California boasts over 39 million people, well over 200 sunny days a year, and a laid-back lifestyle. It’s a great place to live no matter what age you are.
However, if you’re approaching 65, you might be thinking about Medicare and how you can make this important benefit work for you. You might wonder who can apply for Medicare in California, or if you need to even bother — aren’t you enrolled automatically?
This guide can help you understand how Medicare in California works and how you can ensure that you end up with the plan that’s right for you. Let’s get started!
Medicare is a federal program designed to help people access health coverage when they are less likely to have it through an employer — for example, those who are retirement age or disabled.
Original Medicare and Medicare Advantage are the two main varieties of Medicare. Original Medicare is the standard plan, although it may not be appropriate for your requirements. Part A (hospital insurance) and Part B (medical insurance) are included in original Medicare, as well as optional extras such as Part D (prescription drug insurance).
Medicare Advantage, also known as Medicare Part C, is a complete replacement for Original Medicare that may include additional perks. Private health insurance firms in the state sell Advantage plans, so California's Advantage plans will be distinct from those available in another state.
To be eligible for Medicare in California, you’ll need to meet specific requirements. You need to be a U.S. citizen or permanent resident who has lived in the US for at least five years, and one of the following conditions must also apply:
Once you qualify, you’ll be given an initial enrollment period to select the plan that’s best for you. You can enroll directly in a plan or be automatically enrolled in the default option.
Keep in mind that the default options are Original Medicare Part A and Part B. If you want additional coverage options or an Advantage plan, you’ll need to take action during your initial enrollment period to select those plans. It’s best to compare a few choices before making a final decision.
Can you get Medicare for free? As we mentioned, Medicare coverage is divided into different parts. Medicare Part A (hospital insurance) is premium-free for most Americans, based on you or a spouse paying into the Medicare system through your work for a specific period of time.
Medicare Part B (medical insurance) and Part D (prescription drugs) each have a monthly premium. In addition, when you use any of your Medicare coverage, you’ll have an annual deductible and coinsurance to take care of, while Medicare pays the rest. Learn more about premiums, deductibles, and Medicare costs in this guide.
Medicare Advantage plans have a monthly premium as well, although it may be the same as if you had Medicare Part B, which means you’re not paying any extra. These plans also have deductibles and coinsurance or copayments.
Medicare Advantage plans are available in all states. These are offered by private insurance companies and have at least the same level of coverage as Original Medicare, although they often have additional benefits as well. There are more than 29 million people enrolled in Medicare Advantage in California.
The important thing to note before choosing an Advantage plan is the medical provider network. While Original Medicare has a national network of providers, Advantage plans tend to be focused on your local area. You’ll need to ensure that your preferred doctors and specialists are included, and keep in mind that you may not have access to non-emergency care when you’re traveling.
Because there are a variety of Advantage plans available in California, you’ll want to carefully compare your options before you make a final decision. You’ll need to do this during your initial enrollment period, and you can make changes to your plan during the annual enrollment period (AEP) each fall.
How much are Medicare services in California? It depends on which coverage applies to your Medicare services.
For Original Medicare, you’ll generally pay no premium for Part A and $170.10 for Part B each month in 2022. Part D will have its own monthly premium based on the plan you choose.
If you choose a Medicare Advantage plan, you’ll pay the premium for that plan instead of A, B, and D. Often, an Advantage plan will charge the same as Medicare Part B.
Once you start using your coverage, you’ll have an annual deductible you cover first, and then Medicare coverage kicks in. After that, you’ll pay your coinsurance or copayment, and Medicare will cover the rest.
For example, for doctor’s visits, you use Medicare Part B, which has a deductible of $233 in 2022. Then you pay a coinsurance of 20% of the Medicare-approved cost, and Medicare pays the remaining 80%.
For a hospital stay, you use Medicare Part A, which has a deductible of $1,556. Then you have a $0 coinsurance for the first 60 days, and specific coinsurance amounts for days 61-90.
A Medicare Advantage plan will have its own deductible, coinsurance, and copay amounts. Contact the insurance company to get the details for your plan.
If you struggle to pay your Medicare premiums in California, there are Medicare Savings Programs (MSPs) available for those who have lower income and assets.
