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Medicare Options in California

Medicare is a government-run health insurance program covering a wide range of medical expenses. The US Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) oversees the program’s administration (HHS).

Medicare covers 64 million individuals nationwide, with over 10% of those residing in California. The number of Californians covered by Medicare will reach about 6.5 million by October 2021.

In most cases, Medicare coverage is automatically activated when an individual reaches the age of 65. In addition, a person is eligible for Medicare if they have received disability benefits for at least 24 months.

Roughly 14% of Medicare enrollees in the United States qualify for disability benefits. However, just 10% of Medicare members in California are registered due to a qualifying disability or chronic illness.

With healthcare expenses rising every year, you must find an insurance plan that doesn’t cost you a fortune but also fulfills all your needs. Find out more about different Medicare plans in California and learn why you need the services of a licensed Medicare insurance agent.

An elderly couple

Original Medicare

This is the traditional Medicare that is regulated by federal law. Parts A and B belong within the Original Medicare category. Part A deals with health care services in a hospital. This covers hospital inpatient treatment, hospice care, certain specialized nursing facilities, and some home healthcare.

Part B covers medical insurance. This plan covers everything from outpatient care to in-home care and durable medical equipment. It also includes certain preventive care, such as vaccines and screenings, to maintain your health and prevent illnesses from getting worse.

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Medicare Supplement (Medigap) Plans in California

There is no cap on out-of-pocket expenses under Original Medicare, so most beneficiaries choose to carry supplemental coverage. Medicare Supplement or Medigap plans in California are designed to cover some or all the out-of-pocket payments that Medicare members would otherwise bear.

There are ten Medigap plans to choose from in California. Two of these plans also feature high-deductible choices. Each policy has a slightly different price and level of coverage. The following are the most popular options in California:

Plan F

Plan F’s most popular Medicare supplement has been on the market for more than a decade. It fills all the shortfalls in Medicare, leaving you with no out-of-pocket expenses. However, Congress planned to discontinue Medigap Plan F in 2020.

Though this did not happen, Plan F is now exclusively available to those who were eligible for Medicare before January 1, 2020. Enrollment is not terminated for those who are currently enrolled in Plan F unless they switch plans or fail to pay their premiums.

Plan G

Medigap Plan G, which provides full coverage, is a popular alternative for many Medicare beneficiaries. Plan G isn’t going anywhere and covers all Plan F benefits minus the annual deductible for Medicare Part B.

The Birthday Rule

California’s “Birthday Rule” allows Medigap subscribers to shift to a Medigap plan of equal or lesser benefits on their birthday. The Birthday Rule allowed you to transfer insurance policies without undergoing a medical examination 30 days after your birthday.

CA residents now get 60 days following their birthday to make the switch according to California Senate Bill 407. Thanks to the new policy, members who switch plans are not subject to being denied coverage because of an existing medical condition.

No one can deny your application based on your health during this period. However, there is one condition. You need to have a Medicare Supplement plan active before you can exercise the birthday rule. You can either keep your current plan or select a Medigap plan with fewer benefits.

Note: Medicare Advantage programs are exempt from this provision. If you go for a Medicare Advantage plan, you may not be able to get new Medigap coverage with waived underwriting in the future. You will go through the standard health underwriting process to apply for California Medigap coverage outside of your birthday open enrollment period.


Medicare Advantage Plans in California

Though California Medicare Supplement plans offer the most extensive coverage; beneficiaries can also go for Medicare Advantage plans in California. Medicare Advantage plans are offered by private organizations that contract with Medicare. The best copays are only available if you agree to use the plan’s network of physicians and hospitals.

California Medicare Advantage plans may be less expensive than Medicare Supplements when it comes to premiums. However, you will incur copays along the way. For example, an appointment with your primary care physician (PCP) can cost you $20, while a specialist might cost you $60 or more.

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As with many other types of healthcare, you’ll have to foot the bill for certain services, including hospital stays, physical exams, lab work, supplies, etc. Before signing up for a health insurance plan, ensure that your provider is in the network.

Even though most counties in the US offer Medicare Advantage plans, 14 counties in northern and central California offer Original Medicare Plans only. 44 of California’s 58 counties offer Medicare Advantage plans as of 2022. Within the 44 counties, plan availability ranges from one in Humboldt County to 117 in some regions of Los Angeles County.

There are four types of Medicare Advantage plans in California:

Health Maintenance Organization (HMO)

Most HMOs mandate that you use only in-network providers for all healthcare services:

  • You must have a PCP (primary care physician), specialist referrals, and prior approvals for certain procedures and prescriptions.
  • Plans typically provide drug coverage. You can’t purchase separate drug coverage.
  • Staying within your network keeps costs low.


A Medicare insurance agent talking to clients
An elderly couple talking to a Medicare insurance agent

Preferred Provider Organization (PPO)

Medicare PPO plans have a recommended network of providers, but you can also choose doctors or hospitals outside the network for a higher price.

  • You don’t need to have a PCP or referrals for specialists.
  • Most plans provide drug coverage.
  • Drug coverage cannot be purchased separately.
  • Out-of-network charges and higher premiums.

