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The Basics
When you work, some of the money you earn automatically comes out of your paycheck and helps fund Medicare, a national public health insurance program which helps pay for the medical costs of people who qualify.
If you or your spouse works enough time while paying Medicare taxes, you qualify for Medicare:
- When you turn 65
- After you get Social Security Disability Insurance (SSDI) benefits for two years, or
- If you have end-stage kidney disease (ESRD) or Lou Gehrig’s disease (ALS).
If you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record, you also qualify for Medicare.
If you have Medicare coverage, it’s important for you to understand:
- Which parts of Medicare might help you
- The differences between Original Medicare and Medicare Advantage
- What you have to pay for Medicare
- How you can get help paying for Medicare, and
- How to sign up for different Medicare benefits.
If you have questions about Medicare and need to talk with somebody:
- Call Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY), or
- Call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
- After you get SSDI for two years, Part A and Part B of Original Medicare coverage start automatically.
- Each year, Medicare has open enrollment between October 15 - December 7. During this time, you can switch between Original Medicare and Medicare Advantage or change which Part D or Medicare Advantage plan you have. If you also get Medi-Cal benefits, you can change plans at any time.
- You can have Medicare and other health coverage at the same time and they may work together to pay for your medical expenses.
- If you have low income, Medi-Cal, Medi-Cal's Working Disabled Program, Medicare Savings Programs, and the Low Income Subsidy (LIS) may help you pay for Medicare.
- If you get SSDI benefits, but they stop because you make too much money at work, Medicare coverage may continue for 93 more months (seven years and nine months) or more.
Learn more
Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
Medicare
- The Basics
- What Medicare Options Are Right for You?
- What It Covers
- What You Pay
- How to Sign Up
- Example
- FAQs
- Pitfalls
- Next Steps
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What Medicare Options Are Right for You?
If you qualify for Medicare, some of the choices you need to think about include:
- Whether you want Original Medicare or a Medicare Advantage plan.
- If you want Original Medicare, which Part D prescription drug plan to sign up for (if any), whether to decline Part B, and whether to sign up for a Medigap (Medicare Supplemental Insurance) policy.
- If you want Medicare Advantage, which plan to choose.
People make these choices when Medicare coverage starts, but can change their minds and their Medicare coverage at certain times.
Comparing Original Medicare and Medicare Advantage
To understand what Medicare options are right for you, it’s important to get a sense of how Original Medicare and Medicare Advantage work.
Note: Medicare Advantage is sometimes called Medicare Part C.
- Part A helps pay for hospitalization. Most people do not pay a monthly premium for Part A.
- Part B helps pay for outpatient medical care, like when you go to the doctor’s office. Most people pay a $164.90 monthly premium for Part B (or a bit less).
- Private Part D plans help pay for prescription drugs for people with Original Medicare coverage. You have to pay an extra monthly premium for Part D and the amount depends on which Part D plan you get.
- Private Medigap policies cover some expenses that Original Medicare doesn't cover. You have to pay an extra monthly premium for these policies, also called Medicare Supplement Insurance.
- You can visit any doctor or hospital who accepts Medicare payments.
- A private company offers a policy that combines the benefits offered by Part A, Part B, Part D, and Medigap policies into a single plan.
- There are many plans to choose from in most counties.
- The exact benefits and the cost of those benefits depend on the plan you choose.
- You may be restricted to certain hospitals or networks of doctors.
- There is a $8,300 out-of-pocket maximum each year for expenses besides the premium.
Original Medicare |
Medicare Advantage |
|
---|---|---|
Run by |
The federal government |
Private companies |
Medical providers |
Any who accept Medicare |
May be a limited provider network |
Costs |
Based on Medicare’s rules |
Depends on the plan; has a $8,300 annual out-of-pocket maximum |
Services covered |
At least everything Original Medicare covers |
|
Additional Benefits |
Not included |
May be included with plan |
Drug Coverage |
With a separate Part D policy |
May be included with plan or through a separate Part D policy |
Advantages |
More service providers to choose from |
Usually lower cost |
The bottom line: Both Original Medicare and Medicare Advantage have advantages and are good ways to get Medicare benefits. In California, 48% of Medicare beneficiaries choose Original Medicare and 52% choose Medicare Advantage.