The most comprehensive plan is known as the Qualified Medicare Beneficiary program (QMB), and it takes care of your Advantage plan or Part A and Part B premiums, deductibles, and coinsurance payments. However, it also has the most restrictive requirements.
On the other end, the Qualified Individual (QI) program has looser requirements but only pays your Medicare Part B premiums.
If you have lower income and assets and have Original Medicare, you can also look into whether you qualify for Extra Help with Part D (prescription drugs).
Medicare Advantage plans can vary widely in cost and benefits, which is why it’s so important to compare coverage options before you commit to a plan.
Many plans will not have a higher monthly premium than you would normally pay for Medicare Part B. However, others will charge that amount plus an additional premium. If you see a Medicare Advantage plan advertising a $0 cost, they are referring to $0 above the Part B premium.
Each plan will have its own annual deductible and copayment or coinsurance amounts. You can get the latest information on cost changes to Medicare in 2022 in this guide. Be sure that those fees make sense, especially for the medical care you’re most likely to need. You’ll also need to make sure that the doctors you prefer are part of the provider network since there’s likely to be no non-emergency care outside the network.
An Advantage plan will have at least as many benefits as Original Medicare, but most offer additional benefits as well, such as vision or dental coverage. By comparing the costs and the benefits, you can choose the plan that’s best for you.
This guide answered many of the questions we’ve heard about Medicare in California, but don’t let that stop you from reaching out with your own specific concerns. We want to help you understand your Medicare benefits and compare Medicare quotes so you have the coverage you need. For more information, contact us today!
When planning ahead for your healthcare expenses and how they align with your Medicare coverage, it’s very important to stay informed on the changes to Medicare each year. Several aspects of Medicare - particularly related to out-of-pocket costs - can change on an annual basis. Beyond costs or plan changes, Congress also occasionally proposes and passes legislation that often impacts Medicare benefits. In this article, we’ll review the recent changes, including the 2023 Medicare costs and an overall look at the state of Medicare in 2023. 2023 Medicare Costs: An Overview The Medicare costs that change each year are: Part A deductiblePart A daily coinsurancePart B deductible Medicare Part A CostsThe changes to Part A costs include:Part A deductible - $1,600, an increase of $44 from 2022Part A daily coinsurance for hospital stays over 60 days - $400 per day, an increase of $19 per dayPart A daily coinsurance for hospital stays over 90 days - $800 per day, an increase of $22 per dayPart A daily coinsurance for skilled nursing facility stays longer than 20 days - up to 100 days $200, an increase of $5.50 per month Keep in mind that it is possible to pay the Part A deductible more than once in a year. This would only happen when you have multiple hospital stays in one year, and your stays are separated by more than 60 days. In this situation, you’d pay the Part A deductible each time.When you pay the Part A deductible, that gets you 60 days in the hospital and 20 days in a skilled nursing facility. If your stay goes beyond those times, you’ll have to pay the updated daily co-insurance amounts indicated above. Medicare Part B CostsThe Part B deductible for 2023 decreased to $226. It was $233 for 2022. You have to pay the Part B deductible each year before Medicare starts paying its portion of your outpatient care. Unlike the Part A deductible, you’ll only be required to pay the Part B deductible once per year.After you’ve met the Part B deductible, Medicare will pay the first 80% of the cost for your care; you’ll be responsible for the remaining 20%. Besides standard Part B coinsurance, you might encounter Part B excess charges, which can be as much as 15% of the Medicare-approved cost for your care.There were no changes to these coinsurance costs for 2023. How Much Will Medicare Premiums Increase in 2023? The standard Part B premium for 2023 is $164.90, which is a decrease of $5.20 per month. This decrease takes some of the sting out of last year’s increase, which was one of the largest in history. You may pay a higher premium for Medicare if you have incomes exceeding $97,000 (single filers) or $194,000 (married filing jointly).In addition to the costs for using your coverage, you’ll also have to consider the cost for getting your coverage. Most people don't have to pay a