为什么人寿经纪人要懂这块Why a life agent needs this

2027 是规则大变的一年Why 2027 changes the rules

四条线同时在变：奥巴马保险的 400% 悬崖回来了；白卡有了工作要求和半年审查； 红蓝卡 D 计划自付封顶 $2,400；联邦补贴和红蓝卡的身份条件收紧。 每一条都是今年秋天给老客户打电话的理由：「明年规则变了，我帮您看一下您家有没有受影响。」

Four things change at once: Covered California's 400% cliff is back; Medi-Cal adds a work requirement and six-month renewals; Part D caps out-of-pocket drug costs at $2,400; and immigration-status rules tighten for federal subsidies and Medicare. Each is a reason to call existing clients this autumn: "the rules change next year; let me check whether your family is affected."

先把客户放进格子里Place the client first

按年龄 + 身份 + 收入三个条件，就能定位客户落在哪一档、该翻到本文哪一部分。 收入按联邦贫困线 FPL 的百分比算。

Three conditions decide which bucket a client is in and which part of this page to turn to: age, immigration status, income. Income is measured as a percentage of the federal poverty level (FPL).

身份这一格 2026 年起变了：19 岁以上、没有合格移民身份的成年人，新申请全幅白卡已冻结。以前「加州不论身份都能拿白卡」的说法，对新申请的成年人已不成立，见第二部分。

Status changed in 2026: new full-scope Medi-Cal enrollment is frozen for adults 19 and over without satisfactory immigration status. "California covers everyone regardless of status" no longer holds for new adult applicants; see part 2.

一 · 国际旅游与短期医疗1 · Travel medical

新移民、留学生、探亲客户的第一张保单。它承保什么：保险生效之后新发生的疾病、 受伤或意外，包括门诊、急诊、住院、处方药。关键词是三个：生效后、新发生、急性的。

The first policy for new arrivals, students and visiting relatives. What it covers: a new illness, injury or accident arising after the policy takes effect, including office visits, emergency care, hospitalisation and prescriptions. Three words: after, new, acute.

投保资格以产品条款为准：Patriot America Plus 是给非美国居民来美用的，美国居民出国要用面向出境旅行的产品。 另外，加州从 2019 年起禁止销售短期有限期医疗险（STLDI），本地居民的保险空窗期，先看 Covered California 的特殊投保期。 给客户的定位是：「意外 + 急性病」的短期保障，不是综合医疗，不能替代奥巴马保险或红蓝卡。

Eligibility follows the product terms: Patriot America Plus is for non-US residents visiting the US; US residents going abroad need an outbound travel product. California has banned short-term limited-duration medical plans (STLDI) since 2019, so a resident with a coverage gap should look at a Covered California special enrollment period first. Position it as short-term cover for accidents and acute illness, not comprehensive medical; it doesn't replace Covered California or Medicare.

四类客户Four kinds of buyer

一个报价，就是一个钩子One quote is the hook

Patriot America Plus®，承保公司 SiriusPoint Specialty Insurance Corporation。成稿时的示例报价，不是当期价格：自付额可从 $0 选到 $2,500（越高保费越低），年龄段、天数都会影响价格，80 岁以上最高保额只有 $10,000。

Patriot America Plus®, underwritten by SiriusPoint Specialty Insurance Corporation. An example quote as of writing, not a current price: the deductible runs from $0 to $2,500 (higher means cheaper), age band and length of stay change the price, and from age 80 the maximum is $10,000.

开口的钩子就是这一句：一杯咖啡的钱，换一份 30 天的安心。 但讲价格之前先讲边界：这 $50 万保的是新发生的意外和急病，先讲边界、再讲价格，客户签单之后才不会觉得被骗。 每次都在系统里按客户的真实情况重新出报价。

The hook is one sentence: the price of a coffee buys thirty days of not having to worry. But state the boundary before the price: the $500,000 is for new accidents and acute illness. Boundary first, price second, and the client never feels misled. Re-run the quote for the client's real details every time.

从旅游医疗延伸到人寿的五步Five steps from travel cover to life

二 · 白卡 Medi-Cal2 · Medi-Cal

白卡是政府出钱的医疗保障：全幅白卡一般没有保费，自付为零或极低。 一句话概括 2027 年：拿到白卡不难，保住白卡变难了。

Medi-Cal is government-funded cover: full-scope Medi-Cal generally has no premium and little or no cost sharing. 2027 in one line: getting Medi-Cal isn't hard; keeping it is getting harder.

谁能拿：收入线（2026 FPL）Who qualifies: income limits (2026 FPL)

年收入，按 2026 年联邦贫困线，已含 5% 收入扣除，可以直接拿客户的收入来比；来源 DHCS ACWDL 26-01。2027 年初会换新贫困线。

Annual income at the 2026 poverty guidelines, including the 5% income disregard, so the client's income compares directly. Source: DHCS ACWDL 26-01. New guidelines arrive in early 2027.

• 孩子的门槛高得多：到 266%，一岁以下婴儿到 322%；2022 年 7 月起不收保费。 四口之家年收入 $8 万：父母超过 $45,540 拿不到白卡，孩子在 $87,780 以内可以拿，父母去 Covered California 买带补贴的计划， 同一张申请表，系统自动分开判断。
• Children qualify much higher: to 266%, and infants under one to 322%; there's been no premium since July 2022. A family of four on $80,000: the parents are over $45,540, the children are under $87,780, so the children get Medi-Cal and the parents buy subsidised cover through Covered California, on one application.
• 孕妇分两段：213% 以内是孕妇白卡；213%–322% 是另一个州项目 MCAP， 免保费、不看移民身份、产后保 12 个月。严格说 MCAP 不是白卡，对客户说「孕妇有一个免费的州项目」就准确。
• Pregnancy has two tiers: Medi-Cal up to 213%; from 213% to 322% a separate state programme, MCAP, with no premium, no immigration-status test, and twelve months of postpartum cover. Strictly, MCAP isn't Medi-Cal; "there's a free state programme for pregnancy" is accurate.
• 65 岁以上 / 残障：也是 138%（单人每月 $1,836、夫妻 $2,490），但 2026 年起还要看资产，见下面「三个误会」。
• 65 and over, or disabled: also 138% ($1,836 a month single, $2,490 for a couple), but from 2026 assets count too; see the three misconceptions below.

白卡包哪些服务What Medi-Cal covers

2027 年：资格审查越来越严2027: stricter checks

这些变化来自联邦 H.R.1 法案，五条：

These come from the federal H.R.1 law. Five changes:

• 工作要求：2027 年 1 月 1 日起，19–64 岁的「扩展成人」（按 138% 收入线进来的那一组），每月要满足一项，细节见下表。
• Work requirement: from January 1, 2027, "expansion adults" aged 19–64 (the group that qualifies at 138%) must meet one test each month; details in the table below.
• 续保审查从一年一次改为半年一次；联邦法 2027 年 1 月生效，加州现有会员从 2027 年 3 月那一轮续保开始。
• Renewals move from yearly to every six months: federal law takes effect January 2027, and California applies it to current members from the March 2027 renewals.
• 追溯期缩短：以前申请时可往回报销 3 个月的医疗账；2027 年 1 月 1 日以后的申请，扩展成人只能往回 1 个月，其他人 2 个月。生了病再去申请，晚了就是自己付。
• Shorter retroactive coverage: it used to reach back three months; for applications from January 1, 2027, one month for expansion adults and two for everyone else. Apply late and the bill is the client's.
• 共付：2028 年 10 月 1 日起，收入超过 100% FPL 的扩展成人看病有小额共付，每次最多 $35，全年不超过家庭收入的 5%；急诊、初级保健、心理健康、孕产和儿科不收。
• Copays: from October 1, 2028, expansion adults above 100% FPL pay small copays, at most $35 per service and no more than 5% of household income a year; emergency, primary care, mental health, maternity and paediatric care are exempt.
• 豁免不会自动给：州政府查不到的话，要自己主动申报。
• Exemptions aren't automatic: if the state can't confirm one, the member has to report it.

