Frequently Asked Questions - California Medicare Agency
Medicare Basics & Parts
Medicare is a federal health insurance program for people 65 and older, as well as younger individuals with certain disabilities or specific conditions like End-Stage Renal Disease. It’s made up of different “parts” that cover different types of care.
Part A is your hospital insurance. It covers inpatient hospital stays, care in a skilled nursing facility, hospice, and some home health care. Most people don’t pay a monthly premium for Part A if they or their spouse paid Medicare taxes for at least 10 years.
Part B covers outpatient medical care – doctor visits, preventive services like screenings and vaccines, durable medical equipment, and lab tests. Unlike Part A, most people pay a monthly premium for Part B.
Part C, also called Medicare Advantage, is an alternative to Original Medicare offered by private insurers. It bundles Part A and Part B coverage, and often Part D, into a single plan – usually with a provider network.
Part D is prescription drug coverage. It’s either offered as a standalone plan alongside Original Medicare, or bundled into a Medicare Advantage plan (called MAPD). You pay a monthly premium plus deductibles and coinsurance based on your specific medications.
No, enrollment isn’t strictly mandatory, but most beneficiaries choose to enroll in each part to limit their out-of-pocket costs and avoid late enrollment penalties, particularly for Parts B and D.
other creditable prescription drug coverage once you’re first eligible, you’ll face a late enrollment penalty added to your monthly premium. This penalty is permanent and doesn’t go away, which is why it’s worth enrolling as soon as you’re eligible.
Medicare Costs
Your total cost depends on which parts and plans you choose. Many people get premium-free Part A, but Part B, Advantage, Medigap, and Part D plans all carry their own premiums, deductibles, and cost-sharing. Costs also tend to increase annually.
Both parts have separate annual deductibles that must be met before Medicare starts covering costs, with an exception for Part B preventive care, which is typically covered without a deductible. Once your deductibles are met, Medicare generally covers 80% of approved services.
Yes. Higher-income beneficiaries can be charged an increased premium for Part B. If you believe you were placed in the wrong income bracket, you have the option to contest the charge and potentially have it lowered to the standard rate.
Yes. Programs like Extra Help can assist with Part B deductible and coinsurance costs for those who qualify, and the Medicare Savings Program can help with additional expenses. Our advisors can help you check your eligibility.
Medicare Eligibility
You’re generally eligible starting at age 65. You may also qualify earlier if you have certain disabilities or specific conditions such as End-Stage Renal Disease.
Coverage typically starts at age 65, or after 24 months of receiving disability benefits. Enrollment isn’t automatic for everyone, so your actual start date depends on when you submit your application.
Yes, in most cases. To enroll in a Medicare Advantage plan or a Medigap (Medicare Supplement) plan, you must already be enrolled in both Original Medicare Part A and Part B.
Medicare Coverage
Think of it this way: Part A covers your care while admitted in a hospital setting, while Part B covers services and visits you receive as an outpatient – like doctor’s appointments and preventive screenings.
Yes. Part B includes coverage for a range of preventive services, including cancer screenings, vaccines, and routine lab tests, generally without requiring you to meet your deductible first.
You have a few options: request a formulary exception, pay out-of-pocket for the medication, or file an appeal asking your plan to reconsider its coverage decision.
Medicare Enrollment Periods
Your IEP is a seven-month window: it begins three months before your 65th birthday, includes your birthday month, and ends three months after. This is your first and best opportunity to enroll in Parts A, B, and D.
The ICEP is similar to the IEP but applies specifically to enrolling in a Medicare Advantage (Part C) plan. It also begins three months before your 65th birthday, and ends on either your Part B effective date or the end of your IEP, whichever is later.
An SEP lets you enroll outside your normal window if you experience a qualifying life event, such as losing employer coverage. Not everyone qualifies, so it’s worth confirming your eligibility with an advisor.
You may be able to enroll during the General Enrollment Period, but this can result in a gap in coverage and possible late enrollment penalties for Part B and Part D.
Yes. There are dedicated windows – such as the Annual Enrollment Period and Medicare Advantage-specific enrollment periods – that allow you to make changes to your existing coverage each year.
Missing a relevant enrollment period can mean penalties, delayed coverage, or being locked out of changing your plan until the next window opens. Our advisors track these dates so you don’t have to.
Medicare Supplements (Medigap)
Medigap, or Medicare Supplement Insurance, is designed to help pay for costs that Original Medicare doesn’t cover – like copayments, coinsurance, and deductibles. It works alongside Parts A and B, not as a replacement.
In California, Medigap plans are standardized. That means a specific plan, like Plan G or Plan N, offers the same core benefits regardless of the insurance company selling it – though the premium can vary by carrier.
If you apply outside of your Medigap open enrollment window, insurers can require a health evaluation, which may raise your premium or limit your options, particularly if you have pre-existing conditions. Applying during your open enrollment window helps you avoid this.
No. If you’re enrolled in a Medicare Advantage plan, you cannot also purchase a Medigap policy. You would need to choose one path or the other.
Medicare Advantage Plan Types
HMO plans generally require you to choose a primary care provider and get referrals to see specialists, and they typically don’t cover out-of-network care except in emergencies. PPO plans offer more flexibility – you can see out-of-network providers, though at a higher out-of-pocket cost – and usually don’t require referrals.
An HMO-POS plan is a hybrid between a traditional HMO and a PPO. It offers more flexibility than a standard HMO, including some out-of-network coverage, though you’ll pay more out-of-pocket when going outside the plan’s network.
A Private Fee-for-Service plan is offered by a private insurer and determines how much it will pay providers and how much you’ll pay out-of-pocket for care. These plans are required to offer coverage at least equal to Original Medicare, and often include extra benefits.
An SNP is a type of Medicare Advantage plan designed for people with specific health conditions or circumstances. To qualify, you must be enrolled in Medicare Parts A and B and meet the plan’s specific eligibility criteria.
MAPD stands for Medicare Advantage Prescription Drug plan – a Medicare Advantage plan that includes built-in Part D prescription coverage, so you don’t need a separate standalone drug plan.
Working With California Medicare Agency
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