How Other Coverage Can Affect Your Medicare Choices
Having another form of health coverage, such as employer-sponsored coverage or Medi-Cal, is one of the biggest factors that can affect how you should get Medicare. Answer these questions to see how they might affect your Medicare choices.
If you need to talk with someone about these questions, call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
Do You Have Private Coverage That Covers What Parts B and D Cover?
If you get employer-sponsored coverage that covers what Medicare Parts B and D cover, you may want to opt out of Parts B and D, so that you don’t have to pay their premiums. (You still have Part A coverage, which usually has no premium.)
However, you might have to pay monthly penalties if you opt out and want Parts B and D later:
- For Medicare Part B, you can only opt out without paying penalties later if you have an employer-sponsored insurance policy. If you do, make sure to check with your employer or insurer whether it's safe for you to opt out of Part B.
- If Medicare Part D says the other coverage you have is “creditable,” which means it meets certain standards, you can opt out of Part D and you don’t have to pay a penalty if you decide to sign up for it later within certain time limits.
- If you opt out of Parts B and D and your coverage doesn't meet these standards, you may have to pay monthly penalties if you want Parts B and D later. The longer you go without coverage, the higher the penalties might be.
Note: If your income is below certain levels, you may qualify for a Medicare Savings Program, which would pay your Part B premium, and the Low Income Subsidy (LIS), which would pay your Part D premium. Look into these before you opt out of any parts of Medicare.
The bottom line: Don’t opt out of any Medicare coverage without carefully researching your options. If you decline Part B, you cannot sign up for Medicare Advantage either. If you have any questions, contact the Health Insurance Counseling & Advocacy Program (HICAP).
Do You Also Have Medi-Cal Coverage?
People who qualify for both Medicare and Medi-Cal coverage are called “dual eligibles.” Most dual eligibles do not have to pay Medicare premiums, because either Medi-Cal (or Medi-Cal's Working Disabled Program) pays them or because the person also qualifies for a Medicare Savings Program. Medi-Cal, including Medi-Cal's Working Disabled Program, may also help pay for Medicare co-insurance and deductibles, as well as some services Medicare doesn’t cover. That’s why you shouldn’t decline Medicare Parts B or D if you also qualify for Medi-Cal.
If you qualify for both Medicare and Medi-Cal, there are different ways to get your medical coverage:
- You can have separate Original Medicare and Medi-Cal coverage. This gives you more flexibility to choose your medical providers, but some may not accept Medi-Cal or Medicare as payment, which could mean you have to pay more.
- You can have a Medicare Advantage plan with separate Medi-Cal coverage. This can be a problem if you have a Medi-Cal managed care plan with a different provider network than your Medicare Advantage network.
- You can have a Medicare Advantage plan that is integrated with Medi-Cal coverage. These are called Dual Special Needs Plans (D-SNPs) or Medi-Medi Plans. With a D-SNP or Medi-Medi Plan, there’s less paperwork (you only have one insurance card) and you don’t have to worry so much about which of your benefits pays for which medical services.
The bottom line: If you like your Medi-Cal managed care program, signing up for its D-SNP or Medi-Medi Plan could make it easier for you to deal with your combined health coverage and may let you get additional benefits that Medicare doesn’t usually offer, such as dental, vision, and hearing aid coverage. However, if you want more flexibility than a managed care program, look into Original Medicare.
If you have more than one type of coverage, including Medi-Cal, employer-sponsored coverage, Veterans (VA) health benefits, military (TRICARE) benefits, or any other health coverage, one coverage may pay for costs that your other coverage doesn't pay for, meaning you have to pay less out of your own pocket. If you are in this situation, make sure you understand how Medicare interacts with other types of coverage.
