California Dreamin’: A Senior’s Guide to Health Care

As people age, it can be increasingly difficult to maintain health and wellness. Fortunately, California offers a variety of healthcare options specifically dedicated to seniors; ranging from free or low-cost services such as Medicare and Medi-Cal, to more comprehensive programs like In-Home Supportive Services (IHSS) and Long-Term Care Insurance. These plans provide access to important medical resources while ensuring that seniors have the support they need— financially, physically, and emotionally—to live their best life. Keep reading for more information about the range of healthcare options available to California seniors.

In California, Medi-Cal is the state’s program that provides healthcare services to people with limited income and resources. It covers medical services for both children and adults. On the other hand, Medicare is an insurance program funded by the federal government, which covers eligible individuals who are 65 years old or older. A reverse mortgage can also be a great option for seniors who need help with their medical expenses.

Key Takeaways

• To select the right healthcare plan, it’s important to consider your health needs, lifestyle, preferences, and financial situation. This will help you choose a plan that meets your needs and fits your budget.
• You can make an informed decision by comparing the premiums, deductibles, copayments, coinsurance, out-of-pocket maximums, and scope of coverage for various healthcare options. This will help you balance the costs and benefits.
• Make sure to check the reputation, quality, and accessibility of healthcare providers and facilities that are associated with each option. This will help ensure that you receive top-notch care and have access to the required services and specialists whenever necessary.

Medicare

Original Medicare (Part A and Part B)

Original opens in a new windowMedicare is the federal government’s health insurance program for eligible individuals aged 65 and older, as well as certain younger individuals with disabilities or end-stage renal disease. Original Medicare is composed of two parts, Part A and Part B.

Medicare Part A (Hospital Insurance):

Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and limited home health services. It helps pay for a shared room, meals, general nursing care, and other related inpatient services. Most people do not pay a premium for Part A because they or their spouse paid Medicare taxes while working. However, if someone does not qualify for premium-free Part A, they can still enroll by paying a monthly premium.

Medicare Part B (Medical Insurance):

Part B of your insurance plan covers necessary medical services and supplies, including doctor visits, outpatient care, preventive services, and some home health services. Additionally, it covers durable medical equipment like wheelchairs and walkers. Unlike Part A, Part B is associated with a monthly premium that is determined based on your income. The premium may change annually.

Enrolling in both Part A and Part B is voluntary, but it is important to understand that if you delay enrollment, you may face late enrollment penalties.

Original Medicare does not cover everything, and recipients usually have out-of-pocket costs, such as deductibles, copayments, and coinsurance. To help cover these expenses, some people choose to purchase supplemental insurance, such as a Medigap policy.

Medicare Advantage (Part C)

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare (Part A and Part B). It is provided by private insurance companies approved by Medicare. These plans combine the coverage of Part A and Part B and often include additional benefits not covered by Original Medicare. Many Medicare Advantage plans also offer prescription drug coverage, similar to Medicare Part D.

Some key features of Medicare Advantage plans include:

1. Comprehensive coverage: In addition to covering the services offered by Original Medicare, Medicare Advantage plans often include extra benefits such as dental, vision, and hearing care, as well as wellness programs and other services.
2. Prescription drug coverage: Most Medicare Advantage plans include prescription drug coverage, which can be a convenient option for individuals who want all of their coverage under one plan. This eliminates the need to enroll in a separate Part D plan.
3. Cost-sharing and out-of-pocket limits: Medicare Advantage plans typically have different cost-sharing structures than Original Medicare. They may have lower copayments or coinsurance for certain services, but could also include higher costs for other services. Importantly, Medicare Advantage plans have an annual out-of-pocket limit, which can help protect beneficiaries from excessive healthcare costs. Original Medicare does not have an out-of-pocket limit.
4. Provider networks: Medicare Advantage plans often have specific networks of healthcare providers (doctors, hospitals, and other facilities). Depending on the plan, beneficiaries may need to use in-network providers to receive coverage or pay more for out-of-network services. Original Medicare, on the other hand, allows beneficiaries to see any healthcare provider that accepts Medicare.

Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plans, also known as Medicare Part D, provide prescription drug coverage for individuals enrolled in Medicare. These plans are offered by private insurance companies approved by Medicare and help cover the cost of prescription medications.

Here are some key aspects of Medicare Part D:

1. Standalone or integrated coverage: Part D plans can be standalone prescription drug plans (PDPs) that supplement Original Medicare (Part A and Part B) or can be included as part of a Medicare Advantage plan (Part C) that offers prescription drug coverage (MAPD).
2. Formulary: Each Part D plan has a list of covered drugs called a formulary, which is divided into tiers based on cost. Generally, drugs in lower tiers have lower copayments or coinsurance than those in higher tiers. Formularies can vary between plans, so it is essential to review them to ensure your medications are covered.
3. Premiums: Medicare Part D plans require a monthly premium, which can vary based on the plan and your income. Higher-income beneficiaries may pay an additional amount called the Income-Related Monthly Adjustment Amount (IRMAA).
4. Deductibles, copayments, and coinsurance: Part D plans may have a deductible, which is an amount you must pay before the plan begins to cover drug costs. Once the deductible is met, you’ll typically pay a copayment (a fixed amount) or coinsurance (a percentage) for each prescription.
5. The “donut hole” or coverage gap: In some Part D plans, there is a temporary coverage gap, often called the “donut hole.” This gap occurs when you and your plan have spent a certain amount on covered drugs. While in the coverage gap, you’ll pay more for your prescriptions until you reach the out-of-pocket spending limit, after which catastrophic coverage begins, and you pay a smaller portion of the costs.
6. Enrollment periods: You can enroll in a Medicare Part D plan when you first become eligible for Medicare during your Initial Enrollment Period (IEP) or during the Annual Election Period (October 15 – December 7) each year. There are also special enrollment periods for specific circumstances, such as moving out of your plan’s service area.
7. Late enrollment penalty: If you don’t enroll in a Medicare Part D plan when you’re first eligible and don’t have other creditable prescription drug coverage, you may have to pay a late enrollment penalty when you eventually join a plan. This penalty is added to your monthly premium for as long as you have Medicare drug coverage.

Medigap (Medicare Supplement Insurance)

Medigap policies are private health insurance plans that cover the expenses that are not covered by the Original Medicare Plan. They help pay some of the healthcare costs that are not covered by Medicare. If you have a Medigap policy along with Original Medicare, both Medicare and the policy will pay a portion of the expenses that are covered.

To buy a Medigap policy, you need to have Medicare Part A and Part B, and pay the monthly Medicare Part B premium as well as a premium to the Medigap insurance company. As long as you keep paying your premium, your Medigap policy will be automatically renewed each year. However, in certain states, insurance companies may not renew a Medigap policy purchased prior to 1992.

Medigap policies sold by insurance companies have to follow Federal and state laws, and are standardized. These laws are in place to protect you. Additionally, the front of the policy has to clearly identify it as “Medicare Supplement Insurance”.

Comparing Medigap policies is important as the costs can differ. Insurance companies offer standardized Medigap policies with the same benefits. The only variation between Medigap policies offered by different insurance companies is the price.

Please note that both you and your spouse need to purchase individual Medigap policies. Your Medigap policy will not provide coverage for any medical expenses incurred by your spouse. Certain Medigap policies provide coverage for additional benefits that are not included in Medicare. You have the right to purchase a Medigap policy under specific circumstances that are guaranteed.

Medi-Cal

If you’re a California resident who is a U.S. citizen, permanent resident, legal alien, or U.S. national, you may be eligible for Medi-Cal. Eligibility depends on your household income, health status, or age. If you meet the eligibility criteria, you can receive Medi-Cal benefits.

