Medicare Qualifications and Enrollment Windows
Before You Turn 65
Generally speaking, you will be granted Medicare Part A and Medicare Part B benefits (Original Medicare) before you are 65 if you have been receiving Social Security Disability Income for 24 consecutive months, are living with ESRD, or have been diagnosed with ALS. In order to qualify for Medicare under these conditions, you will need to apply for it.
When You Turn 65
All U.S. residents are eligible for Medicare insurance when they turn 65. If you are approaching your 65th birthday and are not covered under yours or a spouse's’ employer-sponsored plan, are not on disability, or have not received Social Security retirement benefits. You should get Medicare information on any Medicare website and sign up for the plan that best suits you, including premiums and supplement.
Surrounding your 65th birthday, you have an Initial Medicare enrollment period that lasts for seven months. This enrollment period starts three months prior to when you turn 65, includes the month of your birthday, and goes for three months after you turn 65. During this Medicare enrollment period, you can sign up for Medicare Part A, Medicare Part B and/or Medicare Part D plans. If you do not sign up for Medicare Part A or Medicare Part B during your Initial Medicare Enrollment Period, you can sign up for them during the General Medicare Enrollment Period which is January 10 to March 31 each year, and your Medicare Enrollment benefits will begin the following July 1. Please be sure to understand your Medicare plans and options before you turn 65 as signing up for Medicare Part A or Medicare Part B outside of your Initial Medicare Enrollment Period or a Special Enrollment Period (e.g. after ending an employer health insurance plan) may require you to pay a late Medicare Enrollment penalty. See more on Medicare Part A late enrollment and penalty and Medicare Part B late enrollment penalty .
If you are already receiving Social Security retirement benefits when you turn 65, you will not need Medicare to sign up . Instead, you are automatically enrolled and you should automatically receive your red, white, and blue Medicare enrollment card in the mail to use for Medicare benefits. These benefits will become active on your 65th birthday.
If You Turn 65 and Have Employer-Sponsored Health Insurance
If you are approaching your 65th birthday and are receiving health insurance benefits from an employer or a spouse’s employer group plan, you have the option to continue your coverage or you can sign up to utilize Medicare Part A or Medicare Part B benefits. If you are covered by an employer plan and decide to wait to sign up for Medicare, you can sign up for Medicare at any time during a Special Medicare Enrollment Period. If you lose work-sponsored health insurance coverage after you turn 65, you will also qualify for a Special Medicare Enrollment Period
Example Scenario 1: You may already know that you will not receive long-term benefits after retirement. Although this may be true, you may find that your employer-sponsored insurance premiums are much lower than Medicare’s. If this is the case, you may find it financially advantageous to opt out of Medicare A and B when you turn 65 and maintain your employer-sponsored benefits. Then, once those employer-sponsored benefits stop, you can sign up for Medicare and incur the late enrollment penalty at that time.
Example Scenario 2: You may find that Medicare premiums (Part A or Part B) are lower than your employer-sponsored benefits and decide to switch over to Medicare coverage when you turn 65.
Example Scenario 3: You may be expecting to receive long-term benefits after retirement because of pension, long public service careers, or because you belong to a union. If this is you, you may want to opt out of Medicare Part A and Medicare Part B when you turn 65 and continue using your employer benefits until they are no longer available.
NOTE: Retiree health plans and COBRA do not constitute coverage based on current employment, which means you will not be eligible for a Special Enrollment Period when your retiree benefits end if you were covered under these benefits.
NOTE: Once you enroll in a Medicare program of any kind (Original Medicare or Medicare Advantage), you can no longer make contributions to a Health Savings Account. If you choose to decline Medicare coverage, AARP and CMS (Centers for Medicare and Medicaid Services ) recommend that you call or notify the Medicare office to let them know that you are declining benefits and that you have other health insurance coverage.
The AARP website has more information and may be helpful as you are exploring your Medicare options.
California Medicare Plans
Original Medicare Part A Plan (Hospital Insurance)
Part A of Medicare pays for most of the hospital needs for which people need insurance coverage: hospital visits, skilled nursing facilities, home healthcare, and hospice care.
Original Medicare Part B Plan (Medical Insurance)
Medicare Part B Plan provides coverage for a majority of the medical issues for which people need coverage. It pays for doctor services, outpatient services, laboratory, imaging, durable medical equipment, home care, and much more.
California handles Medigap plans a bit different than other states. Medigap (Plan F or Plan C) can be purchased to help cover the cost of Medicare Part B Plan deductibles. Normally, when you purchase a Medigap plan, it can be difficult to switch plans because there is not a set enrollment window during the year. In order to help relieve issues where a patient feels trapped in a plan that does not meet their needs, the federal government provided seven situations that allow someone to change their plan. Examples include things like moving, your plan isn’t holding their end of the bargain, etc. California went one step further and implemented a “birthday rule.” This provides someone enrolled in a Medigap plan the opportunity to change plans during the 30 days after their birthday every year.
