Medicare Plans in California – Coverage and Benefits
Any California resident who is 65 years of age can enroll in one of the many Medicare plans in California. When you enroll, you’ll be signing up for both parts A and B. These first two parts of Traditional Medicare are designed to cover most of your health care needs, including hospital visits and outpatient care. Although Medicare aims to be comprehensive, it does not cover everything – and the things which it does not cover could end up costing you a lot of money.
Depending on your employment history, you could end up paying premiums for Part B only, or for both parts A and B. Unfortunately, Part B premiums are mandatory for every Medicare beneficiary. You could be excluded from paying premiums on Part A, but only if you have a 10 year employment history (a total of 40 quarters). If you have less than that, it is highly likely that you will be required to pay a premium for Part A as well.
Below are some specifics on what type of coverage Original Medicare provides:
|Medicare Part A (Hospital Coverage)
||Medicare Part B (Medical Insurance)
|Medicare Part C (Medicare Advantage)
||Medicare Part D (Drug Coverage)
California Medicare Insurance Programs
There are over 5 million Medicare beneficiaries located within the state of California. Of those 5,000,198 recipients, 38% are enrolled in a Medicare Advantage program (approximately 1.9 million members). Unfortunately, reporting laws in the state of California make it difficult to know for sure how many residents are enrolled in a Medigap policy, an employer benefit program, or whether they are relying on Traditional Medicare alone to cover their healthcare needs.
For the record, you can’t qualify for any form of Medicare supplement in California unless you are currently receiving Medicare benefits from the federal government. Click here for more information on federal Medicare benefits, or for the option to enroll online.
The Importance of Supplemental Medicare Coverage
Health care costs have been rising significantly in recent years. Although Medicare Parts A and B are intended to comprehensively cover your healthcare needs, there are holes in its coverage options which you could be required to pay for out-of-pocket. If this happens, you might be saddled with thousands of dollars in medical expenses. Below are some examples:
|Medicare Part A Costs||Medicare Part B Costs|
The good news is that there are options when it comes to supplementing Original Medicare. Most people either decide to replace Medicare with a Medicare Advantage plan, or to cover the “gaps” in Original Medicare coverage with a Medigap policy. We’ll discuss these two popular options in detail below.
Supplementing Your Medicare with a Medigap Policy
Unlike Medicare Advantage, a Medigap Policy will not replace your Medicare benefits. Medigap policies are a form of private insurance that works with the government to cover the “gaps” in Original Medicare. There are ten federally-approved plans. These plans are labeled alphabetically: A, B, C, D, F, G, K, L, M, and N. There used to be plans N, E, H, and I; however, those were phased out in 2010 due to the Medicare Modernization Act. All Medigap plans offer identical benefits from state-to-state. But prices and providers will vary by location.
This handy chart details what each Medigap plan covers:
Top Medicare Supplement Plans in the Area
|Type||Starting From||Part A Deductible||Part B Deductible||Excess||Nursing||Travel|
|F||$116||$0||$0||100% Covered||100% Covered||100% Covered||Request Info|
|C||$118||$0||$0||Not Covered||100% Covered||100% Covered||Request Info|
|G||$105||$0||$147||100% Covered||100% Covered||100% Covered||Request Info|
|B||$104||$0||$147||Not Covered||Not Covered||Not Covered||Request Info|
|N||$70||$0||$147||Not Covered||100% Covered||100% Covered||Request Info|
|D||$97||$0||$147||Not Covered||100% Covered||100% Covered||Request Info|
|A||$69||$1||$147||Not Covered||Not Covered||Not Covered||Request Info|
|L||$76||$304||$147||Not Covered||75% Covered||Not Covered||Request Info|
|K||$45||$608||$147||Not Covered||50% Covered||Not Covered||Request Info|
|M||$97||$608||$147||Not Covered||100% Covered||100% Covered||Request Info|
Medicare Part C: Medicare Advantage
Medicare Part C, also known as Medicare Advantage, is a private variation of Original Medicare. It offers the same exact benefits that Traditional Medicare does (as required by law), but through a private insurance company. Sometimes, there may be additional coverage options in addition to what Traditional Medicare provides. But if you opt into a Medicare Advantage plan, you’ll essentially be opting out of getting your Medicare needs met by the government.
