Medicare Advantage Plans are Discontinuing Coverage in Tuolumne County
As of January 1, 2026, three of four existing Medicare Advantage (MA) plans will no longer be available to Tuolumne County seniors. Aetna Medicare Eagle Plus II (PPO), Aetna Medicare Core Elite (PPO), and Anthem Medicare Advantage (PPO) are terminating coverage on December 31.
Only one MA plan, Imperial Health, will continue offering managed care plans in Tuolumne County. At this time, Imperial Health has a minimal list of providers and currently does not appear to have a contract with Adventist Health. Of its two 2026 plans, only one includes drug coverage.
Open enrollment for Medicare started October 15 and runs through December 7. You should have received notices from your 2025 plan and from Medicare explaining your 2026 options. This article will review options and let you know where to get help. First, let’s study the alphabet soup of Medicare.
Medicare Basics
Traditional Medicare has four parts: Part A, Part B, Part C, and Part D.
Medicare Part A is referred to as inpatient hospital insurance. Part A covers much of the cost of hospital admissions, skilled nursing stays, hospice care, and home health services. Part A is furnished at no cost as a result of paying your mandatory payroll taxes while employed.
Medicare Part B covers outpatient medical services and services provided by a health care professional. It helps with the costs of doctor visits, physical and occupational therapy, lab work, diagnostic tests (X-ray, CT, MRI), and durable medical equipment (walker, wheelchair, oxygen, hospital bed, etc.). The Part B monthly premium for 2026 will be $202.90.
Part B usually covers 80% of the cost of medical services. Many seniors enroll in supplemental (Medigap) insurance that covers the remaining 20%, which can be costly in the event of a serious medical condition such as cancer or heart disease
Medigap Plans. This is where it can get really confusing. Medicare-approved, private Medigap plans are standardized supplemental plans that cover some out-of-pocket costs not covered by “traditional” Medicare Parts A and B. These supplemental plans are labeled with letters A, B, C, D, F*, G*, K, L, M, and N. You must sign up for a Medigap plan within a certain time frame, or you could be denied coverage or charged more due to a pre-existing condition.
Medicare Part C, or Medicare Advantage Plan, is a Medicare-approved alternative to combined Parts A and B provided by a private health insurer. Most MA plans offer drug coverage as well.
What are the advantages and disadvantages of these plans? Their monthly premiums are far less than the combined cost of Medicare Part B, a Medigap plan, and Part D coverage for medications, and may have no monthly premium. Consumers should carefully review any MA plan because, although it may appear less expensive, it often requires a higher annual deductible, copays, and other cost sharing requirements.
Further, Medicare Advantage plans limit members to providers in their network, including physicians, labs, and hospitals. Many are structured like a Health Maintenance Organization (HMO) requiring a primary care referral to specialists. They almost always require prior authorization for procedures and treatments and will sometimes deny payment for care even if recommended by a doctor. Many providers are declining contracts with MA plans because they reimburse less than traditional Medicare and require prior authorization for services beyond primary care.
In most cases, Parts A and B do not require prior authorization for services and allow patients to choose their provider of choice. For some consumers, the predictable cost of the Part B and Medigap premiums offsets the possibility of cost savings by a Medicare Advantage Plan.
Medicare Part D helps cover costs for brand name and generic drugs. You must sign up for Parts A and B to participate in a Part D plan. As discussed earlier, you may not need a separate drug plan if you enroll in a Medicare Advantage plan.
OPEN ENROLLMENT IS NOW THROUGH DECEMBER 7
During Open Enrollment you can change your Medicare Advantage, Medigap, or Part D plans. You can also switch from traditional Medicare Parts A and B to a Medicare Advantage plan or vice versa.
Your insurance card and policy will identify your current Medicare plan(s). If you are not sure what kind of coverage you have, you can call Medicare (1-800-MEDICARE or 1-800-633-4227).
Once you confirm your current Medicare participation, these questions may be helpful:
1. If you are enrolled in a Medicare Advantage plan, will it be available in 2026?
2. If you are enrolled in a Medicare Advantage plan, are you satisfied with it? Should you remain in that plan, switch to a different Medicare Advantage plan, or sign up for traditional Medicare Parts A and B instead?
3. If you are enrolled in traditional Medicare Parts A and B, do you have a Part D plan that covers medication? If not, you can sign up for Part D during open enrollment.
4. If you have a Part D plan, are you satisfied with its coverage? You can switch Part D plans during open enrollment, or if you are leaving a Medicare Advantage plan, you can sign up for Part D, along with Part B and a Medigap policy.
According to Medicare’s website, if your Medicare Advantage plan is discontinued and you take no action, you will be placed into traditional Medicare Parts A and B. And if you want prescription drug coverage, you will need to sign up for Part D prior to December 7, 2025.
If you are returning to traditional Medicare Parts A and B, you may choose to sign up for Medigap coverage as well. You can avoid screening for pre-existing conditions by signing up for Medigap insurance either 60 days before your Medicare Advantage coverage ends, or no more than 63 days after your Medicare Advantage coverage ends.
We all have different priorities/needs when selecting health insurance. Make sure to investigate your options before you finalize your Medicare choices for 2026. You can:
- Talk or text with Medicare (1-800-633-4227).
- Contact a licensed insurance broker.
- Call Tuolumne County’s HICAP program at Area 12 on Aging (209-532-6272) and ask to make an appointment with one of their insurance counselors. Their service is free and confidential. The office address is 19074 Standard Rd., Sonora, CA 95370.
The handbook “Medicare and You 2026” is available as a digital download. A paper copy was mailed to all Medicare recipients this fall. It is also available in large print, audio, or braille.
NOTES