Is Medicare Your Only Health Coverage?
If you do not have any private health insurance, don’t qualify for Medi-Cal, and don’t have any other medical coverage besides Medicare, then you need to make sure that your Medicare coverage will be enough for all of your health needs.
If Medicare is your only health coverage:
- Do not decline Parts B and D. They provide coverage you need, since you don’t have any other insurance that will pay for those medical expenses. Furthermore, if you turn them down, you have to pay a penalty if you want them later.
- See whether you would prefer a Medicare Advantage plan. Medicare Advantage plans have to offer at least the benefits that Original Medicare offers, but some Medicare Advantage plans might also offer coverage for things that Original Medicare doesn’t cover. Use the Medicare Plan Finder to see if there’s a Medicare Advantage plan that meets your needs.
- If you don’t want Medicare Advantage and are 65 or older, think about a Medigap policy (Medicare Supplement Insurance). If you are a senior and get Original Medicare, you can pay an extra monthly premium to get a private Medigap policy that covers some of the expenses that Medicare Parts A and B won’t cover, such as co-insurance, copayments, and deductibles. The California Health Advocates' website has an excellent description of Medigap in California. Learn more about Medigap policies or find one in your area.
The bottom line: If you don’t have other coverage, make sure that your Medicare coverage meets your needs.
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Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
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What It Covers
If you get Medicare coverage, it helps with many different types of medical expenses. The exact coverage you have depends on:
- Whether you have a Medicare Advantage plan or Original Medicare
- If you have Medicare Advantage, which plan you have
- If you have Original Medicare, whether you have Part B and Part D, and, if so, which Part D plan you have
What Full Medicare Coverage Usually Offers
This list presents many of the medical expenses that Original Medicare Parts A and B help pay for. Medicare Advantage plans also pay for all of these services, but some plans also pay for more services not listed here. For all of these, you may have to pay copayments, co-insurance, or a deductible. Learn more about what Medicare costs and how to get help paying for it.
Part A and Medicare Advantage plans both cover hospitalization expenses, including:
- Medical care when you are admitted to the hospital
- Hospital stays
- Short-term stays in a skilled nursing facility
- Hospice care
Part B and Medicare Advantage plans both cover outpatient expenses, including:
- Medical care when you are not in the hospital
- Preventive screenings and services, including an annual checkup and some vaccines
- Lab tests, such as X-rays, MRIs, and blood tests
- Home health care
- Emergency services, including ambulance transit and emergency room treatment
- Medical and surgical services and supplies
- Mental health care
- Urgent care
- Doctor and practitioner services
- Rehabilitation, such as physical therapy or speech therapy
- Supplies and equipment, such as prosthetics, orthotics, diabetes supplies, or wheelchairs
- In some situations, other things like chiropractic services, eye exams, eyeglasses, diabetes management, hearing and balance exams, and injectable cancer or immunosuppressive drugs.
Part D and Medicare Advantage plans that include drug coverage pay for prescription drugs on a plan’s formulary. Formularies are reviewed by Medicare and must cover certain types of medications.
Get more information about what Medicare covers:
- For Original Medicare, read Medicare & You or download Medicare's "What's Covered" app from Google Play or the Apple App Store.
- For Part D, a Medigap policy, or Medicare Advantage, contact your private insurance company.
- See Medicare.gov’s list of services that Original Medicare doesn’t cover, such as dental care, eye exams, hearing aids, cosmetic surgery, and acupuncture.
Long-term care includes help with things like bathing, getting dressed, and using the bathroom. You might get this help in your home, elsewhere in the community, or at a skilled nursing facility. If you have low income and low resources, Medi-Cal may help pay for these costs.
If you need long-term care and have Medicare, you can:
- Read Medicare.gov’s introduction to long-term care.
- Visit LongTermCare.gov to get an introduction to long-term care issues and decisions.
- Contact the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222 with questions about how Medicare covers your long-term needs.