Private Fee-For-Service (PFFS)

PCPs and specialist referrals aren’t necessary under PFFS programs:

  • You can consult any Medicare-approved doctor or healthcare facility, provided that they agree to the plan’s
  • Drug coverage may be included, or you can purchase a separate drug plan.
  • You’ll pay more if you go with a provider who doesn’t agree with the rules of your insurance plan.

Special Needs Plan (SNP)

SNPs are only available to people with certain medical conditions, and they feature care coordination and benefits that are specifically designed to match their specific needs:

  • You require a PCP and recommendations for specialists.
  • Plans always include prescription coverage.
  • SNPs are open to everyone who meets the eligibility criteria at any point in time.
a person holding a prescription

Comparing Medicare Advantage Plans in California

Medicare Advantage enrollment is on the rise in California – keeping in line with the nationwide trend. 40% of Medicare beneficiaries in California were enrolled in private Medicare Advantage plans as of 2018 – which is huge considering the 34% nationwide. This figure also rose to 48% in 2021.

When weighing your Medicare insurance options, the following factors are important to consider:

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Provider Network

Medicare HMO plans require that you use only providers in their network for all your healthcare needs. Otherwise, you will bear the healthcare expense yourself. To keep costs low, make sure your providers are in the network before signing up for a health insurance plan.

Amount of Coverage Required

Are there any key benefits you want out of your plan? Many Medicare Advantage and Medigap plans include dental, vision, and hearing benefits not included in the original Medicare plans. Make sure you keep a list of benefits handy to find a plan that covers all your needs.

Check Plan Ratings

To compare plans before open the enrollment period begins, check the Centers for Medicare & Medicaid Services (CMS) website for annual Part C and Part D performance data. The plans are rated on a scale of 1 to 5 (5 being the highest rating).

Out-of-Pocket Expenses

As the name implies, these are the costs you bear. Out-of-pocket expenses include deductibles, copayments, and coinsurance. If you stick to the provider network, these costs are the maximum that comes out of your pocket. Enrollees can use our plan finder tool to learn more about the expenses they’ll incur on different plans.

Monthly Premium

Since you’re already paying Part B deductibles, your Medicare Advantage or Supplement plan premiums add to your monthly cash flow. You’re responsible for these expenses whether you use your benefits or not. To keep your costs low, it is important to have at least one zero-premium plan with affordable drug coverage in your area.

Drug Coverage

Check the plan’s formulary to see if your medications are covered and how much they will cost you each time you get a prescription. Ask your doctor if they can recommend an alternate or generic version of a medicine that isn’t on the list.

Deductibles, Coinsurance & Copays

These are the costs you bear when you use your Medicare insurance benefits. Make sure you have complete information about your plan’s hospital and medical coverage. This includes hospital visits, prescriptions, and other healthcare services.

Freedom to Travel

Plans that provide travel coverage are popular among California residents who frequently travel out of state. While Medigap plans allow you to get treatments wherever you go, Medicare Advantage plans often stick to their network only allowing for emergency only insurance coverage. Before choosing a plan, check with your provider to see what kind of travel coverage you require.

SCAN Health Plan is a popular option for Medicare beneficiaries throughout California due to its broad network options.  


A senior couple enrolling for Medicare online

Medicare Eligibility in California

Patients of chronic or incurable conditions, such as end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS), can also enroll for Medicare at any point in their lives.

Medicare Enrollment in California

Medicare will register you automatically if you have received at least four Social Security or Railroad Retirement Board payments before your 65thbirthday. Otherwise, you can reach out to your local Social Security Office or apply online. We recommend not mailing your application as that is a much slower process.

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Enrollment in Medicare is open during the following time frames:

Initial Enrollment

The initial registration period begins three months before and ends three months after your 65thbirthday. This is the time to enroll if you have never had Medicare before. You can also change or update your current Medicare plan if you began receiving it at a younger age.

General Enrollment

For those who missed the initial enrollment time, you get another window that runs from January 1 to March 31. You can enroll in Original Medicare (Parts A and B), Medicare Advantage (Part C), Medigap, and Part D plans during this period.

Open Enrollment

You get a 3-month window from October 15 to December 7 each year, during which you can make changes to your Part C plan.

Special Enrollment

If you lose your insurance coverage or your eligibility changes due to unforeseen circumstances, you may be eligible for a special enrollment period.


Why Should You Choose Integrity Now insurance Brokers Insurance Agents?

At Integrity Now Insurance Brokers, our Medicare Insurance Agents are accredited annually by America’s Health Insurance Plan (AHIP). Your Medicare Insurance needs are in good hands with us. We work with the elderly, youth with disabilities, and others who need help taking care of their healthcare expenses.

Every year, new Medicare insurance providers and policies enter the market. Existing plans can also experience adjustments and updates. We keep tabs on all of these changes for you, so you don’t have to.

A Medicare insurance agent in California will review your healthcare needs and weigh all your options. This includes figuring out if a Medicare Supplement Plan or a Medicare Advantage Plan is best for you.

With our guidance, you can compare quotes and find the best Medicare insurance plan for your needs. We have all the information you need to get started on debt-free and stress-free living.

We service all California cities and counties.

Call us to speak with one of our representatives and get started today!

: A Medicare insurance agent

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