premium for Part A coverage (because it’s been pre-funded through payroll tax deductions), but you do have to pay a premium for Part B coverage. Medicare Part D Changes Another major component of your Medicare coverage is Medicare Part D, also known as Prescription Drug Plans (PDPs). Part D is offered by private insurance carriers with a Medicare contract - not offered by the federal Medicare program. There have been major changes to Part D in the past year as a result of the Inflation Reduction Act. Some of these changes won’t take effect until 2024 or later, but a few of them will be effective in 2023. The changes that will be applicable for 2023 include:Caps on the cost of certain insulinTaxes on excessive increases in the cost for prescription drugsLowering the cost of many vaccinations covered under Part DEach of these changes will have an impact on both standalone Part D Prescription Drug Plans (PDP) and Medicare Advantage Prescription Drug Plans (MAPD). New Caps On Insulin PricesThe Inflation Reduction Act has brought us the Insulin Savings Program, which was a temporary “test program” that began in 2020. The program is now permanent and mandatory. But previously, it was optional: Part D plans could choose to participate on a voluntary basis.The Inflation Reduction Act limits monthly cost sharing for covered insulin products to no more than $35 for Medicare beneficiaries, as long as the insulin is on the plans formulary. No deductible will apply to these insulin prescriptions. For 2023 and beyond, insulin prescriptions are capped at $35 for a one month supply. This price level stays the same throughout the year, even if you enter the coverage gap or “donut hole.” Excise Tax On Excessive Cost Increases Cost increases on prescription drugs, which are set by the manufacturers, will be subject to a new tax beginning in 2023. Medicare will use 2022 drug prices as a baseline and will investigate the prices for 2023 prescription drugs. If the increases from 2022 to 2023 are larger than the official rate of inflation, the manufacturer will pay a tax equal to 100% of the amount that the increase exceeded inflation for the year. Drug prices will be tracked each year in this way. The hope is that manufacturers will be less likely to increase prices aggressively since they won’t be able to keep any of the extra revenue that large cost increases used to bring them.While this new policy doesn’t directly reduce or limit the prices you pay through your drug plan, over time, it may allow for smaller copayments and coinsurance for your prescriptions. Reduced Vaccine Costs Under Part D The Inflation Reduction Act is also impacting how much you’ll pay for vaccinations under Part D. Prior to 2023, most non-essential vaccines were subject to cost-sharing, which meant that you had to pay a copayment or coinsurance for them. For example, the shingles vaccine was famously expensive. For 2023 and beyond, many Part D covered vaccines will be available at no cost. This brings the Part D vaccinations into alignment with the rules and cost structure for Part B vaccines (like the COVID-19 and flu shots). This includes the shingles shot, so protecting against this painful illness will be cheaper starting in 2023. There are still vaccines that you’ll have to pay for under Medicare, even after these recent changes. Vaccines that are needed to treat injuries or exposure to certain diseases may still require cost-sharing. General Enrollment Period (GEP) ChangesThe last major change to Medicare in 2023 relates to entering Medicare when you’ve missed your original enrollment window. Most people get to enter Medicare when they turn 65-years-old. In that case, you have a seven-month enrollment period known as your Initial Election Period (IEP) during which you can enroll. If you miss this chance, you have to enroll during the General Enrollment Period (GEP). GEP runs from January 1st to March 31st each year. Previously, if you enrolled during the GEP, your Medicare coverage wasn’t effective until July 1, which left you with a significant gap in your medical coverage.For 2023 and beyond, your coverage will be effective on the first day of the month after you sign up during the General Enrollment Period, eliminating the lengthy waiting period. Learn MoreIf you still have questions about 2023 Medicare costs and how they impact you, call 800-620-4519 to speak to one of our licensed insurance agents. You can also view our Medicare resources online:Compare Medicare plans: Visit our Medicare plan comparison tool.Learn about Medicare: View our Medicare Learning Center.Note: These 2023 Medicare costs and updates are courtesy of the Centers for Medicare & Medicaid Services (CMS). For more information, visit the CMS newsroom.
