Choosing the right Medicare plan is crucial for Southern California residents to receive essential medical care without incurring high expenses. With many Medicare plans to choose from, the task can be daunting.
Hence, understanding how Medicare works and how each type of plan works will help you in deciding which plan is right for you.
Filter and compare suitable plans to save time and headaches among the many available carriers and options.
Types of Plans Available in Southern CA
There are four main types of Medicare plans available.
Original Medicare (Part A and Part B)
Original Medicare is the traditional fee-for-service Medicare plan that includes hospital insurance (Part A) and medical insurance (Part B).
Part A of Medicare covers a range of hospital services: inpatient hospital care, limited home healthcare visits, short-term skilled nursing facility stays, and hospice care.
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Medicare’s Part B covers general medical services, including preventive, diagnostic, and treatment services for various health conditions. It also covers emergency room visits and costs associated with emergency medical transportation.
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Medicare Advantage (Part C) Plans
Insurance companies offering Medicare Advantage (Part C) plans cover hospital insurance (Part A) and medical insurance (Part B). They may also provide prescription drug coverage (Part D) and extra services such as vision, dental, and hearing.
Medicare Prescription Drug (Part D) Plans
Medicare beneficiaries with Original Medicare or a Medicare Supplement plan (Medigap) can also purchase a stand-alone prescription drug plan. Many Medicare Advantage plans have Medicare part D (prescription drug coverage) built into the plan for ease.
Medigap (Supplemental) Plans
Medigap (Medicare Supplement) policies are health insurance policies offered by private insurance carriers. A monthly premium covers gaps in Original Medicare based on age, health, and not covered medical expenses. The monthly premium amount covers deductibles, copayments, and coinsurance.
However, it does not cover additional services offered by Medicare Advantage nor Part D prescription drug coverage. Medigap policyholders will need to purchase additional policies for hearing, vision, and dental coverage and prescription drug coverage.
Selecting the Best Medicare Plan for Seniors in Southern CA
Coverage options
The plan should cover specialist care, prescription drugs, hospital services, and other benefits that meet the individual’s medical needs, such as vision, dental, and hearing.
Cost
Evaluate premiums, deductibles, copays, and coinsurance to select a plan that fits your budget. Comparing the prices of different plans can help find the most cost-effective option. See Medicare costs for 2023.
Prescription drug coverage
Ensure the plan covers your required medication, especially if you take prescription drugs regularly.
Provider networks
Check if the plan’s provider network includes the hospitals, clinics, and other healthcare facilities you prefer. If not, look for a plan with a broader network or out-of-network care options.
Additional benefits
Consider extra benefits, such as wellness programs, dental and vision coverage, transportation, home services, and hearing aids.
Comparison of Medicare Plans in California for Seniors
Original Medicare
Original Medicare is available to qualifying beneficiaries 65+ and those under 65 with specific disabilities. It consists of Medicare Part A (Hospital) and Medicare Part B (Doctor).
Pros:
- Flexibility: With Original Medicare, you can visit any doctor or specialist that accepts Medicare. There are no restrictions or networks to worry about.
- Nationwide Coverage: It provides coverage nationwide, making it a great option for seniors who travel frequently.
- Guaranteed Acceptance: Guaranteed issue Original Medicare ensures that coverage cannot be denied to individuals, regardless of their health status.
- Comprehensive Coverage: Original Medicare covers a wide range of medical services, including doctor visits, hospitalizations, medical equipment, and lab tests, among others.
- Minimal Out-of-Pocket Expenses: It has low out-of-pocket costs, making it a cost-effective option for seniors on a tight budget compared to others plans.
Cons:
- Limited Coverage: Original Medicare does not cover all medical services, such as dental, vision, and hearing care and prescription drugs. It may require seniors to purchase additional insurance plans to fill the gaps.
- No Annual Out-of-Pocket Maximum: It does not have an annual out-of-pocket maximum, meaning seniors could face significant medical bills requiring extensive medical care.
- No Added Benefits: It lacks extra benefits like wellness programs, gym memberships, and vision or dental care available in other Medicare plans.
- No Prescription Drug Coverage: Original Medicare lacks drug coverage; seniors must register for a separate Part D plan to obtain coverage.
- Cost Sharing: Original Medicare requires seniors to pay coinsurance, deductibles, and copayments, which can add up over time.
Medicare Advantage Plan (Part C)
Medicare Advantage Plans, or Medicare Part C, are offered by private insurance companies and provide comprehensive coverage, in addition to the benefits offered by Original Medicare.
Pros:
- Comprehensive Coverage: Covers all services provided by Original Medicare and may offer additional benefits such as dental, vision, and hearing coverage.
- Out-of-Pocket Maximum: Has an annual out-of-pocket maximum, protecting seniors from significant medical bills.
- Prescription Drug Coverage: Includes prescription drug coverage, eliminating the need for a separate Part D plan.
Provider Networks: Plans have provider networks that may include lower-cost options for medical care.