加州等州的诉讼没有拿到临时禁令（2026 年 7 月），就当它 2027 年一定实施。很多人掉保不是因为不符合，而是没看信、没交材料。 你可以帮白卡客户做三件不花钱的事：地址保持最新、州政府的信一定拆开看、工资单和上学证明留好。

The states' lawsuit, California's included, failed to win a preliminary injunction in July 2026, so assume it starts in 2027. Most people who lose coverage miss a letter or a deadline rather than fail the test. Three free things to help with: keep the address current, open every letter from the state, and keep pay stubs and school records.

无身份成年人的白卡Medi-Cal for adults without status

加州 AB 116（2025）及 2026–27 州预算。难民、庇护等人道身份的人，联邦白卡资金 2026 年 10 月起受限，加州用州钱保他们全幅到 2027 年 6 月 30 日。这些规定变得很快，讲之前查最新的州政府公告。

California AB 116 (2025) and the 2026–27 state budget. For refugees, asylees and other humanitarian statuses, federal Medi-Cal funding was restricted from October 2026; California is covering them full-scope with state funds through June 30, 2027. These rules move quickly; check the latest state notices before presenting.

关于白卡的三个误会Three Medi-Cal misconceptions

申请白卡：三种方式Three ways to apply

白卡全年都可以申请，不受开放投保期限制。客户收入突然降了、失业了，当月就可以帮他申请。

Medi-Cal takes applications all year, outside open enrollment. If a client's income drops or they lose their job, they can apply that month.

白卡客户 ≠ 没有保险需求Medi-Cal clients still have needs

白卡只管看病：不管身故后的收入、房租、孩子教育。低收入家庭最经不起顶梁柱出事。 合适的方向是低保费的定期寿险、最终费用保险，按他真实的现金流谈保额，保费上限由客户自己定。

Medi-Cal pays for care, not for income after a death, the rent, or the children's education, and a low-income family is the least able to absorb losing its earner. The fit is low-premium term life or final expense cover, sized to real cash flow, with the client setting the budget.

三 · 奥巴马保险3 · Covered California

「奥巴马保险」是大家的叫法，联邦法律叫 Affordable Care Act（ACA），加州的官方市场叫 Covered California。 它服务没有雇主保险、需要自己买保险的个人和家庭。用一句话帮客户区分： 白卡是政府全包；奥巴马保险是自己出钱，政府按收入补一部分。

"Obamacare" is the everyday name; the federal law is the Affordable Care Act (ACA), and California's official marketplace is Covered California. It serves individuals and families without employer coverage who buy their own. The one-line distinction: Medi-Cal is paid by the government; with Covered California you pay, and the government helps according to income.

Covered California 用标准化福利设计：同一个金属等级，不管哪家公司，免赔额、自付上限、共付额都一样。 所以选公司比的就三样：价格、医生在不在网络里、离家近不近。最该看奥巴马保险的四类人：

Covered California uses standard benefit designs: within a metal tier, every carrier has the same deductible, out-of-pocket maximum and copays. So choosing a carrier comes down to three things: price, whether the doctors are in network, and how close they are. Four groups should look here first:

ACA 改了哪五件事The five things the ACA changed

• 禁止既往症排除：2014 年起，不能因既往病史拒保或加价。
• No pre-existing condition exclusions: since 2014, insurers can't decline or surcharge for them.
• 十大基本福利：门诊、急诊、住院、孕产与新生儿、精神健康与戒瘾、处方药、康复、化验、预防保健、儿科（含儿童牙科和视力）。
• Ten essential health benefits: outpatient, emergency, inpatient, maternity and newborn, mental health and substance use, prescriptions, rehabilitation, lab, preventive care, and paediatric care including children's dental and vision.
• 取消年度与终身理赔上限。
• No annual or lifetime caps.
• 大雇主强制：50 名全职等效员工以上的雇主必须提供保险（2027 年罚款见第四部分）。
• The large-employer mandate: employers with 50 or more full-time equivalents must offer coverage (2027 penalties in part 4).
• 联邦个人罚款已归零，但加州有自己的罚款。
• The federal individual penalty is $0, but California has its own.

补贴怎么算How the subsidy works

公式只有一行：补贴 = 基准银级的全价 − 你该自付的部分。 基准银级是所在地区第二便宜的银级；「该自付的部分」是收入的一个比例，2027 年联邦比例是 2.15%–10.22%，收入越低比例越低，300%–400% FPL 统一是 10.22%。补贴是固定金额，选铜级、金级也减这么多。

One line: subsidy = full price of the benchmark silver plan − your expected contribution. The benchmark is the area's second-cheapest silver plan; the expected contribution is a share of income, 2.15% to 10.22% federally in 2027, lower for lower incomes and a flat 10.22% between 300% and 400% FPL. The subsidy is a fixed dollar amount, applied the same to bronze or gold.

• 收入超过 400% FPL，联邦补贴直接归零：单身 $63,840，两口 $86,560，四口 $132,000。不是慢慢减少，是一刀切。
• Above 400% FPL the federal subsidy drops to zero: $63,840 single, $86,560 for two, $132,000 for four. Not a taper; a cliff.
• 加州州补贴：2027 年州政府拿出 $3 亿，给 200% FPL 以下的家庭多补一块。150% 以下基准银级 $0；150%–200% 只付收入的 2.8%–5.28%（联邦是 4.30%–6.78%）。
• California's state subsidy: $300 million in 2027 for households under 200% FPL. Below 150% the benchmark silver plan costs $0; from 150% to 200% the contribution is 2.8%–5.28% of income instead of the federal 4.30%–6.78%.
• 按预估收入预付，报税时对账：用 1095-A 和 Form 8962 多退少补；从 2026 税年起，多领的补贴要全额还，不再有上限。 上面那位客户如果预估 $63,000、实际赚了 $65,000，一整年约 $7,020 补贴报税时要全部还回去。
• Paid on estimated income, reconciled at tax time with the 1095-A and Form 8962; from tax year 2026, excess credits are repaid in full, with no cap. If the client above estimated $63,000 and earned $65,000, the whole year's subsidy, about $7,020, comes back at tax time.

400% 悬崖有多陡How steep the 400% cliff is

同一个人：62 岁、单身、提前退休，住洛杉矶县 91801。在官方工具上跑两次，唯一的区别是年收入：

The same person: 62, single, retired early, zip 91801 in LA County. Two runs on the official tool, with income the only difference:

试算 · 示例：已扣补贴的月保费。来源：Covered California Shop and Compare 官方试算，2027 年，邮编 91801（洛杉矶县 Alhambra），2026-10-07 查询；初步费率，最终以 2027-01-01 生效费率为准。

Estimate · example: monthly premium after subsidy. Source: Covered California Shop and Compare official estimate, plan year 2027, zip 91801 (Alhambra, LA County), run 2026-10-07; preliminary rates, final rates take effect 2027-01-01.

只超出悬崖 $1,160，铜级保费一年多交约 $7,008；多赚的 $2,000 还是税前的。 最容易掉下去的是 60–64 岁提前退休的人、收入忽高忽低的自雇人士。开放期之前，把收入在这几条线附近的客户先列出来，主动联系。 对刚好超出一点的客户，有些合规降低 MAGI 的做法，比如税前退休账户供款或 HSA（2026 年起铜级也能配 HSA）， 但这是税务问题，一定请客户找税务师确认。

Just $1,160 over the line, bronze costs about $7,008 more a year, and the extra $2,000 was pre-tax. Those most at risk: early retirees aged 60–64 and self-employed people with uneven income. Before open enrollment, list the clients whose income sits near these lines and call them. For someone just over, there are compliant ways to lower MAGI, such as pre-tax retirement contributions or an HSA (bronze plans qualify from 2026), but that's a tax question for the client's tax professional.

四个金属等级The four metal tiers

2027 年个人计划，家庭为 2 倍。来源：Covered California《2027 Patient-Centered Benefit Designs and Medical Cost Shares》（2026 年 9 月）。

2027 individual plans; family amounts are double. Source: Covered California, 2027 Patient-Centered Benefit Designs and Medical Cost Shares (September 2026).

