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Medicare Advantage with Medi-Cal

With a Medicare Advantage Plan (Part C), your are getting three things:

  1. Coordination of your Medicare and Medi-Cal services
  2. Coverage for services not covered by Medicare or Medi-Cal
  3. Drug Coverage included

A Medicare Advantage Plan is simply a Medicare approved private company managing your Medicare and Medi-cal benefits while providing extra benefits. Essentially, Part C combines Part A, Part B, Part D, and your Medi-Cal as well as any other necessary medical services a person may require such as hearing, and vision services. If you have a managed Medi-Cal plan, this operated in exactly the same way, only that it now includes your medicare as part of the coordinated services. Medicare advantage plans that coordinate Medicare and Medi-Cal coverages are often called Special Needs Plans (SNP). Keep an eye out for this term when looking for a plan that works with all your insurances and needs.

The deal is an impressive one. The plan doesn’t cost anything to enroll as long as you have both Part A and Part B on your Medicare card. If either is missing then you will not be able to enroll. You will receive a card that you can use for all medical and prescription benefits. You no longer need to carry your Medicare, Medi-Cal, and drug plan cards everywhere. This one card is all you need for all services. The best part is many services not covered by Original Medicare may be covered with Medicare Advantage Plan. This may include:

  • glasses, transportation
  • over-the-counter medicines
  • gym membership
  • health and nutritional coaching
  • acupuncture, chiropractic and more
Sporty senior white haired man holding yoga mat, looking directly at camera and pointing with index finger, posing isolated over blue background.,

As mentioned above, a SNP Medicare advantage plan will often include a drug plan. In essence, by enrolling into a Medicare Advantage Plan you get gaps covered that were not covered by Medicare and Medi-Cal, simplify your cards and coordination of benefits, and have a drug plan to fulfill your medication needs.

The main thing to know if that you will be part of a network that manages your care. If you are already on a Managed Medi-Cal plan then this will not be new to you. What this means for you is that you will be part of an HMO (Health Maintenance Organization), which means this:

  • Your primary doctor is responsible for obtaining approval for referrals to specialists and select medical services like surgeries and medical equipment.

That’s it. Yet, if you were not aware of this you may encounter issues. For you, the patient, this means you will have to wait a week or two before you can make an appointment for the new doctor or service. If you tried to obtain the service or see the specialist without the authorization (approval for payment) then you would receive a bill. If you do get a bill often Medi-Cal will still pay for it but now you will be required to send it to Medi-Cal and ensure they follow through and pay the service. Now this doesn’t mean you will be left to die in urgent situations. Every Medical Group and Health Plan has a process for urgent matters to allow same day and next day approval for all services and approvals are waived when you visit the emergency room. In short, if a procedure or referral is needed ASAP then it’s possible to get you in ASAP, and if you feel you go to the emergency room then they are allowed to do whatever they feel is necessary to take care of you.

Now, we’ve mentioned Medical Groups and Health Plans a few times so far. Once enrolled into the plan the distinction will be irrelevant to you, but you must understand what each is and their role when you are deciding your options to enroll. This is because of two facts:

  1. Once enrolled, your care will be managed behind the scenes for you
  2. Your doctors all have to be contracted with the same Medical Group to be covered by the Health Plan

Number 2 is the most important in choosing the right plan and ensuring you have great experience. To show why, take a look at the picture below.

medicare HMO+hierarchy

Lets Start with definitions:

  • Health Plan: The insurance company you enroll in. These include the major brands you would recognize, such as Humana, Anthem Blue Cross, and Health Net. They are responsible for deciding what is covered and your copay/share of cost.
  • Medical Group/IPA: You may not recognize these entities but they are always named on your ID card. When it comes to determining your quality of care these people may arguably be more important. They are responsible for determining who you can see and where you can have services done at.
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Because the Medical Group determines who you can see, it’s important that you ensure all of your doctors accept the same Medical Group. To find out if they do you should either call each doctor or check out our doctor search by (Clicking Here). If you happen to choose a Medical Group that your doctors don’t take then you will not ave coverage to see them. Interestingly, each Medical Group only work with certain Health Plans. Because of this there may be health plans with great benefits that may not be available to you. Your doctor only determines what Medical Group they work with and not what health plan. The Medical Group determines what health plans a doctor can work with. To avoid any issues or confusion this process can be managed by an agent or kept identical to your managed Medi-Cal, if you have it. So if you have a Managed Medi-Cal, check the medical group on your card and choose a Health plan that accepts that same network.

Once it’s set-up the plan will take care of itself and you. We at Local Medicare Agents Insurance can support you in this process by ensuring you find a plan that covers the benefits you want and the doctors you see.

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