- Check out the California Health Advocates website, which has an excellent section on long-term care.
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Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
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What You Pay
Medicare doesn’t pay for all of your medical expenses. You may have to pay:
- Premiums, monthly payments you must make whether or not you use any medical services. Medicare premiums may be deducted directly from your Social Security Disability Insurance (SSDI) or Social Security retirement benefits.
- Copayments, a set amount you have to pay for a medical visit or service. The amount depends on the service.
- Co-insurance, a set percentage of the cost of a visit or service that you must pay.
- A deductible, a set amount of money that you pay out of your own pocket each year before Medicare begins to pay for certain services. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
The exact amounts you have to pay vary:
- With Medicare Advantage, you need to make sure you understand your plan, because each plan is different. All Medicare Advantage plans have an out-of-pocket maximum of at most $8,300 for covered services and treatment, not including prescription drugs.
- With Original Medicare, the costs are more standardized for Parts A and B, though if you have a Part D plan or Medigap policy (Medicare Supplement Insurance), costs may vary. Original Medicare does not have an out-of-pocket maximum. Learn more about Original Medicare expenses.
Help Paying for Medicare
Regardless of whether you have Original Medicare or Medicare Advantage, you may qualify for help paying for Medicare. There are two main types of help: Medicare Savings Programs (MSPs) and the Low Income Subsidy (LIS) for prescription drug coverage.
Note: If you have both Medi-Cal (or Medi-Cal's Working Disabled Program) and Medicare coverage, they may pay your Part B premium and you may be automatically signed up for an MSP and the LIS. You can check on this with your county social services agency or by calling the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
Medicare Savings Programs (MSPs)
An MSP may help you pay Medicare premiums and other expenses, such as copayments, co-insurance, and deductibles, if you:
- Have countable income at or below 135% of FPG ($1,641 per month, $2,219 for couples); and
-
Have resources at or below the limit ($130,000 for individuals, $195,000 for couples)
- Note: Beginning January 1, 2024, there will no longer be any resource limit for MSPs
If you qualify, an MSP may help with Parts A and B of Original Medicare, or with any Medicare Advantage plan.
The three main Medicare Savings Programs help in different ways. Generally speaking, the less income you have, the more they help:
-
The Qualified Medicare Beneficiary (QMB) program helps people with countable income that’s 100% of FPG or less ($1,215 per month or less if you live alone).
- If you have Original Medicare, QMB helps pay for your Part B and Part A premiums, copayments, and deductibles.
- If you have a Medicare Advantage plan, QMB helps pay your premium, copayments, and deductibles.
- Note: If you qualify for QMB, you also qualify for Medi-Cal coverage.
-
The Specified Low-Income Beneficiary (SLMB) program helps people with countable income that’s more than 100% of FPG, but at or below 120% of FPG ($1,458 per month or less if you live alone).
- If you have Original Medicare, SLMB helps pay for the Part B premium.
- If you have a Medicare Advantage plan, SLMB helps with the premium.
-
The Qualified Individual (QI) program helps people with countable income that’s more than 120% of FPG, but at or below 135% of FPG ($1,641 per month or less if you live alone).
- If you have Original Medicare, QI helps pay for the Part B premium.
- If you have a Medicare Advantage plan, QI helps with the premium.
Call your county Health Insurance Counseling & Advocacy Program (HICAP) office to learn more about whether you qualify for a Medicare Savings Program. If you do, they'll explain how to apply at your local county social services agency.
Many people who qualify for an MSP or the LIS never apply. You should apply, even if you think you don’t qualify, because MSPs and the LIS only look at your countable income, which may be a lot lower than you realize. For example, they count less than half of your earned income. If you have any questions, call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
Low Income Subsidy (LIS)/Extra Help for Prescription Drug Coverage
The Low Income Subsidy, often called Extra Help, may help you with Medicare prescription drug expenses, such as copayments and deductibles, if:
- Your countable income is $21,870 per year or less if you live alone ($29,580 or less for couples), and
- You have less than $15,160 in resources if you are single (the limits are higher for larger households).