Researching your Medicare plan and understanding how to use your benefits wisely is key to maximizing your Medicare plan. But if you don't take the time to learn all that your current plan has to offer, or if you avoid comparing Medicare plans when it may be time to make a change, you could end up paying more money for your healthcare. To help you make an informed choice, we’ve put together this guide about 10 costly mistakes to avoid when picking a Medicare plan. Mistake #1: Using Doctors And Medications That Are Not Covered By Your Plan Medicare Advantage plans have formal networks of providers and lists of medications that are covered (called a formulary). If you see doctors who aren’t in-network, you’ll be paying more for your care than if you use in-network providers. While some PPO plans will allow you to see non-network providers, you’ll save the most money when you use in-network providers. In the same way, plans only provide coverage for medications that are on the formulary. If you use non-covered medications, you’ll end up paying full price for them. So if your current plan doesn’t work with your doctors and medications, you may want to consider making a change to your coverage a qualifying enrollment period. Our online guided Medicare enrollment tool also allows you to check and see if your doctor and drugs are covered in a Medicare Advantage plan. Mistake #2: Not Taking Advantage of Additional BenefitsOne of the reasons Medicare Advantage plans are increasingly popular is because they usually provide benefits that are not covered by Original Medicare. These kinds of benefits can include dental, vision, hearing, or prescription drug coverage.These benefits also may be included in your plan at no additional cost. If you don’t use them, you might be paying more than you need to for these services. In addition to the potential cost savings, these additional benefits are designed to help you live a healthier life. Mistake #3: Paying Cash For Your MedicationsIt can be tempting to pay cash for some of your less expensive medications. This is especially true when you look into any of the various prescription discount card programs that are currently available. However, it's wise to avoid paying for your medications if you're expected to reach the third coverage stage of the Medicare Part D drug program (often called the donut hole). Your drug plan tracks your spending, so if you pay cash for a prescription, it doesn’t count towards your official spending. This means that you might not be able to move out of the donut hole if you pay cash for some of your medications. Instead, consider using your plan even if you’ll pay more, if it means that you’ll move out of the donut hole faster. Mistake #4: Not Understanding Your Plan’s CostsWhile Medicare Advantage plans generally help to limit your healthcare costs, it’s important to remember that there are costs you’ll be expected to pay for your care. These costs are usually referred to as cost-sharing. Cost-sharing can include deductibles, copayments, and coinsurance. Besides these amounts, you’ll want to double check your plan’s Out-of-Pocket Maximum (OOPM), which is the most you could possibly spend in one year. Mistake #5: Choosing A Plan Based On Premiums AloneIt can be tempting to focus on the monthly premium you pay for your coverage, and not dig deeper into the costs you’ll pay to use your benefits. Pay particular attention to any deductible that you have to meet, as well as co-payments for services you’re likely to use. Besides these, consider your total costs in light of any costs for prescription drugs you take, too. Mistake #6: Not Checking To See If You Qualify For Financial AssistanceThere are a number of federal and state programs that are designed to help you pay for the cost of your health care. These can include Medicaid, Extra Help, Low Income Subsidy, and state pharmaceutical assistance programs. While there are income and asset limits for participation in some of these, you should apply for them if you think there is any chance that you could be eligible. Many times the limits are dependent on household size so you may qualify even if your income appears to exceed the limits. The upside is huge and there’s no downside to applying, so don’t miss out any potential for savings with these programs. Mistake #7: Not Considering Late Enrollment PenaltiesIt’s very important to consider the impact of late enrollment penalties, especially when you’re first entering Medicare. You can potentially be subject to enrollment penalties for both Part B and Part D. These penalties are assessed in the form of an additional monthly premium. Importantly, these penalties are generally permanent; once you’re subject to them, you’ll pay them for the rest of your life.If you’re already in Medicare, and you have avoided late enrollment penalties so far, just make sure that you continue to have Part D drug coverage, either from a Medicare Advantage Plan or a standalone Prescription Drug Plan.Mistake #8: Not Reviewing Changes In Your CircumstancesIt's important to review any changes in your circumstances on an annual basis. If you’ve been referred to a new specialist, prescribed a new medication, or diagnosed with a new medical condition, you might be better served by a different plan for the new year. So be sure to consider the impact these kinds of circumstances may have on your Medicare coverage. Mistake #9: Automatically Renewing Your Plan Each YearEach year, your plan will mail your Annual Notice of Change (ANOC) before the fall Annual Enrollment Period (AEP). The ANOC outlines changes in your plan benefits or costs for the upcoming year. Use this document, along with your plan’s overall Evidence of Coverage (EOC) to know how to use your benefits for this year.If you don’t make a change during AEP, you’ll automatically stay in your current plan. But plan benefits change from year to year, as do Medicare Advantage plan networks. So it's essential to review your coverage each year. Mistake #10: Not Working With A Licensed Insurance AgentAs you research the plans available in your area, consider working with a licensed insurance agent like one of our TogetherHealth agents. We work with a network of the nation’s major insurance carriers and can provide you with a variety of plan options to fit your healthcare needs, remain in-network with your doctors, and give you strategies to save money on prescription drugs. Get Help With MedicareIf you need more guidance, call 1-800-620-4519 (TTY 711) to speak to one of our licensed agents and get advice on how to avoid these 10 costly Medicare mistakes.