百分比是保险公司平均承担的比例，不是每次看病的报销比例，客户常误会成「白金卡看病报 90%」。 等级越高，月保费越贵、看病自付越少。有一个实用算法：一年最坏的情况 = 全年保费 + 自付上限。 前面那位 62 岁、年收入 $63,000 的客户：铜级约 $3,115 + $11,650 ≈ $14,765；白金每月 $576.16，一年约 $6,914 + $5,500 ≈ $12,414。 身体不好的客户，白金反而可能更省。

The percentage is what the plan pays on average across members, not a reimbursement rate per visit; clients often hear "platinum pays 90%". Higher tier, higher premium, less at the point of care. A practical test: the worst year = a year of premiums + the out-of-pocket maximum. For the 62-year-old on $63,000: bronze about $3,115 + $11,650 ≈ $14,765; platinum at $576.16 a month, about $6,914 + $5,500 ≈ $12,414. For a client in poor health, platinum can come out cheaper.

银级专属减免：94 / 87 / 73Silver-only help: 94, 87, 73

收入在 250% FPL 以下的人，只要选银级，系统会自动升级成 Silver 73、87 或 94， 这叫自付成本减免（Cost-Sharing Reduction，CSR）：付银级的保费，看病接近金级甚至白金级。选了铜级，减免就没了。

Below 250% FPL, choosing silver automatically upgrades the plan to Silver 73, 87 or 94. This is the cost-sharing reduction (CSR): silver premiums with near-gold or near-platinum cost sharing. Choose bronze and the reduction is gone.

来源：Covered California 2027 福利设计表（2026 年 9 月）、2027 FPL 资格表（2026 年 10 月）；个人计划数字。收入在 138% 以下的成年人一般先被判到白卡，所以 Silver 94 实际多见于 138%–150% 这一小段。

Source: Covered California 2027 benefit designs (September 2026) and 2027 FPL eligibility chart (October 2026); individual-plan figures. Adults under 138% are generally routed to Medi-Cal first, so Silver 94 mostly applies between 138% and 150%.

Silver 87 的自付上限 $4,000，比白金的 $5,500 还低。所以收入落在补贴区间的客户， 比价永远先看银级，再往两边比。另外 Silver 94 在 2027 年第一次有了 $200 免赔额、上限也翻了一倍多， 见到老客户主动提一句，别等他看病时才发现。

Silver 87's $4,000 maximum is lower than platinum's $5,500. So for a client in the subsidy range, always start the comparison at silver and work outward. And Silver 94 has a deductible for the first time in 2027, $200, with its maximum more than doubled; mention it to existing clients before they find out at the doctor's.

2027 的保障：有进有退2027 coverage: some better, some worse

个人计划医疗免赔额与年自付上限，家庭为 2 倍。来源：Covered California 2026、2027 Patient-Centered Benefit Designs；2027 初步费率（2026-07-21 公布）。

Individual medical deductibles and out-of-pocket maximums; family amounts are double. Source: Covered California 2026 and 2027 Patient-Centered Benefit Designs; 2027 preliminary rates (announced 2026-07-21).

「进」是银级免赔额降了；「退」是自付上限几乎全线上涨，背景是联邦自付上限天花板 2027 年提高到个人 $12,000、家庭 $24,000。 保费方面，2027 年初步费率全州平均涨 9.9%，最终以 2027 年 1 月 1 日生效的为准。 但 Covered California 估算，换到同等级里更便宜的计划，平均保费变化是 −0.2%，约 60% 的投保人保费不会上涨。 所以结论不是「又涨价了」，而是「今年一定要重新比价」。

Better: silver deductibles fall. Worse: out-of-pocket maximums rise almost across the board, following the federal ceiling, which goes to $12,000 individual and $24,000 family in 2027. Preliminary 2027 premiums rise 9.9% on average statewide, with final rates effective January 1, 2027. But Covered California estimates that switching to a cheaper plan in the same tier averages −0.2%, and about 60% of enrollees see no increase. The message isn't "prices went up again"; it's "this is the year to re-shop."

2027 官方试算：三个家庭2027 official estimates: three families

以下数字都是在 Covered California Shop and Compare 上实际跑出来的，试算 · 示例， 给客户看之前，用他自己的邮编、年龄和收入重跑一次。

These were run on Covered California's Shop and Compare tool. They are estimates and examples; re-run them with the client's own zip code, ages and income before showing anyone.

① 三口之家，年收入 $50,000（约 183% FPL）。父 40、母 39、儿子 10 岁。孩子在 266% 线（$72,672）以内，走白卡； 两个大人投保，落在 Silver 87，还能拿州补贴，每月补贴 $826.91。

1 · Family of three, $50,000 (about 183% FPL). Father 40, mother 39, son 10. The child is under the 266% line ($72,672) and goes on Medi-Cal; the two adults enrol, land on Silver 87 with state help, and receive $826.91 a month.

试算 · 示例：两个大人的月保费（已扣补贴）；免赔额、上限为每人。来源：Covered California Shop and Compare 官方试算，2027 年，邮编 91801（洛杉矶县 Alhambra），2026-10-07 查询；初步费率，仅为示例。

Estimate · example: monthly premium for the two adults after subsidy; deductibles and maximums per person. Source: Covered California Shop and Compare official estimate, plan year 2027, zip 91801 (Alhambra, LA County), run 2026-10-07; preliminary rates, for illustration only.

很多客户看到 $0 的铜级就想选。但 L.A. Care 的 Silver 87 每月 $13.56（一年 $162.72）， 就把免赔额从 $5,800 降到 $1,100、上限从 $11,650 降到 $4,000，看家庭医生从 $60 降到 $15。 金级、白金都比它贵，上限却都比它高：这就是「银级的价钱，白金的福利」。

Many clients see a $0 bronze and stop. But L.A. Care's Silver 87 at $13.56 a month ($162.72 a year) cuts the deductible from $5,800 to $1,100, the maximum from $11,650 to $4,000, and a primary care visit from $60 to $15. Gold and platinum cost more and still have higher maximums: silver prices, platinum-level protection.

② 同一家，年收入 $80,000（约 293% FPL）。孩子超过白卡线，三人都投保； 大人超过 250%，没有银级减免，只是普通 Silver 70；每月补贴降到 $625.56。

2 · The same family at $80,000 (about 293% FPL). The child is over the Medi-Cal line, so all three enrol; the adults are over 250%, so no CSR, just Silver 70; the subsidy falls to $625.56 a month.

试算 · 示例：三个人的月保费（已扣补贴）；免赔额、上限为每人。来源：Covered California Shop and Compare 官方试算，2027 年，邮编 91801（洛杉矶县 Alhambra），2026-10-07 查询；初步费率，仅为示例。

Estimate · example: monthly premium for all three after subsidy; deductibles and maximums per person. Source: Covered California Shop and Compare official estimate, plan year 2027, zip 91801 (Alhambra, LA County), run 2026-10-07; preliminary rates, for illustration only.

Kaiser 银级从 $164.67 涨到 $664.67，一年多 $6,000，免赔额和上限也都变高。到了这个收入，银级不一定最好： Kaiser 金级比银级一年多约 $1,602，免赔额却从 $4,700 降到 $0。先问客户一家去年看了几次病，再推荐等级。

Kaiser silver goes from $164.67 to $664.67, $6,000 more a year, with a higher deductible and maximum. At this income silver isn't automatically best: Kaiser gold costs about $1,602 a year more but takes the deductible from $4,700 to $0. Ask how often the family saw a doctor last year before recommending a tier.

③ 四口之家（40、40、10、8 岁）：$100,000 vs $200,000。 两个孩子都超过 266% 线，不走白卡，四口一起投保。

3 · Family of four (40, 40, 10, 8): $100,000 vs $200,000. Both children are over the 266% line, so all four enrol.

试算 · 示例：扣除补贴后的每月保费。来源：Covered California Shop and Compare 官方试算，2027 年，邮编 91801（洛杉矶县 Alhambra），2026-10-07 查询；初步费率，仅为示例。

Estimate · example: monthly premium after subsidy. Source: Covered California Shop and Compare official estimate, plan year 2027, zip 91801 (Alhambra, LA County), run 2026-10-07; preliminary rates, for illustration only.