The LIS helps with Part D plan expenses or helps pay for Medicare Advantage plans that include prescription drug coverage, sometimes called MA-PD plans.
The LIS has two levels and will help you more if your income and resources are lower:
-
The full subsidy is for people who also get Medi-Cal coverage or who are in a Medicare Savings Program. You may also qualify if your countable income is less than $19,683 per year and your resources are less than $9,090 if you are single (the limits are higher for larger households).
- If you have Original Medicare and a Part D benchmark plan, you don’t have to pay a Part D premium or deductible, and there may be lower copayments.
- If you have a Medicare Advantage plan that includes prescription drug coverage, it helps with your premium and deductible, and there may be lower copayments. The exact amount it helps depends on your plan.
-
The partial subsidy is for people who can’t get the full subsidy, but have less than $21,870 in annual countable income and less than $15,160 in resources if you are single (the limits are higher for larger households).
- If you have Original Medicare and a Part D benchmark plan, you pay 0%, 25%, 50%, or 75% of the Part D premium, depending on your income, and only have to pay a $104 deductible before you get help paying for drugs. You do have to pay co-insurance and copayments for your medications, but they are lower than without the partial subsidy.
- If you have a Medicare Advantage plan that includes prescription drug coverage, the partial LIS helps with your premium and deductible, and there may be lower copayments, but it doesn’t help as much as the full subsidy. The exact amount the partial LIS helps depends on your plan and your income.
You can apply for the Low Income Subsidy online or at your local Social Security office.
If you don’t qualify for an MSP or the LIS and you want to save money, you still have options:
- If you have Original Medicare with a Part D plan, you may be able to find a better Part D plan for the medications you take.
- If you have Medicare Advantage, you may be able to find a more affordable plan.
- If you have a Medicare supplement (Medigap) policy you can see if there’s a less expensive option.
Over the next few years, some Medicare Part D prescription drug costs will go down thanks to the Inflation Reduction Act (signed into law in August 2022):
- You don’t have to pay for any vaccine covered by Medicare Part D (no deductible, co-pay, or other charge) starting on January 1, 2023.
- Insulin can’t cost you more than $35 a month starting on January 1, 2023. If you use a traditional pump, your insulin will be covered starting July 1, 2023.
- The cost of covered drugs may go up more slowly, because drug companies will have to pay rebates to Medicare if their prices rise faster than inflation.
Learn more about these and other changes coming in later years.
How Work Affects Your Medicare Costs
If you currently qualify for an MSP or the LIS, money you make at work might cause your MSP or LIS eligibility to change or end. However, they count less than half of your earned income, so getting a job does not always mean that you lose the help you get.
The other way work could affect Medicare is if you get SSDI, because your Medicare coverage is based on your SSDI eligibility. However, even if you stop getting SSDI, you may be able to keep your Medicare coverage:
- With SSDI, you can try out working without losing your SSDI or Medicare benefits. First, you go through a Trial Work Period. Once you use nine Trial Work months, your Trial Work Period is over. Get more detailed information about the Trial Work Period on DB101’s SSDI and Work page.
- After your Trial Work Period ends, you still get at least 93 more months (7 years and 9 months) of Medicare coverage at the regular cost, as long as Social Security finds that you still have a medical disability.
-
After the 93 months are over, you may still be able to get Medicare at the regular cost through the Qualified Disabled Working Individual (QDWI) Medicare Savings Program, if your countable income is 200% of FPG or less ($2,430 per month or less if you live alone) and you have less than $130,000 in resources if you live alone ($195,000 if you live with someone).
- With Original Medicare, QDWI helps pay for the Part A premium that you otherwise would have to pay. With Medicare Advantage, it also helps with the premium.
- If your income is higher, you may need to pay a higher premium for Medicare, but you still keep your coverage. With Original Medicare, the Part A premium is up to $506 per month. With a Medicare Advantage plan, your premium may go up a similar amount.
