicare alone, and are absolutely worth considering if you are looking for a California Medicare Plan. For further explanation on the differences, please visit our Medicare Advantage HMO and Medicare Advantage PPO pages.

Medicare Advantage Plans can indeed provide a very cost-effective alternative to Original Medicare.  Depending on the county there may not be a plan premium and most care can be received without even a copay.  However, we want to again point out some of the issues you should be aware of before enrolling.

All Medicare Advantage Plans have a physician and hospital network.  If you opt for a PPO plan this is not as much of an issue as when you choose an HMO.  PPO plans will generally allow for you to see out of network providers, albeit at a higher share of cost.  On the other hand, virtually all HMO plans use a primary care physician as “gatekeeper,” to request non-urgent referrals to most specialists.

The HMO network does not mean that the physician is “in the book.”  In order to see a specialist, that doctor must be affiliated with the same medical group as your primary care doctor.  So although both Drs. Smith and Jones have a contract with your HMO, unless they are in the same medical group (think sub-network), you likely can’t see both.

In addition, your physician may be in network when the plan is effective on January 1 but as of June 1 they leave the group.  You will then have to choose another doctor.  Surprisingly, this scenario will not allow you to change or drop your plan.

In the absence of a special enrollment period the plan you choose to be effective on January1 will be the plan you remain in throughout the year.  If you chose an HMO and in April you find that a PPO would have been a better choice you still must wait until the next annual election period to make a new choice which would not be effective until the following January.

The best advice is to speak with an insurance agent that specializes in helping people with Medicare review all the options.  No one has a crystal ball but knowing your choices can minimize poor decisions.

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