California Medicare Advantage Plans
It means that if you sign up for a California Medicare Advantage Plan, you are agreeing to abide by the terms and conditions of the plan, provided by the Private Insurance Company you sign up with. If you sign up with one of these plans, you will not use your Medicare Card when you go to the Doctor or Hospital. Instead, you will use the card provided by the Private Insurance Company. If the Medicare Advantage plan covers your prescriptions, then you will use the same card for prescriptions.
When you join one of the many California Medicare Advantage Plans, keep in mind that you are joining for a whole calendar year. These plans go from January 1st to December 31st of each year. Once you make a selection and join your choice of California Medicare Advantage Plans, you will be in lock-in for the year, unless you are eligible for a special election period or the ADP.
There are a lot of plans provided by lots of different Insurance Companies. They vary a little, or a lot,
as far as benefits and premiums. Some of the California Medicare Advantage Plans available have monthly premiums of zero dollars and there are some plans that charge a considerably higher amount. If you are looking at a Part C Medicare Advantage Plan, the summary of benefits from various companies will help you easily compare plans. Do not just look at the monthly premium, but look at how much all the co-pays and deductibles will cost you.
Often California Medicare Advantage Plans also include the Medicare Part D coverage, a.k.a. Medicare Prescription Drug Plan, as well. This is usually at no additional cost. These Medicare Rx Benefits can be basic or enhanced. You need to look at the Summary of Benefits and Formulary to see if the California Medicare Advantage Plan you are looking at includes a Medicare drug plan, and how extensive those Rx benefits are.
Medicare Advantage Plans will usually be one of these few types:
- HMO or Health Maintenance Organization: This type of plan has a network of doctors and hospitals. You will only be able to use these providers, unless you have an emergency. If you go to a provider that is not in the network, you will have to pay 100% of the charges. It is very important to check to make sure that all the doctors you want are in this network, since this is a big limitation.
- PPO or Preferred Provider Organization: This plan also has a network of doctors and hospitals. A PPO plan is also more flexible, since you can also go to providers outside of the network. If you decide to go to a provider outside of the network, you will need to pay a higher share of the costs.
- PFFS or Private Fee for Service: This plan gives you a lot of freedom, in that you can go to any provider that accepts Medicare. Each time you go to a provider, you must give them your plan’s card, and the provider must accept the terms and conditions of the plan. A provider may not accept the terms and conditions; in such case, you must find another provider. I have clients with a PFFS plan who are very happy and have no problems, but I have heard of issues in the past. The key is to talk to your physicians about this plan first. Make sure they will take the plan. As with most Medicare Advantage Plans, if your provider decides not to take the plan, you will likely have to find another doctor who will accept the plan. If you still use the provider after he tells you he will not accept the terms and conditions, you will be 100% responsible for all charges.
If you are a Medicare Beneficiary and have any pre-existing conditions (other than ESRD), there is really no medical questions to answer for Medicare Advantage Plans. This can be very advantageous for Medicare Beneficiaries that do not currently have Guaranteed Issue status.
I could talk for a long time about Guaranteed Issue and Special Election Periods for California Medicare Advantage Plans, but I will only cover the most basic ones here. If you have any questions about if these might apply to you, contact me or Medicare about your options.
Here are some basic election periods for Medicare Advantage to keep in mind:
- Initial Enrollment Period: The month of, and 3 months before and after, you turn 65 years old. You can enroll in any Medicare Advantage Plan that you wish, during this time.
- Annual Election Period: Currently October 15th through December 7th. This is the time period that you can enroll in or change your Medicare Advantage Plan for the next plan year.
- Annual Disenrollment Period: January 1st through Febuary 14. You may disenroll from your Medicare Advantage plan. During this time, you will be enrolled in Original Medicare and will have the option of choosing a stand-alone prescription drug plan.
- Special Enrollment Periods: These periods will be based on each person’s situation. There are specific rules that may make you eligible.
If you have any questions about this information or want to see what your specific options are give us a call any time.