- You can apply for an MSP at your county social services agency.
Note: If you get Medicare and are 65 years old or older, you keep your Medicare eligibility, no matter how much you earn. However, as your earnings go up, you may need to start paying higher premiums.
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Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
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How to Sign Up
What you have to do to sign up for Medicare depends on how you qualify and whether you want Original Medicare or a Medicare Advantage plan.
Original Medicare is automatic for some people, but not others, while anybody who wants Medicare Advantage has to sign up. And, even if you get Original Medicare automatically, you still need to sign up for a Part D plan.
You should also think about applying for a Medicare Savings Program and the Low Income Subsidy (LIS) — many people lose out on this help because they never bother to apply.
If you need help, call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222 or Medicare at 1-800-772-1213 or 1-800-325-0778 (TTY).
Signing Up for Original Medicare
Some people automatically start getting Original Medicare coverage without having to sign up. This includes anybody who:
- Gets Social Security Disability Insurance (SSDI) or CDB benefits for two years (24 months)
- Turns 65 and already gets Social Security retirement benefits, or
- Has ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s Disease).
If you are in one of these situations, you get a notice in the mail three to four months before your Medicare is supposed to start. The notice will tell you:
-
The exact date your automatic Original Medicare Part A and Part B coverage starts
- You don’t have to pay a premium for Part A
- You probably have to pay a $164.90 monthly premium for Part B. It might be a bit less, depending on your situation.
- How to decline Part B, if you have employer-sponsored coverage and don’t want to pay the premium for Part B
- How to sign up for Part D prescription drug coverage, and
- How to switch to a Medicare Advantage plan instead of Original Medicare.
If you do not automatically start getting Medicare benefits, you can sign up for Original Medicare Parts A and B:
- Online at the Social Security website, or
- At the local Social Security office or by calling Social Security at 1-800-772-1213 or 1-800-325-0778 (TTY).
Learn more about signing up for Original Medicare.
If you decline Part B coverage:
- You can usually only sign up again between January 1 and March 31 of each year, which is called the General Enrollment Period, and your Medicare Part B coverage begins on July 1 of that year.
-
If you lose employer-sponsored coverage, you can sign up for Part B outside of the general enrollment period. You have eight months to sign up, starting with the month when the job ends (or when you lose your coverage). If you sign up during those eight months, you don’t have to pay monthly penalties.
- Note: If you also decline Part D and then you lose your employer-sponsored coverage, you only have two months to sign up for Part D without paying monthly penalties.
Signing Up for Private Plans: Part D, Medigap, and Medicare Advantage
If you have government-run Original Medicare, you have the options of also getting a privately managed Part D prescription drug policy and, if you are 65 or older, a privately run Medigap policy (Medicare Supplement Insurance).
Or, you may decide that you want a privately run Medicare Advantage plan that includes all the benefits you need. Note: Most Medicare Advantage plans include prescription drug coverage, but some allow you to sign up for a separate Part D plan instead.
For all of these types of privately managed Medicare benefits, the signup process is basically the same:
- You decide which types of plans you want to sign up for.
-
You research the private plans you are looking at:
- Compare Medicare Advantage Plans or Part D plans
- Compare Medigap plans (only if you are 65 or older)
-
You sign up:
- On Medicare.gov
- By calling Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY)
- By calling the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222
- By completing a paper application with the plan, or
- By contacting the plan directly.
When to Sign Up for Part D or Medicare Advantage Plans
When you should sign up for a Part D or Medicare Advantage plan (or switch from Medicare Advantage back to Original Medicare) depends on your situation:
-
You can sign up, switch, or drop plans at any time if you:
- Get both Medicare and Medi-Cal (or Medi-Cal's Working Disabled Program) benefits
- Get help from a Medicare Savings Program
- Qualify for the Part D Low Income Subsidy (Extra Help)
- Move into or leave a skilled nursing facility, or
- In certain other situations, like if you move outside of your plan’s service area.