There are benefits and drawbacks to enrolling in Medicare Advantage. On the one hand, it isn’t uncommon for these plans to also offer benefits such as dental or prescription drug coverage – these extra benefits help sell policies and make money for private insurance companies. However, one of the most common complaints associated with Medicare Advantage is the restrictive medical networks. Whether or not your Medicare Advantage policy will require you to change doctors involves a number of variables.
Depending on where you live, California HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Orgnizations) can vary in price. Here are some estimated costs for your area:
Top HMO Plans in the Area
|Cost||Plan Name||Coverage Type||Premium||Deductible||Rating|
|$0||Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)||Health and Drug||$0.00||$0|
|$48||Kaiser Permanente Senior Advantage B Only South (HMO)||Health and Drug||$4.00||$0|
|$0||SCAN Classic (HMO)||Health and Drug||$0.00||$0|
Top PPO Plans in the Area
|Cost||Plan Name||Coverage Type||Premium||Deductible||Rating|
|$960||Anthem Medicare Preferred Standard (PPO)||Health and Drug||$80.00||$149|
Comparing Medigap and Medicare Advantage Policies
Take a look at this informational chart for a more thorough explanation on the differences between Medigap and Medicare Advantage:
|Questions||Medicare Advantage||Medicare Supplement|
|How are the plans funded?||Medicare will pay your insurance company a fixed amount based on average healthcare costs for your region. You may also be required to pay a premium based on your location and insurance company.||Your monthly premium takes care of the majority of your expenses.|
|Do I continue paying for Part B?||Yes||Yes|
|What does it cost me?||Some plans offer a zero-dollar premium (because the government subsidy covers the full cost). Other plans may cost up to 0-0 monthly.||While each plan does require a monthly premium, many of them are affordably priced.|
|What does the plan cover?||Depending on your plan, it will cover at least the same benefits offered by Medicare parts A & B. Possibly other benefits; but the more benefits you sign up for, the higher your out-of-pocket expenses may be.||All eligible expenses are split between Medicare, and your Medicare Supplement plan. If you have a comprehensive plan, such as Plan F, 100% of eligible expenses not covered by Medicare will be covered by your supplement insurance.|
|Can I budget my health care expenses?||It’s challenging; the more often you require medical care, the more often you may be required to pay out-of-pocket.||Budgeting is much easier with a Medicare supplement. You have fewer out-of-pocket expenses, and one simple monthly premium.|
|Can my plan be cancelled?||Yes. Unfortunately, your health insurance company has the legal right to review their Medicare Advantage services annually and decide whether or not they wish to continue providing coverage.||No – not unless you fail to pay your monthly premium, or your insurance company goes bankrupt. Only under such extenuating circumstances could your plan be cancelled.|
|Are pre-approvals or pre-certifications required?||Unfortunately, yes. These Plans usually require pre-certification or other qualification for some specific types of care.||No pre-approvals are required. If you qualify for Medicare, you will qualify for a Medicare supplement plan.|
|Can I use any doctor or hospital?||Usually, you choose from a network of pre-approved providers. These networks can fluctuate over time.||Yes. You are free to choose any doctor and/or hospital in the U.S. which accepts Medicare.|
|Can drug, vision, or dental coverage be included in the policy?||Yes.||No. These forms of coverage must be purchased separately.|
|Who is this plan type generally best suited for?||If you are relatively young, healthy, live in an urban area, and have a limited income, a Medicare Advantage plan could work for you.||If you live in a rural area without easy access to provider networks, if you like to budget your finances, or if you want comprehensive coverage, you might prefer a Medicare supplement plan.|
Need More Information on Medicare Plans in California?
There are a number of variables which will determine whether or not you should supplement your Original Medicare coverage. This article alone can only cover the basics. To make the best possible decisions about your health care, use the contact information below to speak to your local Medicare experts.
Important Medicare-Related Healthcare Terms
- HMO: Health Maintenance Organization, this refers to a network of doctors and hospitals with a plans’ network.
- PPO: Preferred Provider Organization, this refers to a network of doctors and hospitals with a plans’ network.
- Co-Pay: Amount of money charged per visit to doctor, specialist, etc.
- Co-Insurance: A percentage required by the policyholder to pay out-of-pocket. For example, 80/20 coinsurance means the insurance company will cover 80% of the charges, and the policyholder pays the remaining 20% of the charges.
- Deductible: This is the amount of money required out-of-pocket by the policyholder before the insurance will kick-in and pay for any remaining charges. For example, a policy with a $1,000 deductible means that you must pay full healthcare costs out-of-pocket up to $1,000 before the plan will start coverage.