同一张铜级，一年多付约 $8,873，正好是两边补贴的差额：保险公司的价格没变，变的是政府帮你付多少。 四口之家的悬崖在 $132,000，收入在这附近的家庭最需要提前规划；远超悬崖的，你能帮的是网络选择、HSA 和全家的保障安排。 $4 怎么算出来的不用解释，只说官方试算只剩每月约 $4，等于没有。

The same bronze plan costs about $8,873 more a year, exactly the difference in subsidy: the carrier's price didn't change, only how much the government pays. A family of four hits the cliff at $132,000, so families near it need to plan ahead; well above it, your value is network choice, the HSA and the family's protection. Don't explain the $4; just say the official tool shows about $4 a month, effectively nothing.

HMO vs PPOHMO versus PPO

同样是 Silver 87、福利完全一样，差的只是网络和保费（上面三口之家，年收入 $5 万）：

The same Silver 87, identical benefits; only network and premium differ (the $50,000 family of three above):

试算 · 示例：扣除补贴后的月保费。来源：Covered California Shop and Compare 官方试算，2027 年，邮编 91801（洛杉矶县 Alhambra），2026-10-07 查询；初步费率，仅为示例。

Estimate · example: monthly premium after subsidy. Source: Covered California Shop and Compare official estimate, plan year 2027, zip 91801 (Alhambra, LA County), run 2026-10-07; preliminary rates, for illustration only.

最便宜的 HMO 和最便宜的 PPO，每月差 $438，一年约 $5,258。选网络之前，先查客户常看的医生在不在网络里。 客户确实需要直接看专科、或他的医生只在 PPO 里，PPO 就是对的选择，不能为了腾出保费劝他换 HMO。

Cheapest HMO against cheapest PPO: $438 a month, about $5,258 a year. Before choosing a network, check that the client's doctors are in it. If the client needs direct specialist access or their doctor is PPO-only, the PPO is the right answer; never steer them to an HMO to free up premium.

南加州 2027 的保险公司Southern California carriers in 2027

来源：Covered California 2027 初步费率公告（2026-07-21）及 2027 各县铜级 / 银级费率表（2026-10-01）。

Source: Covered California 2027 preliminary rate announcement (2026-07-21) and 2027 county bronze/silver rate tables (2026-10-01).

• CalOptima Health 2027 年第一次进入 Covered California，只在橙县卖；Molina 退出洛杉矶东北区和橙县，约 1,600 位投保人会被转走，你的客户在里面就要主动联系。
• CalOptima Health joins Covered California for 2027, in Orange County only; Molina leaves LA northeast and Orange County, moving about 1,600 enrollees, so contact any clients affected.
• 按公司：IEHP +5.6% 最低，Kaiser 6.7%，L.A. Care 8.1%，Blue Shield 12.5%，Anthem 13.0%，Health Net 13.2%，Molina 16.9%。
• By carrier: IEHP lowest at +5.6%, Kaiser 6.7%, L.A. Care 8.1%, Blue Shield 12.5%, Anthem 13.0%, Health Net 13.2%, Molina 16.9%.
• Anthem 在这些地区只有 HMO；想要 PPO，看 Blue Shield 或 Health Net。Oscar 不是 2027 年 Covered California 的保险公司，Sharp 只在圣地亚哥卖。
• Anthem is HMO-only in these regions; for a PPO look at Blue Shield or Health Net. Oscar is not a 2027 Covered California carrier, and Sharp sells only in San Diego.

看懂账单：四个费用组件Reading a bill: four components

每月保费不算进自付上限。2027 年联邦上限：个人 $12,000 / 家庭 $24,000。来源：Covered California 2027 福利设计；CMS 2027 年参数指引。

Monthly premiums don't count toward the maximum. 2027 federal ceiling: $12,000 individual / $24,000 family. Source: Covered California 2027 benefit designs; CMS 2027 payment parameters.

给客户一句口诀：先垫底、再分摊、有封顶。 还有一个很多客户不知道的细节：官方对照表上蓝色格子的服务不受自付额限制，比如看家庭医生、普通药，第一天就按共付额看病。 对照表也是最快的答案：看专科，银级 $100、金级 $80、Silver 87 $30；急诊，银级 $400、金级 $350、Silver 87 $200、Silver 94 $50，铜级付满自付额后 40%。

A line for clients: pay the deductible, share the rest, stop at the cap. One detail many clients miss: on the official chart, services in blue aren't subject to the deductible, so primary care and generic drugs cost only the copay from day one. The chart is also the fastest answer: a specialist is $100 on silver, $80 on gold, $30 on Silver 87; the ER is $400 on silver, $350 on gold, $200 on Silver 87, $50 on Silver 94, and 40% after the deductible on bronze.

两个算例，第二个最能说明上限的价值（教学用的简化数字，不是真实计划）：

Two worked examples; the second shows what the maximum is worth (simplified teaching numbers, not a real plan):

换成 2027 年真实计划，最坏的一年要准备的现金就是上限：银级 70 个人 $11,650、全家 $23,300。 这也是很自然的需求分析：「最坏的一年要自付 $11,650，同时几个月不能工作，家里的开销靠什么？」

On a real 2027 plan, the cash needed for the worst year is the maximum: $11,650 for one person on Silver 70, $23,300 for a family. A natural needs-analysis question: "in the worst year you'd pay $11,650 and might not work for months; what covers the household bills?"

看懂保险卡Reading the insurance card

下次见客户，主动说一句：「把您的保险卡给我看一下。」一项一项帮他读，读完自然接一句： 「医疗这块清楚了，家里其他的保障，您有没有一张这样的清单？」看客户的卡要先征得同意，不要拍照留存或转发会员号、团体号。

At the next meeting, ask: "may I see your insurance card?" Read it through with them, then: "that's the medical side; do you have a list like this for the rest of the family's protection?" Ask permission first, and never photograph, keep or forward member or group numbers.

2027 年参保的日期Enrolling for 2027: the dates

联邦「开放期 12 月 31 日结束」的规定已被法院撤销，加州照常开到 1 月 31 日。来源：Covered California 2027 年开放投保公告；Covered California 联邦变化指南（2026-06-19）。

A federal rule ending open enrollment on December 31 was vacated by a court; California still runs to January 31. Source: Covered California 2027 open enrollment announcement; Covered California federal changes guide (2026-06-19).

这些触发事件个个都是人生大事，也正是重新看全家保障的时候。申请时准备身份文件、社安号或 ITIN、收入证明（1040 或工资单）、加州居住证明； 收入按整个报税家庭算，每年更新。

Each of these events is a major life change, and exactly when a family's protection needs a fresh look. For the application: ID and immigration documents, SSN or ITIN, proof of income (a 1040 or pay stubs) and proof of California residency. Income is counted for the whole tax household and updated every year.

三个最常见的坑The three most common mistakes

这三个坑正好给了你一年三次有价值的联系：报税季提醒对账，人生大事提醒更新，每年 10 月提醒比价。 可以提醒客户收入要估准，但不要替他决定报多少，更不要教他「报低」拿补贴。

The three mistakes give you three useful contacts a year: reconciliation at tax time, updates at life events, re-shopping every October. Remind clients to estimate accurately, but never decide the figure for them, and never coach them to report low.