• Over the age of 65
• Blind or disabled
• Pregnant
• In a nursing or intermediate care home
• Under the age of 21
• A refugee living in the U.S. temporarily

If you are a parent or guardian of a child under 21 and are taking care of the child because the parents are not able to, you may be eligible for Medicaid assistance.

• Have died
• Do not live with the child
• Are incapacitated
• Are not employed

If you are already enrolled and receiving benefits from any of the programs below, you might also be eligible for Medi-Cal benefits:

• CalFresh: CalFresh is the name of California’s food stamp program, while the federal food stamp program is known as the Supplemental Nutrition Assistance Program (SNAP). To qualify for CalFresh benefits, you must meet income requirements and have documented monthly expenses.
• Supplemental Security Income (SSI) and State Supplementary Payment (SSP): The SSI program provides monthly financial assistance to eligible adults who are blind, over 65, or disabled. SSP is the California equivalent of SSI.
• CalWorks: This program offers monthly cash assistance to families with children in need. To be eligible, families must meet certain criteria such as income, age, resources, and citizenship status. The cash can be used to help pay for essential needs such as food and housing.
• Refugee Assistance: The Refugee Assistance program in California is aimed at assisting refugees who do not have children and are not receiving assistance from any other source. This program offers employment assistance to help them become self-sufficient.
• Foster Care or Adoption Assistance Program: In California, the foster care and adoption assistance program aims to aid individuals who wish to adopt a child that would have otherwise remained in long-term foster care.

If you think you might be eligible for any of the above programs but haven’t yet applied or started receiving benefits, you can do so through  opens in a new windowBenefitsCal. Health for California can help you through the  opens in a new windowMedi-Cal application process.

Private Health Insurance

Private health insurance is provided by private companies rather than the government. These insurance plans are typically offered through employers, purchased individually, or obtained through the Health Insurance Marketplace. Two common types of private health insurance plans are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Each has its own unique structure and features.

Health Maintenance Organizations (HMOs):

An HMO is a health insurance plan that centers on offering healthcare through a provider network. The key traits of an HMO involve:

• Primary Care Physician (PCP): To receive healthcare services in an HMO plan, you need to choose a Primary Care Physician (PCP) from the plan’s network. The PCP will take care of your regular healthcare needs and recommend you to specialists if necessary.
• Referrals: In an HMO, you typically require a referral from your PCP to consult a specialist. Hence, you must visit your PCP initially who will evaluate the need for you to see a specialist and then issue a referral accordingly.
• Limited network: To receive coverage under HMO plans, you can only use healthcare providers within the plan’s designated network. This includes doctors, hospitals, and other facilities, except in emergencies. If you go outside the network, you will usually have to pay for the entire cost of care.
• Lower out-of-pocket costs: Compared to other health insurance plans, HMOs generally have lower out-of-pocket costs including deductibles and copayments.

Preferred Provider Organizations (PPOs):

PPOs are health insurance plans that provide more flexibility when it comes to choosing healthcare providers. The main features of a PPO include:

• No PCP requirement: In a PPO plan, you are not required to choose a Primary Care Physician (PCP). You have the freedom to see any healthcare provider without needing a referral.
• Greater flexibility: You can see both in-network and out-of-network providers without a referral. However, you will typically pay more for out-of-network care.
• Larger network: PPOs generally have a larger network of providers compared to HMOs. This means you have more options when choosing healthcare providers.
• Higher out-of-pocket costs: PPO plans often have higher out-of-pocket costs, such as higher deductibles and copayments, compared to HMO plans.

To make the best decision between an HMO and a PPO, it is important to think about things such as how big the provider network is, if you need referrals, how much you will have to pay out-of-pocket, and how much flexibility you want in managing your healthcare. What is most suitable for you will depend on your personal needs and preferences.

Long-Term Care Insurance

Long-term care insurance is a type of insurance policy designed to cover the costs of long-term care services and support, which may be needed due to aging, chronic illness, or disability. These services can include assistance with daily living activities, such as bathing, dressing, and eating, as well as skilled nursing care, rehabilitation, and other specialized services.

