Medicare Advantage Plans in California

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital) and Part B (medical), and most also include Part D (prescription drug coverage). Many plans offer added benefits like routine dental, vision, hearing, fitness programs, and telehealth.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, but some qualify earlier due to disability, ALS, or ESRD. Late enrollment may result in penalties.

Key enrollment periods include:

• Initial Enrollment Period (IEP)
• General Enrollment Period (GEP)
• Special Enrollment Periods (SEP)

What Types of Medicare Advantage Plans Are Available in California?

California offers the following MA plan types:

• Health Maintenance Organizations (HMOs): Require in-network care. A primary care provider (PCP) and specialist referrals are typically required.
• Preferred Provider Organizations (PPOs): Offer greater provider flexibility. No PCP or referrals needed, but out-of-network care costs more.
• Private Fee-for-Service (PFFS) Plans: Let you visit any provider who accepts the plan’s terms. Some have provider networks.
• Special Needs Plans (SNPs):
  • C-SNPs: For chronic conditions like diabetes or cancer.
  • I-SNPs: For individuals in long-term care or receiving nursing services.
  • Dual Eligible Special Needs Plans (D-SNPs): For those with both Medicare and Medicaid, often with additional support like care coordination and drug coverage.
• Medical Savings Accounts (MSAs): Pair a high-deductible plan with a savings account funded by your insurer to pay healthcare costs.

What Are Your Prescription Drug Options with Medicare Advantage?

Most MA plans include Part D drug coverage, but exceptions apply:

• MSAs and some PFFS plans do not include drug coverage. You may enroll in a separate Part D plan if eligible.
• If your plan doesn’t include drug coverage and you delay enrollment, you may face a penalty for not having creditable coverage.

Always check the plan’s drug formulary to ensure your medications are covered.

How Do You Choose a Medicare Advantage Plan?

Understand Medicare Advantage costs to choose the best plan for your needs:

• Premiums: Many California plans offer $0 premiums. Others vary by county and benefits.
• Deductibles, Coinsurance & Copays: Review all out-of-pocket costs, including fixed copays and percentages owed after deductibles.
• Out-of-Pocket Maximums: Limits how much you’ll spend annually on covered services. The cap for in-network services is often around $7,550.
• Extra Benefits: Many plans include dental, vision, hearing, gym memberships, transportation, and telehealth services.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during these specific enrollment periods:

• Initial Enrollment: Begins 3 months before and ends 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Change, switch, or drop your MA plan.
• General Enrollment (Jan 1–Mar 31): For those enrolling late in Part B. MA coverage starts July 1.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Triggered by:
  • Moving to a new area
  • Loss or gain of Medicaid or employer coverage
  • Plan termination
  • Diagnosis of a chronic condition qualifying for a C-SNP

What If You Want to Change Your Medicare Advantage Plan?

You can switch plans during:

• Annual Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

When you change plans, your old plan is automatically canceled when the new plan starts.

What Are Medicare Resources in California?

California offers several helpful Medicare programs:

• Health Insurance Counseling and Advocacy Program (HICAP): Free Medicare counseling provided through California Health Advocates.
• California SMP (Senior Medicare Patrol): Educates beneficiaries about preventing healthcare fraud.
• California Department of Insurance: Provides assistance with Medicare complaints.
• Medi-Cal: California’s Medicaid program. Contact your local county office or call 1-800-541-5555.

Learn about the differences between Medicare and Medicaid.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, or Medigap, are standardized insurance policies that help cover costs not paid by Original Medicare, such as deductibles, copays, and coinsurance.

• You must be enrolled in Medicare Parts A and B.
• The best time to buy is during the six-month Medigap Open Enrollment Period, which begins when you enroll in Part B. You’re guaranteed coverage during this time.
• After this period, insurers may require medical underwriting.
• Medigap plans don’t include drug coverage. You’ll need a separate Part D plan.

Medicare Supplement Plan G had the highest enrollment in 2023, and Plans G and N are currently the fastest growing. Plan F is no longer available to newly eligible enrollees.

Learn more about Medicare Supplement plans in California.

Next Steps

If a Medicare Advantage plan in California fits your healthcare needs, explore plans available in your ZIP code. Compare provider networks, coverage details, prescription drug lists, and out-of-pocket costs. Be ready to enroll during your eligible window to maximize your coverage and minimize potential penalties.