With the 2020s underway, let’s take a look back at seven key milestones and issues that marked the evolution of healthcare over the past 25 years. 1. The Affordable Care Act became law Just months into 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. The Affordable Care Act, often referred to as the ACA or Obamacare, changed the nation’s health insurance landscape and brought about numerous provisions to help make health insurance more affordable and accessible to as many Americans as possible. Some key provisions include: The creation of a health insurance marketplace in every state to provide consumers with a place to purchase health insurance.Income-based subsidies, including premium tax credits and cost-sharing reductions, for those who purchase individual coverage through the health insurance marketplace (i.e., the state-based and federal exchanges).A requirement that insurance plans cover young adults on their parents’ policies to age 26.Guaranteed issue and renewal of policies.Medicaid expansion to those with incomes below 138% of the federal poverty level, in participating states. Ten years later, uninsured rates have declined. In 2010, nearly 16% of Americans were uninsured. But in 2016, the uninsured rate hovered just above 8% - its lowest point in the decade. Although, it started to increase again slightly in 2017.2. Short-term health insurance kept its strideShort-term health insurance is temporary insurance that provides coverage in certain medical situations like an unexpected accident or illness. However, it doesn't include the same essential health benefits that ACA plans do, making it a more affordable insurance option for many.Short-term health plans remained a relevant health insurance option throughout the decade with sales increasing sharply after the ACA took full effect in 2014. These plans became an attractive option for people who were exempt from the individual mandate or opted to pay a penalty for not having an ACA-compliant health plan.Obama limits short-term policiesConcerned that short-term health insurance was impacting ACA enrollment, the Obama administration created regulations that limited their availability. In 2016, short-term policies were capped at three months.Trump expands short-term policiesIn 2018, the Trump administration lifted Obama-era limits. Policies can now last up to 12 months and can be renewed for up to 36 months, depending on state laws. Arizona, for example, has adopted the Trump administration’s regulation. Some states, such as Oregon, still limit short-term plans to less than 90 days.3. High-deductible health plans grew in popularityHigh-deductible health plans, called HDHPs, were introduced in the early 2000s and were considered "mainstream plans" by 2012. People obtained these plans usually through their employer group-based coverage (if offered), the healthcare exchange, or from private insurers. Here are some interesting facts:HDHP enrollment jumped from 10 million people to 11.4 million people in one year (from January 2010 to January 2011).By 2015, HDHPs accounted for 60% to 80% of plans offered in the individual health insurance marketplace. In 2019, the IRS classified high-deductible health plans as any plan with a deductible of at least $1,350 for an individual and $2,700 for a family. The average annual deductible for individual coverage through a group plan was $1,655 in 2019.But while consumers can appreciate the lower monthly premium of a high-deductible insurance plan, they also tend to delay or skip medical care because of the high out-of-pocket costs associated with HDHPs.The popularity of HDHP may be slowing - at least in the group market. The percentage of employers offering a high-deductible health plan as the only option is projected to decrease in 2020, with more employers beginning to offer additional coverage options.4. Healthcare spending continues to climbIf it seems like your healthcare costs increased throughout the past decade, it probably did. In 2018, the average American household spent $5,000 on healthcare, with nearly 70% of the $5,000 going towards health insurance.The more staggering fact: medical bills are reported to be the number one cause of bankruptcies nationwide. And today, medical costs are considered America’s "real healthcare crisis". And while politicians continue to debate issues including health insurance reform and prescription drug pricing, they have not agreed upon a clear solution.Until things change, consumers must continue to find ways to save on their own, from finding flexible and affordable health insurance options and taking advantage of preventive care, to comparing provider rates before seeking services and getting alternative healthcare through options like telemedicine.5. An opioid epidemic devastates our nationThe opioid epidemic might be the most daunting and complex public health crisis of our time. Heroin-related overdoses increased 