Benefits

1. Financial protection: Long-term care insurance can help protect your savings and assets from being depleted by the high costs of long-term care. Without insurance, paying for these services out-of-pocket can be financially burdensome for many individuals and families.
2. Choice of care setting: Long-term care insurance policies often provide coverage for care in various settings, such as at home, in assisted living facilities, or in nursing homes. This flexibility allows policyholders to choose the care setting that best suits their needs and preferences.
3. Preservation of independence: With the financial support provided by long-term care insurance, individuals can access the necessary care and services to maintain their independence and quality of life.
4. Caregiver support: Long-term care insurance can help cover the costs of hiring professional caregivers, providing relief for family members who may otherwise need to take on caregiving responsibilities.

Cost and considerations

1. Premiums: To have long-term care insurance, you need to pay premiums. The amount of premium you need to pay depends on your age, health condition, and the extent of coverage you will select. Normally, if you are young and healthy when you buy the policy, you will pay a lower premium.
2. Benefit period: Insurance policies have various benefit periods available, such as two years, five years, and lifetime coverage. It is important to note that the cost of the policy is affected by the length of the benefit period.
3. Inflation protection: It is important to purchase a long-term care policy with inflation protection as the costs of care tend to rise over time. This feature will adjust your benefits to keep pace with the increasing costs, but it may also result in a higher premium for the policy.
4. Elimination or waiting period: Long-term care insurance policies typically have an elimination period, also known as the waiting period. This is the length of time you must receive care before the policy starts to provide benefits. Choosing a longer elimination period can reduce the premium you pay, but it might result in higher out-of-pocket expenses.
5. Pre-existing conditions and policy exclusions: It is important to carefully review the terms and conditions of your policy to ensure that it covers the services you require, as some policies may not cover certain pre-existing conditions or may restrict coverage for certain services.

Veterans Health Administration (VHA) Benefits

The VHA is a branch of the VA that offers healthcare services to eligible veterans. It manages over 1,200 facilities, such as hospitals, outpatient clinics, and long-term care facilities, making it the most extensive healthcare system in the country.

Eligibility

To determine your eligibility for VHA benefits, several factors are taken into consideration, including your military service history, discharge status, and other criteria. If you meet the necessary requirements, you may be eligible to receive VHA benefits:

1. If you have served in the military, navy, or air force and your separation was not due to dishonorable reasons, then you meet the requirement.
2. To fulfill your duty, you typically need to serve for at least 24 months without interruption or for the full length of your active duty deployment. However, individuals who were discharged due to a service-connected disability may be exempt from this requirement.
3. Enrolled in the VA healthcare system.

Benefits

VHA provides a wide range of healthcare services to eligible veterans, including:

1. Primary care: This includes regular check-ups, care to prevent health issues, and managing long-term health conditions.
2. Specialty care: We have specialists available for different medical conditions including cardiology, orthopedics, and oncology.
3. Mental health care: Services for mental health conditions like PTSD, depression, and anxiety, as well as substance use disorder treatment.
4. Dental care: Limited dental care benefits, usually based on specific eligibility criteria, such as having a service-connected dental disability or being a former prisoner of war.
5. Vision care: Including routine eye exams and prescription eyewear for eligible veterans.
6. Long-term care: Access to long-term care services like nursing homes, assisted living facilities, and home-based care, depending on eligibility and availability.
7. Prescription medications: Coverage for medications prescribed by VA providers and filled through VA pharmacies.
8. Prosthetics and adaptive equipment: Provision of prosthetic devices, durable medical equipment, and other aids to support veterans with disabilities.

Note that not all veterans will qualify for all benefits. Some benefits may have specific eligibility requirements based on factors such as service-connected disability ratings, income, or other factors. To determine whether you’re eligible and apply for VA healthcare, you can apply online, in person at a VA medical facility, by mail, or by phone.

Community-Based Health Programs

Community-Based Health Programs aim to provide healthcare services and support to individuals within their local communities, with a focus on improving health outcomes, promoting overall well-being, and increasing access to care. Some of these programs are designed to meet the specific needs of seniors and older adults.