2027 联邦新规：身份与补贴2027 federal rules: status and subsidies

• 2027 年 1 月 1 日起，联邦补贴只给绿卡、古巴/海地入境者、COFA 三类。难民、庇护、TPS、工作签证、学生签证等合法居留者拿不到联邦补贴，银级减免也一起没了。Covered California 估计超过 13 万人受影响，平均每人每月保费多约 $650。
• From January 1, 2027, federal credits go only to green-card holders, Cuban/Haitian entrants and COFA migrants. Refugees, asylees, TPS holders, and those on work or student visas lose the credit and the silver reduction with it. Covered California estimates over 130,000 people affected, paying about $650 more a month each on average.
• 收入低于 100% FPL、因身份拿不到白卡的合法居留者：2026 年起已无补贴。
• Lawfully present people under 100% FPL who are ineligible for Medi-Cal because of status: no subsidy since 2026.
• 多领的补贴：2026 税年起报税时全额追回，不再有上限。只因收入变化走特殊投保期入保的：拿不到补贴。
• Excess credits: repaid in full from tax year 2026, with no cap. Enrolling through a special enrollment period based only on income: no subsidy.
• 投保前的收入核实：2028 年才开始。DACA 是另一条联邦规则，2025 年 8 月起已不能在 Covered California 投保。
• Pre-enrollment income verification starts in 2028. DACA recipients, under a separate federal rule, have been unable to enrol in Covered California since August 2025.

来源：H.R.1（P.L. 119-21）第 71301–71305 条；CMS 2025 Marketplace Integrity 规则；Covered California 联邦变化指南。

Source: H.R.1 (P.L. 119-21) §§71301–71305; CMS 2025 Marketplace Integrity rule; Covered California federal changes guide.

把持工卡、学生签证、TPS、难民或庇护身份的客户家庭找出来，开放期之前主动联系：他们仍然可以投保，只是没有补贴， 一起看还有什么选择，比如雇主的团体保险。涉及身份，先问移民律师；补贴对账、报税问题，请咨询税务师。

Find the client families on work permits, student visas, TPS, refugee or asylee status and contact them before open enrollment: they can still enrol, just without a subsidy, so look at alternatives such as an employer plan together. Immigration questions go to an immigration attorney; reconciliation and tax questions to a tax professional.

四 · 团体险与 COBRA4 · Group plans, COBRA, HSA and FSA

考试必考、客户最常问，也最容易讲错的一块。

On every exam, asked by every client, and the easiest part to get wrong.

团体为什么便宜Why group is cheaper

两个原因：一是风险分摊，大群体把理赔风险摊进一个池子； 二是管理成本摊薄，人越多，人均管理成本越低。 连带的好处是通常不需要体检、不需要可保性证明。 代价是资格：必须与某个合格团体相关联，典型是全职雇员。最大的弱点是它跟着工作走。

Two reasons: risk pooling, which spreads claims across a large group, and administrative cost spreading, which falls per head as the group grows. The side benefit is that there's usually no medical exam and no evidence of insurability. The cost is eligibility: you have to belong to a qualifying group, typically as a full-time employee. Its biggest weakness: it goes with the job.

• 福利协调 COB：几份保险合计最多赔实际费用的 100%，谁先付由协调条款决定。夫妻都有公司保险，不会「重复赔」。
• Coordination of benefits: all plans together pay at most 100% of the actual cost, in the order the COB rules set. Two spouses' group plans don't stack.
• 「负担得起」的标准 10.22%：2027 年员工本人那一份保费超过家庭收入的 10.22% 才算负担不起（家属看全家保费）。家庭年收入 $60,000 × 10.22% = $6,132，约每月 $511；公司只扣员工本人每月 $200，就算负担得起，员工本人不能去 Covered California 拿补贴。
• The 10.22% affordability test: in 2027 an employer plan is unaffordable only if the employee's own premium exceeds 10.22% of household income (family members are tested on the family premium). On $60,000, 10.22% is $6,132, about $511 a month; if the employee pays $200 a month for self-only cover, it's affordable, and the employee can't get a Covered California subsidy.
• 雇主强制：50 名以上全职等效员工的雇主，2027 年没提供保险的，按全职员工每人罚 $3,780（前 30 人不算）；提供了但太贵或不达标、有员工因此拿补贴的，每人罚 $5,670。小企业主客户很关心这些数字。
• Employer mandate: for employers with 50 or more full-time equivalents in 2027, offering no coverage costs $3,780 per full-time employee (the first 30 excluded); offering coverage that's unaffordable or inadequate costs $5,670 for each employee who then gets a subsidy. Business-owner clients care about these numbers.

COBRA 与 Cal-COBRACOBRA and Cal-COBRA

资格事件导致团体保险终止时，可以延续同等团体保障。代价是钱：以前公司替你付的那部分，现在全部自己付， 雇主还可以加收 2% 管理费。例：家庭计划总保费每月 $900，在职时只扣 $150，离职后要付 $918。客户通常这时才第一次看到保险的真实价格。

When a qualifying event ends group coverage, the same coverage can be continued. The cost: the share the employer used to pay is now the member's, plus up to a 2% administrative charge. Example: a $900-a-month family plan that cost the employee $150 now costs $918. It's often the first time a client sees what their coverage really costs.

考点：离婚导致配偶 COBRA = 36 个月，不是 18 个月。因严重不当行为（gross misconduct）被解雇者不适用；已有 Medicare 或其他团体保险的人不能用 Cal-COBRA。残障者在 Cal-COBRA 里第 19–29 个月按多少收费，各方资料说法不一，以保险公司寄来的通知为准。

Exam point: divorce gives the spouse 36 months, not 18. Not available after termination for gross misconduct; Cal-COBRA isn't available to someone with Medicare or other group coverage. Sources differ on what Cal-COBRA charges disabled members in months 19–29; go by the carrier's notice.

时间点：至少 60 天决定要不要，选了以后保障追溯到断保那天。COBRA 要付 102%，又只是过渡，正是帮客户比较其他选择的时候： 失去公司保险属于特殊投保事件，60 天内可以去 Covered California 按新收入算补贴，很多时候便宜得多。 但已经选了 COBRA、中途自己不交了，不算失去保险，要等开放期。公司给的团体寿险一般也跟着工作走。

Timing: at least 60 days to elect, with coverage retroactive to the loss date. At 102% and only a bridge, COBRA is the moment to compare alternatives: losing employer coverage opens a 60-day special enrollment for Covered California, priced on the new income and often far cheaper. But dropping COBRA by not paying doesn't count as losing coverage; that waits for open enrollment. Employer group life usually ends with the job too.

HSA vs FSA（2027）HSA versus FSA (2027)

2027 HDHP 门槛：免赔额至少 $1,750 个人 / $3,500 家庭，自付上限不超过 $8,700 / $17,400。2026 年起铜级和灾难级计划（场内场外）一律可以配 HSA。HSA / HDHP：IRS Rev. Proc. 2026-24（正式）；FSA 2027 额度预计 10–11 月公布，外面流传的数字是预测。55 岁追加额是法律定死的，夫妻都满 55 岁，各自的追加额存进各自名下的 HSA。

2027 HDHP: a deductible of at least $1,750 self-only / $3,500 family and out-of-pocket no more than $8,700 / $17,400. From 2026 every bronze and catastrophic plan, on or off the exchange, is HSA-eligible. HSA/HDHP: IRS Rev. Proc. 2026-24 (final); the 2027 FSA limit is expected in October–November, and figures circulating now are forecasts. The catch-up is fixed by statute; if both spouses are 55+, each puts theirs in their own HSA.

HSA 深挖：其实是退休账户Going deeper: an HSA is really a retirement account

三重税优：税前存入、增长免税、用于合格医疗支出（QME）取出免税，在整个税法里几乎是独一份。

Three tax advantages: deductible going in, untaxed while it grows, and tax-free out for qualified medical expenses. Almost nothing else in the tax code does all three.

• HSA 能付的保费：一般保险保费不行，但 COBRA 保费、领失业金期间的健康保险、合格长期护理险保费（按年龄有上限，2026 年 61–70 岁 $4,960、70 岁以上 $6,200，2027 年尚未公布）、 65 岁后的红蓝卡保费（Part B、Part D、联邦医疗优惠，自费买的 Part A）都可以。Medigap 补充险不行。
• Premiums an HSA can pay: ordinary health premiums no, but COBRA premiums, health cover while on unemployment, qualified long-term care premiums (capped by age: in 2026, $4,960 at 61–70 and $6,200 over 70; 2027 not yet released), and Medicare premiums after 65 (Part B, Part D, Medicare Advantage, and premium Part A) all qualify. Medigap does not.
• 65 岁前挪作他用：所得税 + 20% 罚款；65 岁之后只交所得税、不罚，HSA 就成了一个补充退休账户。
• Non-medical use before 65: income tax plus a 20% penalty; after 65, income tax only, at which point the HSA works as a supplemental retirement account.
• 加入红蓝卡的任何一部分（哪怕只有 A），当月起就不能再存。65 岁以后才申请的，Part A 最多往回追溯 6 个月，所以要在申请前 6 个月停存。
• Enrolling in any part of Medicare, even Part A alone, ends contributions from that month. Part A can be backdated up to six months when claimed after 65, so stop contributing six months before applying.