286% from 2002 to 2013, with a significant spike around 2010. Another wave of opioid-related deaths hit around 2013 and this time, synthetic opioids like fentanyl were behind the surge. The crisis continued to escalate from there, with prescription drugs playing a significant role. Here are some of the most shocking reports:Opioid overdoses accounted for more than 42,000 deaths and increased to 47,600 people in 2017. By 2019, more than 90 Americans per day were dying from opioid overdose. And prescription opioid abuse was costing the nation $78.5 billion per year.The epidemic impacted people in both rural and urban environments. But overdose deaths in rural communities surpass deaths in urban settings. So what’s being done about it? In early 2019, the Trump administration launched a $353 million initiative to cut opioid overdoses by 40% over the next three years. The federal government is also working to hold drug companies accountable. For example, top executives at Insys Therapeutics were found guilty of racketeering conspiracy—a charge typically assigned to drug dealers and mob bosses. In 2018, the CDC reported that drug overdose deaths decreased for the first time since 1990.6. Covid-19 pandemic and the U.S. healthcare systemThe 2020 pandemic was not only the biggest health event in the U.S. in the past decade, but a major burden on an already fragile healthcare system. From shortages of hospital beds and staff to healthcare facilities having to ration medical supplies to keep up with COVID-19 cases, we’ve seen how our healthcare infrastructure is in need of improvements to better prepare for crises. Not only that, researchers at the Massachusetts Institute of Technology assert that the pandemic revealed some deeper issues in our healthcare system, such as disproportionate access to care among marginalized groups and the country’s dependence on healthcare services from underpaid workers.7. Medicare enrollment: Medicare Advantage Plans and Original Medicare Medicare Advantage plans, which are an alternative to Original Medicare, have seen a steady increase in enrollment each year over the past decade. As of 2022, there are 28.4 million Medicare Advantage enrollees which account for 48% of the Medicare-eligible population. People enrolled in MA plans back in 2012 represented about a quarter of all beneficiaries, so enrollment rates have just about doubled.Another interesting fact as reported by Kaiser Family Foundation is that “the average Medicare beneficiary in 2022 has access to 39 Medicare Advantage plans, the largest number of options available in more than a decade.”Here’s a breakdown of MA plan enrollment:About two-thirds (18.7M) of the Medicare population are enrolled in a plan available through individual enrollment.Roughly 5.1 million beneficiaries have coverage through an employer or union group plan available to retirees.More than 4.6 million people are enrolled in Special Needs Plans, the majority of which (89%) are those eligible for both Medicare and Medicaid. The healthcare debate continuesDiscussions about healthcare reform and our healthcare landscape did not stop when the ACA was passed. Conversations about legal challenges continue to this day. There has been proposed legislation to repeal and replace the ACA under the Trump administration. Trump administration removes individual mandateNew tax legislation passed in December 2017, which changed one key aspect of the ACA. Previously, you could be penalized for not having health insurance, but Congress and President Trump eliminated the mandate rule for all coverage beginning Jan. 1, 2019. Individual mandate challenged as unconstitutionalThe 5th Circuit also ruled in Texas vs. United States that the individual mandate is unconstitutional, at which time, a A Texas Judge was deciding what, if any, of the ACA still stands. But in 2021, the Supreme Court ruled that states don’t have any grounds to challenge the constitutionality of the ACA mandate.The 2020 electionWith the Presidential election in 2020, Democrats were focused on building upon the ACA with tactics like a “Medicare for all” national health insurance system. However, this agenda never took effect with the Democratic party winning the election. Now twelve years after the passing of the ACA, the Biden-Harris administration has promised to continue upholding the ACA and making affordable health insurance accessible. With ongoing talks of a universal health insurance option for Americans and how to navigate health-related issues post pandemic, there’s no doubt that healthcare legislation will continue to make headlines over the next decade. From Obamacare to the opioid epidemic to the Covid-19 pandemic, healthcare-related issues have made major headlines. And it’s inevitable that they’ll only continue to evolve and impact our lives for years to come. We’ll continue to follow the trends and changes as well as their impacts on our nation.