Senior health clinics

Senior health clinics are specialized healthcare facilities that cater specifically to the needs of older adults. These clinics may be located within community centers, hospitals, or as standalone facilities. They offer a range of services, including:

• Primary care: Routine check-ups, preventive care, and management of chronic conditions.
• Geriatric care: Specialized care for age-related health issues, such as dementia, arthritis, or falls.
• Health screenings: Regular screenings for common age-related conditions, like high blood pressure, diabetes, or cancer.
• Health education: Workshops and resources to help seniors maintain a healthy lifestyle and manage their health conditions.
• Immunizations: Vaccinations, including flu shots and pneumonia vaccines, to protect against common illnesses.
• Referrals: Assistance with connecting seniors to other healthcare providers or specialists, as needed.

Home and community-based services

The purpose of home and community-based services (HCBS) is to support seniors and individuals with disabilities to live on their own in their homes and communities. These services can be offered by government programs (like Medicaid), non-profit organizations, or private agencies. Some examples of HCBS are:

• Personal care: Assistance with daily living activities, such as bathing, dressing, eating, and mobility.
• Homemaker services: Help with household tasks like cleaning, laundry, and meal preparation.
• Home health care: Skilled nursing care, physical therapy, or occupational therapy provided in the individual’s home.
• Adult day care: Supervised programs that offer socialization, meals, and activities during daytime hours, providing respite for caregivers.
• Transportation: Assistance with transportation to medical appointments, grocery stores, or other necessary destinations.
• Home-delivered meals: Programs like Meals on Wheels provide nutritious meals to homebound seniors.
• Caregiver support: Education, training, and respite services for family caregivers.

To access these services, factors such as eligibility for government programs, availability of services in the community, and the individual’s financial resources should be considered. Contact your local Area Agency on Aging or community centers to find community-based health programs and services for seniors in your area.

Tips for choosing the right healthcare option

Assessing personal needs

To select the appropriate healthcare option, begin by evaluating your individual needs and preferences. Take into account your present health condition, any existing medical conditions, and how often and what type of medical services you require. Additionally, consider your lifestyle, the significance of having a consistent primary care doctor, and the requirement for specialist access. Finally, reflect on your choices for healthcare providers and the flexibility to see out-of-network providers if needed.

Financial aspects also play a crucial role in choosing the right healthcare option. Evaluate your budget, including how much you can afford for premiums, deductibles, copayments, and out-of-pocket maximums. If you’re eligible for government-sponsored programs like Medicare, Medicaid, or VA healthcare, research the benefits and limitations of each program to determine if they align with your needs.

To choose the right private health insurance, make sure to compare the benefits, costs, and provider networks of different plans, including HMOs and PPOs. If you require specific services like long-term care or prescription drug coverage, ensure the plan you select covers them sufficiently.

Make sure to check the quality and reputation of the healthcare providers and facilities for each option. This involves looking at patient reviews, accreditation, and other quality indicators to ensure that you receive a high level of care. Also, take into account the location of the providers and their availability for appointments when deciding.

Finally, it’s recommended that you seek advice from a healthcare professional, insurance agent, or financial advisor to help you choose the healthcare plan that’s most suitable for your specific needs and circumstances. Bear in mind that your healthcare requirements may evolve over time, so make sure to periodically review your situation and make changes if needed to ensure that you have the appropriate coverage and access to care.

Comparing costs and coverage

To make a wise choice about your healthcare plan, it is crucial to take into account multiple factors including costs and coverage. You should carefully examine premiums, deductibles, copayments, coinsurance, and out-of-pocket maximums to fully comprehend the possible financial implications of each option.

Assess the range of medical services that will be covered, such as general medical consultations, visits to specialists, hospitalization, prescription drugs, mental health care, and any other specific healthcare requirements you may have.