组合打法，作为需求分析的框架来讲：HSA 攒税优医疗金 ＋ IUL 现金值在规划得当的前提下做补充退休 ＋ 带长期护理功能的人寿或长期护理保障，是退休医疗的三层防线。顺序上 HSA 通常排在前面，因为额度小但税务效率最高， 理由见投资基础课的资金优先级瀑布。 不要说「HSA 加 IUL 一定免税」：IUL 是否适合，要看客户的收入、预算和健康；税务结论交给税务师。

How it combines, framed as needs analysis: an HSA for tax-advantaged medical savings, IUL cash value as a properly structured retirement supplement, and life insurance with long-term care features or LTC cover, giving three layers against medical cost in retirement. The HSA usually comes first because the room is small but the tax treatment is the best available; see the funding waterfall in Investing Fundamentals. Never say "an HSA plus IUL is guaranteed tax-free": whether IUL fits depends on income, budget and health, and tax conclusions belong to a tax professional.

五 · 红蓝卡 Medicare5 · Medicare in 2027

红蓝卡是「父母一代」的入口。原始红蓝卡 = A 住院 + B 门诊，联邦政府直接管； C 计划（私人公司承包）、D 计划（药品）自己选着加；65 岁前后要主动办理，组合要自己定；低收入老人还可以同时有白卡。 帮客户的父母搞懂红蓝卡，你就自然进入这个家庭的财务对话。

Medicare is the door into the parents' generation. Original Medicare is Part A (hospital) plus Part B (medical), run by the federal government; Part C (a private plan) and Part D (drugs) are optional additions; enrolment around 65 is up to the client, and so is the combination; low-income seniors may also have Medi-Cal. Help a client's parents understand it and you're inside the household's financial conversation.

谁有资格Who qualifies

「连续住满 5 年」是给工作季度不够的人自费参保用的条件，不是通则。跟父母一代讲资格， 先问「本人或配偶有没有 40 个工作季度」，不要一开口就问「住满五年了吗」。 不满 40 季度也能付费买 Part A：2027 预估 30–39 季度每月 $330、不到 30 季度 $600（2026 正式为 $311 / $565）。 例：一位父亲 62 岁拿绿卡来美、没有工作记录，67 岁住满五年可以自费买入，A $600 + B $209.50，每月约 $809.50（2027 预估）。

The five-year rule is for people buying in without enough work quarters; it isn't universal. With a client's parents, ask first "do you or your spouse have 40 work quarters?", not "have you been here five years?" Part A can be bought without 40 quarters: projected for 2027 at $330 a month with 30–39 quarters or $600 under 30 (2026 final: $311 / $565). Example: a father arrives on a green card at 62 with no US work record; at 67 he can buy in, $600 for A plus $209.50 for B, about $809.50 a month (2027 projections).

2027：非公民的资格收紧2027: Medicare narrows for non-citizens

• H.R.1 第 71201 节：只有四类人还能享有或加入红蓝卡（A、B、C、D 全部）：美国公民或国民、绿卡持有人、古巴和海地入境者、COFA 合法居民。
• H.R.1 §71201: only four groups keep or gain Medicare (all parts): US citizens and nationals, green-card holders, Cuban and Haitian entrants, and COFA residents.
• 难民、庇护、暂缓遣返、TPS、人道假释、人口贩卖受害者等失去资格，缴满 40 季度也一样；只影响红蓝卡，社安退休金、SSDI、SSI 照发。
• Refugees, asylees, those with withholding of removal, TPS, humanitarian parole, trafficking victims and others lose eligibility, even with 40 quarters; only Medicare is affected, and Social Security, SSDI and SSI continue.
• 新申请：2025 年 7 月 4 日起不再受理。已在红蓝卡上的：法定 2027 年 1 月 4 日起适用；CMS 提案是 2027 年 2 月 1 日实际终止，以最终规则为准（预计 11 月公布）。
• New applications: not accepted since July 4, 2025. Current enrollees: the statutory date is January 4, 2027; CMS has proposed actual termination on February 1, 2027, subject to the final rule (expected in November).
• 拿到绿卡就重新符合资格；CMS 提案给重新符合的人 6 个月特殊加入期加入 A、B。
• Getting a green card restores eligibility; CMS has proposed a six-month special enrollment period to rejoin A and B.

我们能做的是提醒客户留意社安局的信，提前想好断了红蓝卡怎么办。涉及身份，先问移民律师；不要替客户判断他属于哪一类。

What we can do: remind clients to watch for Social Security letters and plan for a loss of coverage. Immigration questions go to an immigration attorney; never decide which category a client falls into.

四个部分The four parts

Part A：住院不是全包Part A: the hospital isn't free

2027 为预估（2026 年受托人报告）；CMS 11 月公布正式数字。日额是免赔额的 1/4、1/2、1/8。

2027 figures are projections (2026 Trustees Report); CMS publishes official numbers in November. The daily amounts are a quarter, a half and an eighth of the deductible.

Part B：那个没有封顶的 20%Part B: the 20% with no ceiling

「20% 没有封顶」这几个字，是整个红蓝卡对话的支点。 一场大病的 20%，可能就是几万块。这个缺口怎么补，就是下面两条路。

"Twenty percent, uncapped" is the pivot of the entire Medicare conversation. Twenty percent of a serious illness can run to tens of thousands. How that gap gets filled is the next two options.

IRMAA：高收入加费（2026 表）: the high-income surcharge (2026 table)

按两年前的报税 MAGI 计算（2026 年看 2024 年，2027 年看 2025 年）， 而且是悬崖式的：只要超过门槛 $1，就整档跳上去。

Based on MAGI from two years earlier (2026 uses 2024 returns; 2027 uses 2025), and it is a cliff: one dollar over moves you a whole bracket.

2027 年的分档 CMS 预计 11 月公布；公布前的 2027 分档只是估算，不要写进客户材料。

CMS is expected to publish the 2027 brackets in November; until then any 2027 bracket is an estimate and stays out of client material.

20% 的缺口：两条路二选一Filling the 20%: pick one of two

两条路只能选一条，不能同时要。$9,850 / $14,800 为 2027 法定上限，出自二手报道（CMS 2026-04-22 备忘录），以 CMS 公布为准；平均保费：CMS 2026-09-28。

It's one or the other, never both. $9,850 / $14,800 are the 2027 statutory limits as reported secondhand (CMS memo of 2026-04-22); go by CMS's own publication. Average premium: CMS, 2026-09-28.

怎么帮客户选？看三件事：看病习惯（有没有一定要看的专科医生）、预算（每月保费和出事时的自付哪个更能承受）、 生活方式（是不是常在外州、两地跑）。

How to help a client choose: how they use care (a specialist they must keep?), budget (which is easier to carry, the monthly premium or the bill when something happens?), and how they live (often out of state, or splitting time between two places?).

