The gaps in Traditional Medicare coverage might seem insignificant when you are new to Medicare, but not having those health benefits can become expensive over time if you aren’t protected. Medicare Advantage is a private form of health coverage which aims to protect seniors from those gaps. Essentially, it replaces your federal Medicare coverage with a private policy, plus additional coverage to avoid paying out of pocket for expensive coverage gaps.
Federal Regulations for Medicare Advantage
Medicare Advantage plans are required by federal law to offer you at least the same coverage as Traditional Medicare. Many plans contain more, such as extra benefits which cover gaps in Medicare, and/or dental. There are also very comprehensive plans which cover Medicare Part D (prescription drugs). These are referred to as MAPD plans.
Medicare Advantage Enrollment In California
Out of the total population of Medicare-eligible seniors in California, 40% of them are getting their benefits provided through a Medicare Advantage plan. Among these plans are different sub-categories, which the chart below details (as well as an approximate % of enrollees). The other 60% of California seniors might be signed up with an alternative, such as Medigap insurance.
|Plan Type||Enrollment Percentage|
|Local PPO Plans||13%|
|Special Needs Plans||11%|
|Regional PPO Plans||9%|
|Private Fee-For-Service Plans||5%|
|Other (Cost Plans, MSA’s, etc.)||3%|
Plan Coverage & Cost
Do you smoke? Are you male, or female? Did you enroll in Medicare once you turned 65, or did you delay enrollment for some reason? All of these factors, and more, will determine your monthly premiums for a Medicare Advantage rate. The chart below displays estimated quotes for what seniors near you are paying:
Most Popular Medicare Advantage Plans in California
Medicare’s Overall Star Rating system can give you an idea of the most efficient Medicare Advantage plans in California. The system generates an annual report based on data that Medicare has collected on each company providing healthcare services associated with Medicare. Companies are evaluated and star ratings, much like crash test ratings, are assigned. The more stars the better the performance. For Medicare Advantage plans, companies are rated on their use of preventive medicine measures like screenings and lab tests, the management of chronic illnesses, membership interaction and changers in performance, and effectiveness of customer service. You can use these ratings when comparing plans that interest you.
Doctor/Provider Network Restrictions
Different Medicare Advantage plans come with different provider restrictions (restrictions on which doctors you are allowed to see, and which hospitals you are allowed to visit). Some networks, like HMOs, are highly restrictive whereas PPOs and PFFS plans give you more freedom. However, restrictions on these networks could change at any time, as well as the approved doctors and facilities you are allowed to use. You should have a game plan ready for if and when these restrictions change.
Where you generally need to get your care and services from for:
- HMO Plans: HMO plans are popular in California but they are also the most restrictive in terms of healthcare provider choices. The HMOs have comprehensive networks including primary physicians, specialists, hospitals, labs, home-care therapists etc. and require members to use these in-network resources. Some may offer Point of Service (POS) plans that allows you to go out of network for a premium copay.
- PPO Plans: PPO plans also have networks and members will spend less on copays if they choose providers within the network. However, there is no restriction on using providers outside the network as long as they accept the insurance. There is a higher copay for using out-of-network resources.
- PFFS Plans: Private Fee For Services (PFFS) plans have no restrictions on healthcare provider choice. You can use any provider you like so long as they accept the insurance plan. Many do not. Some PFFS plans publish a list of participating providers but it is always a good idea to confirm plan acceptance when making an appointment.
- Special Needs Plans: If you have a chronic illness, live in a nursing home or qualify for both Medicare and Medicaid you are eligible for a Special Needs Plan. Your choice of doctors and facilities will typically be restricted to those in the Medicare SNP Network. These groups include specialists and facilities that routinely treat your illness or condition.
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans: With an HMO your decision should be based on the quality of the entire network because your ability to choose providers is severely limited. You may, or may not be able to select your primary care physician, and that person is responsible for referring you to other HMO providers if the need arises.
- PPO Plans: Preferred Physician Organizations (PPO) also have networks but unlike HMOs you can select the ones you like. You can go out of network if you like but you will pay a higher copay for those visits. PPOs typically have a comprehensive list of primary care and specialist physicians, hospitals, home-care specialists, labs, and other diagnostic facilities. Going outside network is purely a personal choice not one caused by a shortage of quality care within the network.
- PFFS Plans: Private-Fee-For-Services plans have no restrictions on who you can see. However, many physicians and hospitals won’t accept your insurance because the reimbursement schedules are so low. It is a good idea to always confirm that the provider accepts your insurance when making an appointment.
- Special Needs Plans: As a member of a Special Needs Plan, your selection of healthcare providers is typically limited to those in the Medicare SNP Network. This network is comprehensive, and the groups are organized to focus on a specific disease or condition.
Locating healthcare providers for the Medicare Advantage plan you are interested is fairly easy. Just like Medicare’s physician search tool, almost all plans have easy to use online directories for providers in your area. However, you need to be aware of some conditions.
Drug, Vision and Dental Coverage
Sadly, Medicare Parts A and B do not offer coverage for dental, vision, or prescription drugs. While Medicare Part D is an option to help you with your expensive prescriptions, few other supplements offer affordable access to these ancillary benefits. But with a Medicare Advantage plan, you can get some or all of them bundled into the same policy, should you choose. But keep in mind that this will increase your rates.
- Eye care and eye health is not covered by Medicare except for eye exams related to diabetes and age-related macular degeneration. Most Medicare Advantage plans have basic eye care benefits. Typically, these include annual eye exams, new and replacement lenses, glasses, and contacts. A list of participating eye care providers can be found in the plan’s directory.
- Dental care is another healthcare area where Medicare offers no benefits. But most Medicare Advantage plans have a list of participating dentists who will provide basic dental care. This usually consists of a routine exam, x-rays, cleaning, and fillings. Additional work like crowns, dentures, and root canals are not covered.
Enrollment Options & Best Time To Enroll
Keep in mind that, while it is easy for some seniors to get covered with a Medicare Advantage policy, your provider may wish to give you a health screening or gather information about any pre-existing health conditions if you try to enroll outside of the Open Enrollment Period. You may or may not have trouble getting affordable coverage due to extreme health conditions such as End Stage Renal Disease (ESRD). If you contact a licensed insurance agent, they can help you determine what your options are based on your circumstances. For more questions about enrollment, please visit our Medicare Advantage Enrollment Page.
- Initial Enrollment Period: The enrollment period during your first 6 months of being enrolled in Medicare.
- Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
- Special Enrollment Period (SEP): Circumstances which happen outside of the AEP window, such as employer coverage loss or moving out of state, which may require you to find new coverage immediately.
What Medicare Advantage Plan Is Best For Me?
The best Medicare Advantage plan for you can only be decided by you. That means you need to do your research. At a minimum it should be a plan that allows you to visit healthcare providers that you have confidence in and who can provide the specific treatment that you need. If it provides Part D drug coverage, it should carry the medicine you need. Not all plans carry all drugs. And of course, it should be affordable.
Selecting the right program the first time is important because changing can be problematic due to enrollment period requirements. Cost is always important but be sure to take the company’s reputation, time serving your area of California, and financial stability in the equation as well.