Complete Plan Guide
Medicare Plans Explained
A plain-language guide to every part of Medicare — so you can choose the right coverage for your life in California.
Part A — Hospital Insurance
Part A covers inpatient hospital care, skilled nursing facility stays, hospice care, and some home health services. Most people pay no premium for Part A if they or their spouse worked and paid Medicare taxes for at least 10 years (40 quarters).
What Part A Covers
- Inpatient hospital stays
- Skilled nursing facility care (after a qualifying hospital stay)
- Hospice care
- Home health care (limited)
- Inpatient care in a religious nonmedical health care institution
2026 Costs
Good to know: A "benefit period" starts the day you're admitted and ends when you've been out of the hospital or skilled nursing facility for 60 consecutive days. There's no limit to the number of benefit periods you can have.
Part B — Medical Insurance
Part B covers medically necessary services like doctor visits, outpatient care, preventive services, and durable medical equipment. Most people pay a standard monthly premium, which is typically deducted from your Social Security benefit.
What Part B Covers
- Doctor visits and specialist care
- Outpatient hospital services
- Preventive screenings and vaccines
- Mental health services
- Durable medical equipment (wheelchairs, walkers, etc.)
- Ambulance services
- Clinical research and lab tests
2026 Costs
Good to know: High-income enrollees pay an Income-Related Monthly Adjustment Amount (IRMAA) surcharge on top of the standard premium. IRMAA is based on your income from 2 years prior. In 2026, IRMAA applies to individuals with income above $106,000.
Medicare Advantage (Part C)
Medicare Advantage plans are offered by private insurers approved by Medicare. They bundle Part A and Part B coverage — and usually Part D drug coverage — into a single plan. Many plans include extras like dental, vision, hearing, and fitness benefits. In 2026, the maximum out-of-pocket limit for in-network services is $9,350.
HMO
Health Maintenance Organization — requires a primary care doctor and referrals for specialists. Lower premiums, but limited to in-network providers.
PPO
Preferred Provider Organization — more flexibility to see out-of-network providers, but at higher cost. No referrals needed.
SNP
Special Needs Plan — designed for people with specific chronic conditions, dual Medicare/Medi-Cal eligibility, or those in certain institutions.
PFFS
Private Fee-for-Service — you can see any Medicare-approved provider who accepts the plan's payment terms.
Advantages
- Often $0 or low monthly premiums
- Includes dental, vision, and hearing in many plans
- Annual out-of-pocket maximum ($9,350 in-network in 2026) protects against catastrophic costs
- Usually includes Part D drug coverage
- Extra benefits like gym memberships and transportation
Limitations
- Restricted to plan's provider network (especially HMOs)
- Prior authorization required for some services
- Plan benefits and networks can change each year
- May not cover care when traveling outside your service area
California note: California has one of the most competitive Medicare Advantage markets in the country. Most counties offer 20–40+ plan options from carriers including Kaiser Permanente, Blue Shield, Anthem, Humana, and UnitedHealthcare.
Part D — Prescription Drug Coverage
Part D plans cover prescription drugs. They're sold by private insurers and can be added to Original Medicare (Part A + B) or are often bundled into Medicare Advantage plans. Each plan has a formulary — a list of covered drugs organized into tiers that determine your cost. The $2,000 annual out-of-pocket cap introduced in 2025 remains in effect for 2026.
Medigap — Medicare Supplement Plans
Medigap plans are sold by private insurers to cover the out-of-pocket costs that Original Medicare doesn't pay — like deductibles, copays, and coinsurance. They're standardized by letter (Plan G, Plan N, etc.) so the benefits are identical across insurers; only the premium differs.
Plan G
Covers everything except the Part B deductible ($257 in 2026). After you pay that deductible, Plan G covers 100% of remaining Medicare-approved costs. The most comprehensive plan available to new enrollees.
Plan N
Similar to Plan G but with small copays (up to $20 for office visits, up to $50 for ER visits that don't result in admission). Good balance of coverage and cost for healthy seniors.
Plan A
Covers Part A coinsurance and hospital costs, Part B coinsurance, first 3 pints of blood, and Part A hospice coinsurance. Lowest premium option.
California Birthday Rule: California has a unique "birthday rule" — during the 30 days following your birthday each year, you can switch to a Medigap plan with equal or lesser benefits without medical underwriting, regardless of your health status. This is a significant consumer protection not available in most other states.
Important: Medigap plans do NOT include prescription drug coverage. You must enroll in a separate Part D plan if you choose Original Medicare + Medigap.
Which Path Is Right for You?
The two main coverage approaches each have real trade-offs. Here's how they compare.
Original Medicare + Medigap + Part D
Pros
- See any Medicare-accepting doctor or hospital nationwide
- No referrals needed for specialists
- Predictable costs with Medigap coverage
- No network restrictions
Cons
- Higher monthly premiums (Part B + Medigap + Part D)
- No dental, vision, or hearing coverage included
- Medigap requires medical underwriting outside open enrollment
Medicare Advantage (Part C)
Pros
- Often $0 or low monthly premiums
- Dental, vision, and hearing often included
- Out-of-pocket maximum ($9,350 in-network in 2026) limits exposure
- Usually includes drug coverage (Part D)
Cons
- Limited to plan's provider network
- Prior authorization may be required
- Benefits and networks change annually
- May have difficulty switching back to Medigap later
Ready to Find the Right Plan?
Every person's Medicare situation is different. Our free consultation helps you compare options based on your doctors, medications, and budget — with no sales pressure.