Medicare in California
- Medicare in California can be a complex topic. Learn more about your options and when you might need to enroll in this federal benefit for people of retirement age.
What California Medicare Plans Are Available?
Administered by the Social Security Administration, Medicare is the federal health insurance program that provides insurance for eligible participants who are 65 or over. People diagnosed with a long-term disability may also qualify for Medicare.
California offers all Medicare plans, including what's known as Original Medicare (Medicare Parts A and B), Medicare Advantage (Part C), Medicare Part D (prescription drug coverage) and Medicare Supplement Insurance, often known as Medigap. In California, 3,612,462 people were enrolled in Original Medicare as of 2020, with 2,759,912 participants in Medicare Advantage plans.
Medicare Part A
Medicare Parts A and B were initiated with the original launch of Medicare in 1965. Medicare Part A is the hospital insurance part of Medicare. It covers:
- Inpatient hospital care
- Care in a skilled nursing facility or post-acute nursing home facility
- Home health care
- Hospice services
- Inpatient rehabilitation services
- Inpatient psychiatric care
Medicare Part A does not cover long-term care or care in an assisted living facility.
While in an approved facility, Medicare Part A covers the charges for:
- Inpatient care, including the cost of the hospital room
- Drugs and medications administered in the hospital
- Registered nursing care
- Other medical supplies and services
Medicare Part B
As the second component of Original Medicare, Medicare Part B covers outpatient services, including office visits and some preventive care. Typically, Medicare Part B covers the following:
- Medical office visits
- Diagnostic tests
- Some durable medical equipment (such as wheelchairs, hospital beds and nebulizers)
- Preventive services, including routine wellness checkups
- Vaccinations, IV antibiotics and a limited number of drugs
- Limited mental health care, including non-residential drug and alcohol rehab
- Medical transportation authorized by a physician
- Some experimental drug trials and therapies
Medicare Part B does not cover the retail cost of drugs bought at a pharmacy.
Medicare Advantage (Medicare Part C)
Medicare Part C, commonly known as Medicare Advantage, was launched in 2006. Medicare Advantage, which is private health insurance, replaces Original Medicare for participants who choose it. Many Medicare Advantage plans also include dental care, vision care and some prescription drug coverage.
Medicare Advantage plans come in several varieties, including HMO (health maintenance organization) plans, PPO (preferred provider organization) plans, private fee-for-service plans and special needs plans for people with chronic conditions, such as diabetes, HIV and stroke.
Medicare Part D
Medicare Part D is optional coverage for prescription drugs. A pre-approved network of insurance providers is authorized to offer Part D coverage, with pre-set prices for different types of drugs. Copays vary, with generic drugs requiring lower copays than brand name or specialty drugs.
Some Medicare Advantage plans already include prescription drug benefits. Participants whose Medicare Advantage plans don't include this coverage may be able to add Part D to their insurance. Seniors with limited income and assets may qualify for low-income subsidies to be able to afford Medicare Part D.
Medicare Supplement Insurance (Medigap)
Original Medicare has a few gaps in coverage, with participants expected to dip into their own pockets to cover copays, deductibles and other costs. Medigap coverage pays for some of those costs. The state of California authorizes certain private insurance companies to offer Medigap policies to people already enrolled in Medicare Parts A and B. People enrolled in Medicare Advantage plans are not eligible for Medigap policies.
Who Is Eligible for California Medicare?
To be eligible for Medicare in California, you must be a U.S. citizen or a legal resident for at least 5 years. You must be 65 years old. And you or your spouse must have worked in Medicare-covered employment for at least 10 years.
In addition, people under 65 may qualify if they have received disability payments from Social Security Disability Insurance (SSDI) or Railroad Retirement for 2 years, if they have amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease) or if they have end-stage renal disease requiring dialysis or kidney transplant.
There are several ways to enroll in Medicare in California:
- Automatic enrollment. If you are already receiving Social Security benefits 4 months before you turn 65, you will automatically be enrolled in Medicare Parts A and B.
- Initial enrollment period (IEP). If you're not automatically enrolled, your initial enrollment period for all parts of Medicare begins 3 months before the month of your 65th birthday and ends 3 months after the month of your 65th birthday, for a total of 7 months.
- General enrollment period. General enrollment runs from January 1 to March 31 every year from Medicare Parts A and B and from April 1 to June 30 for Medicare Advantage and Medicare Part D.
- Special enrollment period. Special enrollment periods are available in California for Medicare Parts B, C and D for people who have lost insurance coverage due to closure of an employer-paid plan, fraud, divorce, retirement, unemployment, being overseas or being in prison. These periods can open at any time.
- Open enrollment periods. Also called Annual Election, these periods open from October 15 to December 7 to allow people to enroll in Medicare Advantage and Medicare Part D.
How Do I Enroll in Medicare in California?
About 3 months before you turn 65, Medicare will send you an enrollment package. If you are already receiving Social Security benefits, you don't have to do anything — you will be enrolled in Medicare Parts A and B automatically. All you have to do is sign the Medicare card included in your packet.
If you're not eligible for automatic Medicare enrollment, apply at the Social Security Administration (ssa.gov or 800-772-1213) during your initial enrollment period. If you are still employed and have employer-provided health insurance, you may want to enroll in Medicare Part A only. In this case, you need to decline medical insurance (Medicare Part B) when you enroll. Later, if you want to add Part B to your Medicare coverage, perhaps after you retire, you can only do so during the general enrollment period.
Contact Information for California Medicare, Medicaid and Insurance Help
California's version of Medicaid, which is known as Medi-Cal, is available to low-income residents of the state who meet eligibility qualifications. Learn more about Medi-Cal eligibility and enrollment here.
You can also get further help understanding your health insurance options through the California Health Insurance Counseling and Advocacy Program, which is California's version of the State Health Insurance Program (SHIP).
California offers about 90 Medicare Advantage programs to choose from. Learn more about Medicare Advantage in California here. In addition, California offers several Prescription Drug Assistance programs for people on Medicare as well those who aren't eligible for Medicare.