Medicare Advantage Plan (MA) - Part C
California Medicare Advantage provides an alternative to the traditional Medicare Part A or B. Advantage plans are provided through private insurance companies who have contracted with Medicare to provide the same benefits that one would have with the original Medicare, but allows for additional coverage for things like chronic conditions, nursing homes, and long-term care, as well as dental and vision. In 2015, 38% of California’s Medicare population was enrolled in a Medicare Advantage plan. In order to be eligible for Medicare Advantage, you must already be enrolled in Medicare A/B and live in the appropriate service area.
Medicare Rx Plan - Part D
California Medicare Part D provides additional coverage for prescription drugs. While you are automatically enrolled in Medicare Part A and Part B when you turn 65, you have to specifically sign up for Part D. In order to be eligible, you must first be enrolled in Medicare. After that occurs, find the appropriate Medicare D program for your service area. Penalties can be assigned if you do not have appropriate prescription drug coverage, so you will want to ensure that you verify that this step is completed. Currently, over 2 million Californians are enrolled in one of the 28 plans designed to assist in covering the expense of prescription drugs. You will not need Medicare Part D if you currently have a Medicare Advantage Plan.
Now that we’ve talked through the different plans, let’s get to answering some of the questions you may have about Medicare.
What conditions are covered under Medicare?
Medicare Part A covers services that are considered medically necessary to treat a condition or diagnosis. As an example: SNF, long-term care, hospice, home health, hospital stays, and any lab tests, surgeries or DME items required as a result of a condition, are covered if related to a treatment plan.
Medicare Part B, on the other hand, covers preventive services or medically necessary items required to complete a diagnosis. This includes ambulance services, mental health assistance, clinic visits, prescriptions, and obtaining a second opinion.
Medicare Prescription Drug coverage will depend on the formulary, which places drugs in different tiers. Each level will have a defined coverage amount and the formulary can be changed throughout the year.
How do I get Medicare?
- Go to Medicare.gov.
- Decide which California Medicare Plan you want. Choices may include Original Medicare Plan A and B and Medicare Advantage Plan, depending on your qualifications.
- Decide whether or not you will need prescription drug coverage (Medicare Rx Plan - Part D) or Medigap.
- Decide if you want supplemental coverage.
What is a Medicare health plan?
Medicare health plans are Medicare coverage that is offered through a private company that is contracted with Medicare to provide services. These Medicare health plans will usually be in the place of traditional Medicare Part A and B.
What is a Medicare Medical Savings Account (MSA)?
Medicare Medical Savings Account (MSA) Plans are a consumer-directed Medicare Advantage Plan. This basically means that as the consumer, you have a bit more control over what your insurance money goes toward. These MSA plans are similar to a traditional Health Savings Account (HSA) in that you can put money into a special savings account to pay for healthcare costs. The downside is that these savings accounts are typically combined with high-deductible insurance plans. This deductible amount varies by plan.
Medicare Cost Plans are only available regionally if you have Medicare Part A and Part B and need to receive services from a provider that is out of network.
Programs of All-Inclusive Care for the Elderly (PACE) is a program that advocates for home health services. It allows the elderly to stay in their home longer before going to a long-term care facility. It will cover services such as adult day care, home care, meals, occupational therapy, social services, respite care, transportation, and caregiver training.
Medication Therapy Management (MTM) Program is offered through Medicare as an educational benefit. They provide detailed training on the specific medications that the patient is taking and provide an action plan to help ensure compliance.
What is Medigap and what does it do?
Medigap exists to help cover the out-of-pocket expenses related to your Part B coverage (and some Part A depending on the coverage definitions). When a claim is sent to Medicare, they will automatically send it to your Medigap insurance.
Is there cost assistance for Medicare?
There is not a cost associated with purchasing traditional Medicare, but there are options for additional coverage via Medicaid, Medicare Savings Programs, PACE or prescription drugs if deemed that co-payments or deductibles are difficult to meet. In addition, if a patient chooses to purchase an advantage plan or Medigap plan, there are out-of-pocket costs associated that are dependent on what has been purchased.
How does Medicare work with my other insurance?
If you have another insurance, it will almost always be billed before Medicare. The primary payer will pay their portion of the claim first and then bill the remaining amount to Medicare as the secondary payer, who will pay their portion second. The remaining balance will move into patient responsibility.
What is the State Health Insurance Assistance Program (SHIP) called in California and how do I get a hold of them?
The SHIP program in California is called the California Department of Aging’s Health Insurance Counseling and Advocacy Program (HICAP). Their goal is to give Medicare beneficiaries counseling and education on their Medicare benefits, prescription drugs plans and additional health plans. HICAP volunteers will not provide a recommendation for a specific plan, but they will help provide all the necessary information to make an educated decision.
Where can I get help or more information about Medicare?
California Medicare FAQs