Medicare Advantage

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Medicare Advantage, created in 1965, originally consists of Part A (hospital insurance) and Part B (medical insurance) and operates as a fee-for-service system. Under this program, a beneficiary can go to any physician or health facility in California or in other states that accept Medicare payments.

An Alternative to Traditional Plans
Part C plans, or the Medicare+Choice program, was created in 1997 as an alternative to traditional parts A and B. Part C is designed to give beneficiaries access to a wide array of more cost-effective, private health plan choices in California. In 2003, Part C was renamed Medicare Advantage, as part of the Medicare Prescription Drug, Improvement, and Modernization Act (also called the Medicare Modernization Act or MMA). Medicare Part D or the Medicare Prescription Drug Plan (PDP) was also enacted as part of MMA.

California PDP provides some insurance coverage for brand name and generic prescription drugs. Medicare works with insurance companies to offer different PDP plans. To get a PDP, you must already have Part A and/or B. However, the cost of PDP plan differs depending on the company.

Options Under California Medicare Advantage
Each beneficiary in California is entitled to choose to receive benefits through either the Medicare Advantage (Part C) plans or original fee-for-service program under parts A and B or through PDP for drug coverage only. Some offer stand-alone PDP plans to help balance one’s health needs and budget. Stand-alone PDP lets you add drug coverage to your Original Medicare coverage.

California Medicare Advantage (Part C) plan options include:

  • Health maintenance organizations (HMOs)

  • Point of service (POS) plans

  • Preferred provider organizations (PPOs)

  • Provider sponsored organizations (PSOs)

  • Private fee-for-service plans

Benefits Under California Part C
The Medicare Advantage, or California Part C plans are required to provide the same advantages for beneficiaries in California and in other states covered under the traditional fee-for-service plan, except for hospice. The Part C plans can offer supplemental benefits not covered by the traditional plan, and are prohibited from denying or limiting coverage based on health status related factors. The only exception is that Part C plans do not have to accept enrollees from California or from other states who have end-stage renal disease.