Evaluate the healthcare provider network for each plan, including doctor availability, specialist options, hospital access, and available facilities. Determine if the plan mandates using in-network providers or has out-of-network coverage. Research the reputation and quality of the healthcare providers and facilities in each plan by examining patient reviews, accreditation, and other indicators of quality.

To make an informed decision and stay within your budget, it’s important to review the terms and conditions of each healthcare plan for any exclusions or limitations that may not meet your healthcare needs. You should compare the costs and coverage of different healthcare options carefully.

Reverse mortgage for medical expenses

A reverse mortgage may be useful for certain seniors who need to cover medical expenses, but it may not be suitable for everyone. Here are some reasons why a reverse mortgage could be a good choice for paying for medical costs:

1. Tax-free cash: Homeowners who are 62 years of age or older can use a reverse mortgage to turn a part of their home equity into cash that’s tax-free, all without having to sell their home or make monthly mortgage payments. They can use this money to pay for healthcare requirements like long-term care costs and medical expenses.
2. No monthly payments: A reverse mortgage differs from a traditional mortgage in that the borrower is not required to make monthly payments. The loan becomes due for repayment when the borrower sells the home, permanently moves out, or passes away. This feature can be helpful to seniors on a fixed income who are dealing with increasing medical bills and financial difficulties.
3. Homeownership retention: Seniors can access funds to cover healthcare costs while still living in their homes through a reverse mortgage. This helps them maintain financial and emotional stability during difficult times.
4. Flexible disbursement options: Borrowers have the option to receive reverse mortgage funds in different ways, including a lump sum, monthly payments, or a line of credit. This flexibility enables them to select the best choice for their financial situation and needs.

I you’re feeling hesitant, let me tell you that reverse mortgages can be very useful! You just need to get a bit creative, you know? Check out this article where we explore all the possibilities!

Health Care Options For Seniors In California FAQs

What are the eligibility criteria for Medi-Cal?

Medi-Cal is a valuable healthcare option for various populations in need of assistance. You may be eligible for Medi-Cal if you are 65 years of age or older, blind, or disabled. The program is also available to individuals under 21, pregnant women, and those living in skilled nursing or intermediate care home.

If you have refugee status, you can access Medi-Cal for a limited time, depending on your duration in the United States. Furthermore, Medi-Cal extends coverage to parents or caretaker relatives responsible for an age-eligible child, ensuring that vulnerable populations have access to essential healthcare services.

How do I apply for Medicare or Medi-Cal?

You can apply for Medi-Cal online at opens in a new windowwww.CoveredCA.com. Your local county social services office will securely receive your application, as Medi-Cal is administered at the county level.

Can I have both Medicare and Medi-Cal coverage?

Certain individuals can be considered “dual eligible” or Medi-Medi beneficiaries, qualifying for both Medicare and Medi-Cal. If a person has both Medicare Parts A and B, Medicare serves as their primary insurance and typically covers the majority of their medical expenses.

What are the benefits of long-term care insurance?

Long-term care insurance policies provide daily reimbursement (up to a predetermined limit) to policyholders who require assistance with daily activities like bathing, dressing, and eating. You can choose from a variety of care options and benefits to receive the necessary services at your preferred location.

How do I determine if I’m eligible for Veterans Health Administration benefits?

If you served in the military and did not receive a dishonorable discharge, you may qualify for VA health care benefits.

Conclusion

With the right amount of research and comparison, you can select a healthcare plan that is tailored to your needs and fits within your budget. Seniors in California have a wide range of options available to them, and a retirement reverse mortgage may even provide additional financial support for those who are eligible. Ultimately, you want to ensure quality coverage as well as affordable health care premiums. Taking the time to compare plans side-by-side should help you make an informed decision about what kind of insurance is best for you.

Don’t hesitate to reach out if you need assistance navigating the complexities of finding the right healthcare option for seniors in California – this is an incredibly important decision that shouldn’t be taken lightly. Call or schedule a free consultation today to learn how a reverse mortgage could benefit you in your retirement!