Medicare in California
Resources for California Medicare Beneficiaries
Curious about Medicare’s many parts, enrollment periods, and applications, or comparing and choosing a Medicare plan? You’re in luck, dive in.
Getting guidance might be beneficial while making Medicare decisions. As a Californian, you have a number of places where you can get assistance, including the State Health Insurance Program (SHIP), commonly known as the California Health Insurance, Counseling, and Advocacy Program (HICAP). HICAP has counselors around the state who collaborate with local nonprofits, public health agencies, and Area Agencies on Aging (AAAs) specific to your county to provide individuals in California with Medicare information.
Medicare Plan Options in California
As a California resident, you have several Medicare options to select from. Individuals that are 65+ and those with disabilities that qualify for Medicare can apply for Original Medicare. If you prefer more comprehensive coverage, a Medicare Advantage plan may be a better option with a wide selection of plans in California. Some Medicare plan options include prescription drug plans or Medicare supplemental insurance.
Original Medicare (Parts A & B)
Original Medicare is your foundational Medicare program. It is divided into two sections: Part A, hospital insurance, and Part B, medical insurance. Medicare Part A covers hospital stays, skilled nursing facility stays, home health care, and hospice care. Medicare Part B covers doctor’s visits as well as outpatient care, lab testing, and preventive services such as cancer screenings, flu shots, and yearly wellness visits. Medicare Part A and Part B have different deductibles that apply for different services. For example, Part A has an inpatient hospital deductible per benefit period (each time you are admitted), and Part B has an annual deductible before Original Medicare starts to pay. Things to consider if keeping Original Medicare:
- Original Medicare in California is a great option if you want the freedom to choose and access providers who accept Medicare anywhere in the United States.
- If you don’t require a lot of health care services or prescription drugs, know that there is no cap on what you may pay out of pocket. Stand-alone prescription drug plans are available for these scenarios.
Medicare Advantage (Part C)
Part C, another name for Medicare Advantage plans, is an alternative to Original Medicare coverage, offered by private insurance companies. These plans cover at minimum what Medicare Part A and Medicare Part B would, and the best part is they often include additional benefits. Most services are administered by a network of providers, which may require you to have a primary care doctor, a referral to see a specialist, and prior approval for certain services, treatment and medications before you can get them; think like a HMO plan. There are also other insurance products offered like PPO, HMO-POS (a hybrid model of an HMO and PPO), or a Private Fee for Service (PFFS) plan.
Medicare Advantage plans in California cover more of what you need. Medicare Advantage is a good choice if:
- You prefer to get your health care and drug benefits in one plan and don’t mind being limited to a network of providers to choose from.
- You only want to carry one ID Card. Present your chosen Medicare Advantage plan’s ID card to your doctor and pharmacy at the time of service.
- You want the financial protection of an annual cap on how much you spend out-of-pocket for Medicare-covered costs.
To learn more about Medicare Advantage, explore our Medicare Part C Resource Page.
Medicare Prescription Drug Plan (Part D)
Many Medicare Advantage plans automatically include Medicare Part D prescription drug coverage. You can also add a stand-alone Prescription Drug Plan (PDP) plan to Original Medicare or to a Medicare Supplement Insurance policy. Private insurance companies approved by Medicare offer coverage for Part D independently. Depending on the plan chosen, there may be a deductible, copay, or coinsurance associated with covered medications.
- Part D is a great pick if you have Original Medicare, Medicare Savings Account (MSA), or a Private Fee for Service (PFFS) plan that doesn’t include prescription drugs.
- If you wait to sign up for a Part D plan, you may be assessed a late enrollment penalty unless you already have other creditable coverage such as: an employer-sponsored group plan, retiree plan or military coverage to name a few.
- If you don’t need any medications right now, it is recommended to still sign up for a low premium cost Part D plan to avoid late enrollment penalties.
Medicare Supplement Insurance (Medigap)
Some Medicare beneficiaries in California buy Medigap, AKA Medicare Supplement Insurance. The goal of these plans is to help cover what Original Medicare doesn’t. For example, a few of these gaps include coverage for medical care outside of the U.S., Part A and Part B deductibles and coinsurance.