Additional Benefits: Additional benefits like wellness programs, gym memberships, transportation services, Flex cards, and Medicare Part B Premium Giveback.
Cons:
- Limited Provider Choice: Plan members are usually required to use healthcare providers within the plan’s network.
- Plan Changes: Plans can change yearly, including changes to covered services, provider networks, and costs.
- Prior Authorization: Requires prior authorization for some services, which can delay treatment.
Limited Coverage Outside of Service Area: Coverage may not be available outside the plan’s service area without additional costs.
Medicare Prescription Drug (Part D)
The purpose of Part D is to help people with Medicare pay for their prescription drugs and to make those drugs more affordable.
Pros:
- Access to affordable prescription drugs: Part D coverage can significantly reduce the cost of prescription drugs, making them more affordable and accessible for Medicare beneficiaries, mostly for seniors.
- Broad drug coverage: Part D plans offer coverage for a broad range of prescription drugs, including brand-name and generic medications.
- Cost-saving opportunities: Part D plans offer various cost-saving opportunities, such as discounts and copayments for certain drugs and opportunities to enroll in mail-order pharmacy programs.
- Catastrophic drug expenses: Once a beneficiary reaches a certain level of out-of-pocket expenses in a year, Part D coverage provides a safety net for catastrophic drug expenses.
- Extra help available: Additional assistance programs, such as the Extra Help program for seniors, help low-income beneficiaries pay for Part D coverage.
Cons:
- Monthly premiums and out-of-pocket costs: Part D coverage requires beneficiaries to pay monthly premiums and out-of-pocket costs, which can be a financial burden for some people.
- Coverage restrictions and formularies: Part D plans have restrictions on coverage and formularies, which can limit access to certain drugs and treatments.
- Coverage gaps (the “donut hole”): Beneficiaries may have to pay higher drug costs during a coverage gap known as the “donut hole” in Part D coverage until reaching the out-of-pocket limit.
- Plan selection complexity: Part D’s complexity, options, and drug formularies make it hard for beneficiaries to choose a suitable plan.
- Limited coverage for certain drugs: Some drugs, such as certain types of non-prescription drugs and drugs for cosmetic purposes, are not covered by Part D plans.
Medigap (Supplemental) Plans
Medigap, also known as Medicare Supplement Insurance, is a type of private health insurance that helps cover some of the out-of-pocket costs not covered by Medicare.
Pros:
- Out-of-pocket costs not covered: Medigap plans can cover deductibles, coinsurance, and copayments that Medicare does not cover, reducing your out-of-pocket expenses. Also, offers predictable out-of-pocket costs, which can help seniors budget for healthcare expenses.
- Provider freedom: It allows you to see any healthcare provider that accepts Medicare without worrying about network restrictions.
- No network restrictions: Unlike Medicare Advantage plans, Medigap plans do not have network restrictions, so you can see any doctor or specialist that accepts Medicare.
- Guaranteed renewable coverage: Paying premiums on time ensures that Medigap coverage cannot be canceled, even if the policyholder has health problems.
- Standardized coverage options: Medigap plans are standardized, meaning each plan letter (such as Plan F or Plan G) offers the same benefits, regardless of the insurance company that sells it.
Cons:
- Higher monthly premiums: Medigap plans have higher monthly premiums than Medicare Advantage plans, although you may end up paying less out of pocket for healthcare services.
- Limited coverage options: It will only cover certain out-of-pocket costs, and they do not cover benefits such as dental, vision, and hearing.
- Unavailable to those enrolled in Medicare Part C: If you have a Medicare Advantage plan, you cannot enroll in a Medigap plan unless you switch back to Original Medicare.
- Do not cover prescription drugs (Part D): Medigap plans do not cover dental, vision, or hearing benefits, which can be important for older adults who may need these services more frequently.
Watch this video to see a comparison between Original Medicare and Medicare Advantage.
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How to Enroll in a Medicare Plan in California
Here are some important things to know about enrolling in a Medicare plan in California, including eligibility requirements, enrollment periods, and the application process.
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Eligibility Requirements
- Must be 65 years old or older or have certain disabilities
- Should be a resident of California
- Must have been a citizen or legal resident of the United States for at least five years.
Enrollment Periods
- Initial Enrollment Period (IEP): a 7-month period that begins three months before you turn 65, includes the month you turn 65, and ends three months after you turn 65.
- Annual Enrollment Period (AEP): October 15 – December 7 each year.
- Special Enrollment Periods (SEP): Available in certain situations, such as moving to a new area or losing employer coverage.
- Medicare Advantage Open Enrollment Period (MA-OEP): January 1 – March 31 each year. Only available for Medicare Advantage.
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Application Process
- Enroll online through Medicare.gov. Southern CA residents can use my Medicare Plan Finder tool here to find their best plan.
- Contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) to enroll over the phone. Southern CA residents can schedule a call HERE (calendly call link) for a more personalized and faster experience.
- Enroll in person at your local Social Security office. Southern CA residents can schedule an appointment HERE.