Medigap：什么时候买最划算Medigap: when to buy

• 6 个月开放期：从满 65 岁、而且已加入 Part B 的那个月起算。这期间保险公司必须承保，不看健康、不因健康加价；过了就没有这个保证。窗口跟着 Part B 走，延后加入 B 不会浪费。
• The six-month open enrollment period starts the month the client is 65 and enrolled in Part B. During it, carriers must accept them with no health questions or health-based pricing; afterwards there's no such guarantee. It follows Part B, so delaying B doesn't waste it.
• 加州生日规则：每年从生日起至少 60 天，可以换成福利相同或更少的 Medigap，可以换公司，不看健康。例：现在是 A 公司的 Plan G，可以换 B 公司的 Plan G 或福利少一点的 Plan N。每年生日前都是给老客户做检查的好时机。
• California's birthday rule: for at least 60 days from each birthday, a member can switch to a Medigap plan with the same or fewer benefits, at any carrier, without health questions. Plan G at one carrier can become Plan G or Plan N at another. Each birthday is a natural review.
• 最常见的是 Plan G（除 B 的免赔额外基本全包，含 B 的超额费用）和 Plan N（不含 B 的免赔额和超额费用，门诊最多 $20、急诊最多 $50 共付，保费通常低一些）。 高免赔额 G：2027 年先自付 $3,050；K、L 计划 2027 年自付上限 $8,360 / $4,180。
• The usual choices are Plan G (essentially everything except the Part B deductible, including excess charges) and Plan N (no Part B deductible or excess charges, copays up to $20 for office visits and $50 for the ER, usually cheaper). High-deductible G: $3,050 first in 2027; Plans K and L cap out-of-pocket at $8,360 / $4,180 in 2027.
• 考点：2020 年 1 月 1 日以后才有红蓝卡资格的人，不能买 Medigap 的 Plan C 和 Plan F（包括高免赔额 F）。这里的 C 是 Medigap Plan C，不是 Part C。
• Exam point: anyone first eligible on or after January 1, 2020 can't buy Medigap Plan C or Plan F (including high-deductible F). That's Medigap Plan C, not Part C.

Medigap 2027 数字为 CMS 正式公布。

The 2027 Medigap figures are final from CMS.

C 计划：私人公司承包的红蓝卡Part C: Medicare through a private plan

• 保险公司替联邦承包 A / B，大部分连 D 一起包；客户还是在红蓝卡体系里，只是由私人公司管理和理赔。
• The carrier administers A and B for the federal government, usually with D; the client is still in Medicare, with a private company managing care and claims.
• 常见 $0 月费，但 Part B 的月费照交；客户说「我的计划不要钱」，要补一句「B 的两百多块还是要交的」。
• Often a $0 premium, but the Part B premium is still due; when a client says "my plan is free", add "you still pay the $200-plus for Part B."
• 常附牙科洗牙、配眼镜、助听器等老人福利；网络限制，出网看诊贵，搬到另一个县可能要换计划。
• Often adds cleanings, glasses and hearing aids; network limits make out-of-network care expensive, and moving county may mean changing plans.
• 事先授权：2026 年起，加急的 72 小时、一般的 7 天内必须答复，拒绝要说明原因；2027 年 1 月 1 日起还要提供电子事先授权。
• Prior authorisation: since 2026, 72 hours for expedited and 7 days for standard requests, with reasons for any denial; electronic prior authorisation is required from January 1, 2027.

Part D 2027：变化最大Part D 2027: the biggest changes

以上为 CMS 正式公布的 2027 数字。

Final 2027 figures from CMS.

按标准设计算一个例子：一种每月 $2,000 的药。一月先付 $700 免赔额，再付 $1,300 的 25% 即 $325，一月共 $1,025； 二月、三月各 $500；四月再付 $375 就到 $2,400。五月到十二月药费自付为零。（各计划设计不同，以计划为准。） 一月付一千多太吃力的，所有 D 计划都必须提供按月分摊自付的选项，不收利息和手续费。

A standard-design example: a drug costing $2,000 a month. In January, the $700 deductible plus 25% of $1,300, $325, for $1,025; February and March $500 each; $375 in April reaches $2,400. May through December, nothing out of pocket. (Plans vary; the plan's design governs.) If January's bill is too much at once, every Part D plan must offer a monthly payment option that spreads it across the year with no interest or fees.

要提醒的是保费：2027 年全国基础保费 $41.33，而 Part D 保费稳定示范项目 2026 年底结束，部分独立药保保费可能涨得比较多。 低收入可申请 Extra Help（2027 年共付仿制药 $5.80、其他 $14.40），高收入另有 Part D IRMAA。话术： 「药费再也不是无底洞了，但每个月的保费还在，药单每年也会变，所以每年开放期都值得重新比一次。」后半句也说明了为什么你明年还要再来。

The caution is premiums: the 2027 national base premium is $41.33, and the Part D premium stabilisation demonstration ends with 2026, so some standalone drug plans may rise more than usual. Low-income members can apply for Extra Help ($5.80 generic / $14.40 other copays in 2027); higher incomes pay Part D IRMAA. The line: "the drug bill isn't a bottomless pit any more, but the premium is still there and your drug list changes, so it's worth comparing every open enrollment." The second half is also why you're back next year.

2027 年起降价的 15 种谈判药15 negotiated drugs, cheaper from 2027

第二轮药价谈判，2027 年 1 月 1 日生效，CMS 正式公布。加上 2026 年已生效的第一轮十种，一共 25 种药有谈判价。

Second round of negotiation, effective January 1, 2027, final from CMS. With the ten first-round drugs in effect since 2026, 25 drugs now have negotiated prices.

• 谈判价是红蓝卡付给药厂的价格，不是客户在药房付的钱；客户自付多少还是看计划的共付、共保设计。CMS 估计 2027 年投保人整体少自付约 6.85 亿。
• The negotiated price is what Medicare pays the manufacturer, not what the client pays at the pharmacy; their cost still depends on the plan's copays and coinsurance. CMS estimates enrollees save about $685 million out of pocket in 2027.
• 减肥用途：红蓝卡原定 2027 年开始的 GLP-1 减肥药项目已无限期推迟；过渡项目到 2027 年 12 月 31 日，减重用的 Wegovy、Zepbound 等每月共付 $50，需要事先授权并符合 BMI 条件。
• Weight loss: the Medicare GLP-1 weight-loss model planned for 2027 is postponed indefinitely; a bridge programme through December 31, 2027 covers Wegovy, Zepbound and similar for weight loss at a $50 monthly copay, with prior authorisation and BMI criteria.
• 第三轮十五种药（第一次纳入 Part B 的药）谈判价要在 2026 年 11 月 30 日前公布，2028 年生效。开放期帮客户比 D 计划，先拿药单对这张表，再用官方工具比全年总花费。
• Round three, fifteen drugs including Part B drugs for the first time, must be published by November 30, 2026, effective 2028. When comparing Part D plans, check the client's drug list against this table first, then compare total yearly cost on the official tool.

65 岁还在工作？先问三件事Still working at 65? Three questions

选择延后的人：离职或团保结束（以先到者为准）后 8 个月内加入 B 不罚。最常见的坑是退休后先用 COBRA 18 个月再加入 B： COBRA 和退休人员团保都不算在职保险，8 个月早就过了，会有罚金，还可能断保。保留雇主的「可信药保」证明，以后加入 D 才不会被罚。

For those who delay: enrol in B within eight months of leaving work or losing the group plan, whichever comes first, with no penalty. The classic trap is using 18 months of COBRA after retiring and then enrolling: COBRA and retiree coverage don't count as active employment, so the eight months have long passed, bringing a penalty and possibly a gap. Keep the employer's creditable drug coverage notice to avoid a Part D penalty later.

红蓝卡几个关键时间Key Medicare dates

罚金一定要算给客户听。Part B：没有特殊加入期却晚加入，每晚满 12 个月加 10%，通常终身； 晚两年，按 2027 预估 $209.50 × 20% = 每月多 $41.90，一辈子。Part D：连续 63 天以上没有可信药保，每个月加全国基础保费 $41.33 的 1%， 晚 24 个月就是每月多约 $9.92，只要有 D 就一直付；领 Extra Help 的免罚。行动建议：把客户和客户父母里未来 7 个月要满 65 岁的人列出来，提前联系。

Always work out the penalties for the client. Part B: enrolling late without a special period adds 10% for each full 12 months late, usually for life; two years late, at the projected 2027 premium, is $209.50 × 20% = $41.90 more a month, permanently. Part D: 63 days or more without creditable coverage adds 1% of the $41.33 national base premium per month; 24 months late is about $9.92 a month for as long as they have D; Extra Help recipients are exempt. Action: list clients and clients' parents turning 65 in the next seven months and contact them early.

