What is Medicare?
Medicare is the federal health insurance program for Americans 65 and older, as well as certain younger people with disabilities or End-Stage Renal Disease (ESRD). It is run by the Centers for Medicare & Medicaid Services (CMS) — a division of the U.S. Department of Health and Human Services. You can learn more at the official CMS website.
Over 6.7 million Californians are currently enrolled in Medicare — the largest Medicare population of any U.S. state. This makes California unique in terms of the diversity of available plans and the intensity of competition among insurers. To explore national Medicare data and understand your options, visit the official Medicare.gov.
What Medicare Does NOT Cover
It's equally important to understand the limitations. Medicare does NOT cover:
- Most dental care (cleanings, fillings, extractions, dentures, orthodontia)
- Most vision care (routine eye exams, glasses, contact lenses)
- Hearing aids (though Medicare Part B does cover some diagnostic audiology services)
- Long-term care (nursing home care, assisted living)
- Cosmetic surgery
This is why most beneficiaries add supplemental coverage (Medigap or Medicare Advantage) to fill the gaps. Understanding these gaps is essential to choosing the right plan for the beneficiary.
The 4 Parts of Medicare
Medicare is divided into four distinct parts, each covering different services. Understanding what each part covers — and what it costs — is the foundation of choosing the right plan.
Part A — Hospital Insurance
What It Covers
- Inpatient hospital stays
- Skilled nursing facility care (short-term, up to 100 days per benefit period)
- Hospice care
- Some home health care (if medically necessary)
Cost
Most people pay $0/month for Part A if they (or their spouse) worked 40+ quarters (10 years) paying Medicare taxes.
2025 Deductible: $1,632 per benefit period
Part B — Medical Insurance
What It Covers
- Doctor visits and outpatient services
- Preventive services (annual wellness visit, screenings)
- Durable medical equipment (wheelchairs, oxygen, walkers)
- Mental health services
- Physical and occupational therapy
Cost
2025 Standard Premium: $185.00/month
( income exceeds certain limits, they pay IRMAA — additional charges. More on this below.)
2025 Annual Deductible: $257
Coinsurance: You typically pay 20% after the deductible. Important: Original Medicare has NO out-of-pocket maximum — costs can be unlimited.
Part C — Medicare Advantage
What It Covers
- All Part A and Part B benefits
- Usually includes dental, vision, hearing, fitness benefits
- Often includes prescription drug coverage (Part D)
- Offered by private insurance companies approved by Medicare
Cost & Network
2025 Premium: Often $0/month in California (varies by plan and county)
However, you must use the plan's network of doctors. Plan types include:
- HMO: Most restrictive; must use in-network doctors
- PPO: More flexibility; can see out-of-network doctors for a higher cost
Part D — Prescription Drug Coverage
What It Covers
- Prescription medications from pharmacies
- Brand-name and generic drugs
- Can be bundled with Medicare Advantage or purchased separately for Original Medicare
Cost & Design Changes
2025 Average Premium: ~$55/month (varies significantly by plan)
2025 Out-of-Pocket Cap: $2,000
This is a major change from the Inflation Reduction Act (2022). Once the beneficiary reaches $2,000 in out-of-pocket costs, they pay just $0 for generic drugs and 25% for brand-name drugs for the rest of the year.
Medicare Advantage vs. Medigap: The Critical Decision
This is the most important decision most California families will make regarding Medicare. The choice between Medicare Advantage and Medigap shapes everything: monthly costs, freedom to choose doctors, coverage of extras, and financial predictability. There is no universally 'better' option. The right choice depends entirely on the beneficiary's specific doctors, medications, financial situation, and health priorities.
Medicare Advantage (Part C)
Popular CA Plans:
- Kaiser Permanente (5-star consistently)
- SCAN Health Plan (California-based, 4-4.5 stars)
- Alignment Health
- Humana
- UnitedHealthcare
- Anthem Blue Cross
- Aetna
Original Medicare + Medigap
Medigap Plans:
Plans include A, B, C, D, F, G, M, N. Plan G is most popular. Plan C & F are closed to new enrollees.
Medicare Enrollment Periods: Timing Is Critical
Missing enrollment deadlines can result in permanent late enrollment penalties that increase premiums for life. Understanding these windows is essential. Here are the key enrollment periods:
1. Initial Enrollment Period (IEP)
When: 7-month window: 3 months before the birthday month + the birth month + 3 months after
Why It Matters: This is the only chance to enroll in Medicare without a late enrollment penalty. If the beneficiary misses this window, they may pay permanently higher premiums.
Action: Start planning 6 months before the beneficiary's 65th birthday. Contact Alejandra to understand all options before the window opens.
2. Annual Enrollment Period (AEP)
When: October 15 – December 7, every year
What You Can Do: Switch plans, join a new plan, or drop coverage. Changes take effect January 1 of the following year.
Each year, plan premiums, benefits, and star ratings change. This is why reviewing coverage annually is crucial — the 'best' plan in 2024 may not be the best in 2025.
3. Medicare Advantage Open Enrollment (MA-OEP)
When: January 1 – March 31, every year
Who: If the beneficiary is already in a Medicare Advantage plan
What You Can Do: Switch to a different Medicare Advantage plan OR switch to Original Medicare (one change allowed during this period)
4. Special Enrollment Period (SEP)
When: Various times triggered by life events
Qualifies For:
- Losing current health insurance coverage
- Moving out of a plan's service area
- Newly eligible for Medicaid or Medicare
- Changes in household circumstances
If a qualifying event occurs, contact us immediately — you typically have 60 days to enroll in a new plan.
