Medicare Advantage Plans

Explanation of Medicare Advantage:

Medicare Advantage plans, or Medicare Part “C” plans, are offered by many different insurance companies.  In 2020 there will be three Medicare Advantage plans offered in Santa Cruz County (Secure Horizons, Sutter Advantage/Alignment, and Kaiser).  In 2018, no Medicare Advantage Plans were offered in Santa Cruz County.  Plans change every year.

In addition to paying your premium(s) for Medicare parts A & B, depending upon the plan you select, you may also pay a monthly premium to the insurance carrier for the Medicare Advantage plans.  You’ll put your red, white and blue Medicare card away, and carry only the ID card for the Medicare Advantage plan when you see your doctor or other provider.  All of your health benefits will be provided by the Medicare Advantage Plan.

Benefits may be structured as HMO, PPO, PFFS (private fee for service) plans. These plans combine medical and prescription drug coverage into one plan, simplifying your enrollment.  You may purchase a Medicare Advantage plan (MA) or Medicare Advantage and Prescription Drug plan (MAPD) only during certain enrollment windows in the fall and when you’re initially eligible for Medicare, or if you move into a new service area, for example.   Please contact us for rates in your area.

These plans are regional, so if you move out your plan’s service area, you may be automatically canceled from your plan but will have a “special” enrollment opportunity to enroll in a new plan offered in your new region, without waiting until the next open enrollment period.

The Annual Enrollment Period (AEP) begins on October 15 and ends December 7 each year. After this period, there will be a dis-enrollment period for Medicare Advantage plan members. Advantage plan members who would like to dis-enroll from their plan can do so beginning January 1 through February 14. If the member chooses to dis-enroll, they will have an opportunity to return to original Medicare and purchase a stand-alone Part D insurance plan. After that period members will be locked into their choice until December 31 of the following year.

Medicare Advantage Details:

HMO plans require that you select a Primary Care Physician and obtain referrals from that physician to any specialist you may wish to see.  Physicians will refer within your medical group, and routine care will not be available if you’re outside of your regular service area.  Emergency care will be provided, but the plan determines what is and is not an emergency.  HMO plans may be best suited to those Medicare Beneficiaries who reside most of the year in their service area and do not travel extensively.  Copayments are charged for office visits, lab work, X-rays, etc. and you may see coinsurance (the plan pays 80% for example, and you pay 20%) for expensive tests, such as MRI or CT Scans.  There may be per-day copayments for hospitalization (i.e. $295/day).

PPO plans provide more flexibility if you travel, as you’re not limited to a single medical group.  Copayments are charged for office visits, and you’ll see a deductible for other services.  These plans cost less each month than the HMO plans, but will cost you more if you need to seek medical attention.  No primary care physician is required.

PFFS plans generally do not have a network of physicians, but each time you receive care, you’ll need to confirm that the doctor, lab, radiology center, etc., will accept the fees paid by the plan.  You may find a doctor willing to work with your plan one day, but may not be willing to accept the plan on another day.  Enrollment in and availability of these plans is declining.

If you’d like more information about these plans, please contact our office and we’ll be happy to discuss the options with you!

For more concentrated Medicare information, see our other site,

Powered by WordPress | Designed by Elegant Themes