低收入老人：白卡 + 红蓝卡Low-income seniors: Medi-Cal + Medicare

很多客户的父母收入不高，可以同时有白卡和红蓝卡（Medi-Medi）：白卡替他们付红蓝卡的保费和自付， 再加上白卡自己的福利，比如长期护理、牙科、居家照护 IHSS。他们一般加入 Medi-Medi 计划，也不受白卡新的工作要求影响。

Many clients' parents have modest incomes and can have both Medi-Cal and Medicare ("Medi-Medi"): Medi-Cal pays Medicare premiums and cost sharing and adds its own benefits such as long-term care, dental and IHSS home care. They usually join a Medi-Medi plan, and the new work requirement doesn't apply to them.

收入线为 2026 年数字，每年更新。已有白卡、QMB / SLMB / QI 或 SSI 的人，自动有 Extra Help；Extra Help 的资产标准以社安局网站为准。光是 B 的保费，2026 年一年就是 $2,434.80。

Income limits are 2026 figures, updated yearly. Anyone with Medi-Cal, QMB/SLMB/QI or SSI gets Extra Help automatically; check Social Security's site for its asset limits. The Part B premium alone came to $2,434.80 for 2026.

客户最担心「白卡死后要追讨」：在加州只追 probate 遗产里 55 岁以后的长期护理相关费用，配偶在世不追， 这是谈传承规划的自然入口，具体安排请客户咨询遗产律师。底线不变：永远不要建议客户放弃白卡来买任何保险。

Clients worry most about estate recovery: in California it reaches only long-term care costs after 55, only from probate, and never while a spouse is alive. It's a natural opening for estate planning; the arrangements belong to the client's estate attorney. The line doesn't move: never suggest a client give up Medi-Cal to buy any insurance.

六 · 医疗 × 人寿6 · Health meets life

医疗 × 人寿 = 完整家庭保障：医疗险管「治病的账单」，人寿管「走后与重病期间的账单」。 医疗险把钱付给医院，不付给你，下面五笔账它一概不管：

Health plus life is complete family protection: health cover pays the medical bill, life cover pays the bills after a death or during a serious illness. Health insurance pays the hospital, not the family, and these five costs are outside it:

不要一口气念完五件事，而是逐项问：「这一笔，现在如果出事，是谁来付？能付多久？」答得出来的不是缺口，答不出来的才是。 然后请客户自己排先后，预算也由他定；客户自己说出来的缺口，他才会真正重视。每次都讲到： 生前福利是打折提前动用一部分身故金，不是另外多给一笔钱，能拿多少要到理赔时由保险公司按病情和条款计算，签单时谁也给不出这个数。

Don't recite all five; ask each in turn: "if something happened now, who would pay this, and for how long?" What they can answer isn't a gap; what they can't, is. Then let the client set the priorities and the budget; a gap the client names is one they take seriously. Say this every time: living benefits are an early, discounted advance of part of the death benefit, not extra money, and the amount is calculated by the insurer at claim from the condition and the contract; no one can state it at the sale.

四个案例Four cases

五句开场话术Five opening lines

第二句是核心，要练的是问完之后的那几秒沉默，不要急着替客户回答。长辈客户请子女一起参加；整理给客户的资料，数字要标年份和「示例 / 预估」，用公司批准的材料。 如果这次约的是红蓝卡 Advantage 或 D 计划的销售面谈，面谈中不能顺带推销人寿或年金，客户想谈，另约一次。

The second line is the core; practise the few seconds of silence after the question rather than answering for the client. Invite adult children to meetings with older clients; any numbers you send carry the year and "example / projected", on company-approved material. In a Medicare Advantage or Part D sales appointment, you can't bring up life insurance or annuities; if the client wants to, book a separate meeting.

七 · 合规与行动7 · Compliance and action

在加州卖健康险，需要健康险执照，人寿执照不够；红蓝卡计划还要年度认证和承保公司委任，没完成就不要展业，「先帮朋友看看」也不行。 微信记录、朋友圈截图、讲座录像都是证据，发给客户的任何数字都要带年份和「示例 / 预估」。

Selling health insurance in California needs a health licence, not just a life licence; Medicare plans also need annual certification and carrier appointments, and until those are done, don't sell, not even "just looking at it for a friend". WeChat messages, Moments posts and seminar recordings are all evidence; any number you send carries the year and "example / projected".

红蓝卡展业的特别规定Special rules for Medicare sales

• 不主动招揽：不打陌生电话、不上门、不在停车场这类地方拦人、不发对方没同意过的短信和语音留言。
• No unsolicited contact: no cold calls, door-knocking, approaching people in places like parking lots, or texts and voicemails without consent.
• 约见范围确认（SOA）：面谈开始前完成并留档，面谈只谈客户勾选的产品类型。2027 年度营销起不再要求提前 48 小时（CMS 2026 年 4 月最终规则，自 2026 年 10 月 1 日起适用），可以当天签当天谈。
• Scope of Appointment (SOA): completed and kept on file before the meeting starts, and the meeting covers only the product types the client ticked. For 2027 marketing (from October 1, 2026, under CMS's April 2026 final rule) there's no 48-hour wait, so it can be signed and used the same day.
• 红蓝卡销售面谈中不推销人寿、年金；教育讲座只讲一般知识，不推具体计划；电话营销按规定录音、念 TPMO 免责声明。
• In a Medicare sales meeting, no life insurance or annuity pitch; educational events stay general with no specific plans; telephone sales are recorded and include the TPMO disclaimer as required.
• 每年完成年度培训测试（多数承保公司用 AHIP）和各家承保公司认证，拿到委任、系统显示可以销售之前不能展业；10 月 15 日年度选择期开始前完成。
• Complete annual training and testing (most carriers use AHIP) and each carrier's certification; don't sell until appointed and shown as ready to sell, ideally before the annual election period opens on October 15.

适用于 Medicare Advantage 与 D 计划；Medigap 主要归州政府管，规矩不完全一样，但同样要守承保公司的要求。录音保存年限等细节以 CMS 当年规定和承保公司要求为准。

These apply to Medicare Advantage and Part D; Medigap is mostly state-regulated with somewhat different rules, but carrier requirements still apply. Details such as recording retention follow the current CMS rules and carrier requirements.

客户最常问的六个问题Six questions clients ask most

本周行动清单This week's action list

1. 存好三份官方资料：Covered California 2027 收入资格表、2027 福利设计表，以及中文电话（粤语 (800) 339-8938，国语 (800) 300-1533）。
2. Save three official references: Covered California's 2027 income eligibility chart, the 2027 benefit design chart, and the Chinese-language lines (Cantonese (800) 339-8938, Mandarin (800) 300-1533).
3. 列出三类客户：明年满 65 岁的；今年换工作或自雇的；收入靠近 400% 线的（单身 $63,840、四口 $132,000）。
4. List three groups of clients: those turning 65 next year; those who changed jobs or became self-employed this year; and those near the 400% line ($63,840 single, $132,000 for four).
5. 提醒现有客户续约：10/1 起可续约，开放期 11/1–1/31，12/31 前选好 1/1 生效。只联系现有客户，打电话、发短信前先核对「请勿致电」名单；红蓝卡客户按上面的规定来。
6. Remind existing clients to renew: renewals from 10/1, open enrollment 11/1–1/31, choose by 12/31 for a 1/1 start. Existing clients only; check the do-not-call list before calling or texting, and follow the Medicare rules above for Medicare clients.
7. 演练五句话术：两人一组，一人当客户，每句练三遍。
8. Practise the five lines: in pairs, one playing the client, three times each.
9. 检查执照与认证：健康险执照、红蓝卡年度认证、委任；没完成先不展业。
10. Check licences and certifications: health licence, annual Medicare certification, appointments; nothing until they're done.

另记一个日期：11 月中旬 CMS 公布 2027 年红蓝卡 A、B 部分的正式保费和免赔额，到时把本文所有标「预估」的数字换掉。

One more date: in mid-November CMS publishes the official 2027 Part A and B premiums and deductibles; replace every "projected" figure on this page then.