California Guaranteed Issue Rights
California has unique protections for Medigap enrollment. During certain windows (typically after initial enrollment or Medicare Advantage disenrollment), insurers must issue you a Medigap policy regardless of pre-existing conditions. Learn more about your California rights at the California Department of Managed Health Care.
Medicare in California: Special Considerations
HICAP — California's Free Medicare Counseling
California's Health Insurance Counseling & Advocacy Program (HICAP) is a fantastic resource. It's completely free, unbiased, and run by the state. HICAP counselors can explain all available options, help compare plans, and answer questions — but they cannot enroll you directly.
- Website: https://www.aging.ca.gov/hicap/
- Phone: 1-800-434-0222
Think of HICAP for education and unbiased information. Think of Alejandra for enrollment assistance, personalized recommendations, and ongoing support.
Top California Medicare Advantage Carriers (2025)
California has exceptional choice in Medicare Advantage. Here are the major carriers offering plans:
Kaiser Permanente
Consistently 5-star rated. Integrated care model. Strongest in urban CA.
SCAN Health Plan
California-based, established 1977. Strong 4-4.5 star ratings.
Alignment Health
Newer, innovative plans. Growing presence in CA.
Humana
National carrier. Competitive 4-star plans in most CA counties.
UnitedHealthcare
Large network. Options across California.
Anthem Blue Cross
California presence. Competitive offerings.
Star ratings change yearly and vary by county. The 'best' plan depends on the beneficiary's specific needs and location. Alejandra reviews current ratings, available plans, doctors, and medications to identify the best options.
County-Specific Differences
Even within California, Medicare Advantage availability and premiums vary significantly by county. A plan available in San Diego may not be available in Marin County. The number of available plans can range from 10 to 40+ depending on location. Alejandra knows the CA market and can navigate these differences.
Dual Eligibility: Medicare + Medi-Cal
Some Californians qualify for BOTH Medicare AND Medi-Cal (California's Medicaid program). This is called 'dual eligibility,' and it can dramatically reduce out-of-pocket costs.
Who Qualifies for Dual Eligibility?
Dual eligible beneficiaries are typically low-income Medicare beneficiaries who also meet California's Medi-Cal income and asset limits. Medi-Cal can help pay for:
- Medicare Part B premiums
- Medicare deductibles and coinsurance
- Prescription drug cost-sharing
- Long-term care (nursing home)
Special Plans for Duals
Dual-eligible beneficiaries in California can enroll in specialized plans:
Cal MediConnect
A coordinated care plan that combines Medicare and Medi-Cal benefits. Enrollees get integrated medical, behavioral health, and long-term care services through one plan.
Dual Special Needs Plans (D-SNP)
Medicare Advantage plans specifically designed for dual-eligible individuals. Typically $0 premium with extra benefits.
If the beneficiary has low income, ask Alejandra if they qualify for dual eligibility. This can be life-changing — transforming significant healthcare costs into minimal or zero out-of-pocket expenses.
How to Enroll in Medicare
Step 1: Apply for Original Medicare (Parts A & B)
You must enroll in Medicare (Parts A & B) through Social Security — not through an insurance agent. Three ways to apply:
Online (Easiest)
Visit SSA.gov Medicare Sign-Up — You can apply for Part A and Part B online.
By Phone
1-800-772-1213
1-800-325-0778
In Person
Step 2: Choose Medicare Advantage (Part C) or Original Medicare + Medigap/Part D
This is the critical decision. After you enroll in Parts A and B, you work with an agent like Alejandra to:
- Review all available plans in your county
- Verify the beneficiary's doctors are in-network
- Check if all medications are covered and at what cost
- Compare premium, deductible, and out-of-pocket costs
- Enroll in the best plan
What to Have Ready When Enrolling
Checklist: Enrollment Documents
- Social Security number
- Proof of age (birth certificate or passport)
- List of all current doctors (primary care, specialists)
- List of all current medications with dosages and frequency
- Current health insurance cards (if any)
- Medicare card (once received from SSA)
Important Notes
- Enrolling in Medicare Parts A & B is FREE and automatic for most people.
- Choosing a Medicare Advantage plan is also FREE — agents cannot charge you to enroll.
- If the beneficiary misses the Initial Enrollment Period, late enrollment penalties apply permanently.
- Every year during Annual Enrollment Period (Oct 15 – Dec 7), review coverage and switch plans if needed.
Helpful Resources
These official sources provide free, unbiased information about Medicare in California:
Medicare.gov
The official Medicare website. Compare plans, check drug coverage, read detailed benefit information, and enroll online.
Visit Medicare.govSocial Security Administration
Enroll in Medicare Parts A & B, understand benefits, and check your earnings record.
Visit SSA MedicareCalifornia HICAP
Free, unbiased Medicare counseling for all Californians. No enrollment, just education.
Visit HICAPMedicare Plan Finder
Search and compare all Medicare Advantage, Medigap, and Part D plans available in your ZIP code.
Visit Plan FinderCA Dept. of Health Care Services
Learn about Medi-Cal, dual eligibility, and other state health programs.
Visit DHCSCenters for Medicare & Medicaid Services
The federal agency running Medicare. Policy details, regulations, and statistics.
Visit CMSCA Dept. of Managed Health Care
California's regulator of health plans. File complaints, understand patient rights, learn about guaranteed issue.
Visit DMHCSHIP (State Health Insurance Assistance Program)
National program with local counselors in every state. Find your state's SHIP here.
Visit SHIPHelp.org