You should know that Medigap doesn’t pay for anything related to Medicare Advantage. You cannot have both a Medigap policy and a Medicare Advantage Plan simultaneously. If you currently have a Medicare Advantage plan and wish to purchase a Medigap policy, your Medigap policy effective date should start after your Medicare Advantage plan ends. Have no fear;
- Medigap is an excellent choice if you have Original Medicare and want help paying for out-of-pocket costs when you use your Medicare Part A and Medicare Part B benefits.
- You pay a set monthly premium for a policy that will cover most of your out-of-pocket costs associated with Medicare-covered services. So you have peace of mind and no unexpected medical expenses.
- You have flexibility; let’s say you need a lot of healthcare services and want to be able to see any Medicare provider you want; as long as they accept Medicare, your Medigap plan gives you coverage for Medicare-approved care that you can count on.
Medicaid is a public insurance program that was established in 1965 and is funded equally by the state and federal government. It offers health care to low-income families and individuals, including children, parents, pregnant women, elders, and persons with disabilities. Each state runs its own Medicaid program in accordance with federal regulations. The expansive federal rules provide states a lot of latitude in creating and implementing their programs. As a result, Medicaid eligibility and benefits can and frequently do differ significantly from state to state.
California’s Medicaid program is the nation’s largest, commonly called Medi-Cal. Medi-Cal is managed by the California Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS). Medi-Cal helps eligible individuals access medical care for little or no cost if meeting income restrictions.
If you qualify for Medi-Cal, there are a few things to note:
- Fee-for-service is how Medi-Cal pays doctors and other health care providers. When you first sign up for Medi-Cal, you will get your benefits through Fee-for-Service Medi-Cal until you join a managed care health plan. Medi-Cal is almost entirely “managed care,” functioning similarly to how an HMO works. The Medi-Cal Managed Care Health Plan Directory lists all Medi-Cal plans.
- If you have only a Medi-Cal managed care plan, you’ll see your primary care doctor, and your primary care doctor must refer you to a specialist for Medi-Cal to pay.
- Many people 65 or older or with a disability qualify for both Medi-Cal and Medicare. If you are eligible for both, Medicare will pay for most of your medical care and prescription drugs. Medi-Cal gives long-term services and help, like care in a nursing home and services in the home and community. Your Medicare premiums may also be paid for by Medi-Cal.
How and when to sign up for Medicare in California
If you qualify, Medicare is a government-run insurance program funded by the federal government. Original Medicare often refers to Part A (Hospital Insurance) and Part B (Medical Insurance). Additionally, the California Department of Insurance (CDI) advises getting Medicare Supplement Insurance coverage to offset out-of-pocket costs since Original Medicare doesn’t cover all of your medical bills. The majority of Americans are eligible to enroll in Medicare when they turn 65. The following also triggers Medicare eligibility:
- You qualify for disability benefits from the Railroad Retirement Board or Social Security and are under 65 and permanently disabled and have received disability benefits for at least 24 months from Social Security.
- You have been diagnosed with End Stage Renal Disease (ESRD).
- You have been diagnosed with Lou Gehrig’s disease, often known as Amyotrophic Lateral Sclerosis (ALS).
Medicare Advantage Enrollment Periods in California and nationwide
Here is a quick overview of the Medicare enrollment periods and enrollment timeframes in which you can elect or change your Medicare Advantage plan.
We’re almost done, Golden Staters. Healthpilot knows that navigating Medicare can be hard, and adding enrollment timelines is stressful.
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Want a few fun facts about Medicare coverage in California?
- 17% of the state’s population has Medicare coverage, but that number is still technically low because the average US state hits 19%.
- In California, about 48% of Medicare customers are enrolled in private Medicare Advantage programs.
- As of 2022, Medicare Advantage plans are available in 44 of California’s 58 counties.
- In California, around 30 different insurance providers offer Medicare Supplement Insurance (Medigap) plans, and almost 600,000 people have Medigap coverage.
- California has around 26 separate stand-alone Part D prescription programs. These Part D prescription drug plans have monthly premiums starting as low as $7.40.
- And because we promised you a fun fact, we’ll give you a two-in-one: California is known as the world’s artichoke capital, and Norma Jean began her adventure there in 1947. She became Castroville’s first Artichoke Queen, and then she became Marilyn Monroe, a world-famous and award-winning actress.
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We’re here Monday – Friday, 7am – 10pm & Saturday - Sunday, 7am - 7pm Central