- If your Medicare coverage is just starting, you can sign up anytime during the three months before and after your Medicare coverage starts. This is called the initial enrollment period.
- You can add, drop, or switch plans every October 15 - December 7. This is called the annual election period. Any changes you make start on January 1 of the following year. Note: If you want to switch from Medicare Advantage to Original Medicare with Part D, you can do so until February 14.
Medigap enrollment works differently than other private Medicare plans. You have to be at least 65 years old and if you don’t sign up during Medigap’s six-month open enrollment period after turning 65, they are allowed to deny you coverage or charge you more based on pre-existing conditions.
Learn more about Medigap enrollment or call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222 to get live help.
Applying for Help to Pay for Medicare
Regardless of whether you have Original Medicare or Medicare Advantage, you can apply for help to pay for your Medicare coverage:
- You can apply for a Medicare Savings Program online using BenefitsCal or complete the paper MSP application and submit it to your county social services agency.
- You can apply for the Low Income Subsidy online or at your local Social Security office.
Note: If you have Medi-Cal coverage as well as Medicare, you may already be getting help from an MSP and the LIS automatically.
Learn more about MSPs and the LIS. If you want to talk with someone about them, call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
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Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
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Example
Robert’s Story
Robert is 38 years old and became paraplegic after a diving accident a couple of years ago. He’s been getting Social Security Disability Insurance (SSDI) benefits for the last 18 months and private health coverage through Covered California, because he gets too much in SSDI to qualify for Medi-Cal health coverage.
However, Robert knows that he gets Medicare soon, once he’s been on SSDI for two years, and he’s starting to plan for that. This is a big deal, because once his Medicare coverage starts, he wants to stop his expensive private insurance.
Comparing Original Medicare with Medicare Advantage
As Robert starts looking into Medicare, he realizes that he has to choose between Original Medicare or a Medicare Advantage plan. If he does nothing, he’s automatically signed up for Original Medicare Part A and Part B, but he isn’t sure that’s what he wants.
Robert gets online and learns that with Original Medicare, he can choose from more doctors and see specialists when he wants to. He calls up his current medical providers and they all confirm that they accept Original Medicare. He also learns that he doesn’t have to pay a monthly premium for Part A, but he has to pay $164.90 each month for Part B.
The Medicare Advantage plans he looks at limit him to choosing his doctors from specific networks and require him to see a primary care physician before seeing specialists. However, most of the plans he looks at have lower copayments than Original Medicare and an out-of-pocket maximum, meaning that beyond the premium, he never has to pay more than $8,300 in a year for medical care. Furthermore, Medicare Advantage seems a little simpler, since it’s one unified plan, instead of multiple parts. For some Medicare Advantage plans, he has to pay $164.90 per month, the same as with Original Medicare Part B, while for other plans he has to pay higher premiums. After doing some math, he figures that overall, most Medicare Advantage plans are a bit cheaper than Original Medicare.
After exploring the pros and cons of Original Medicare and Medicare Advantage, Robert decides to stick with Original Medicare, because it’s more like his current private health coverage, a PPO that lets him see specialists at various different medical facilities. Even if Original Medicare ends up costing him a little more, it’s worth it to him because he can see the same doctors he has been visiting ever since his accident.
Since he wants Original Medicare, Robert doesn’t have to worry about signing up: Original Medicare coverage starts automatically after he’s been getting SSDI for two years.
Prescription Drug Coverage
However, Robert has to sign up for a separate Part D prescription drug plan, because Original Medicare Parts A and B don’t cover prescriptions and, unlike Parts A and B, Part D coverage doesn’t start automatically.
Robert reads up on Part D and learns that all Part D plans are privately run, but they must follow some basic rules set by the government. Robert has to pay a monthly premium for his coverage, an annual deductible, and copayments or co-insurance for his medications.
Robert takes four different medications and he knows they aren’t cheap, so he starts to worry, until a friend tells him that some companies may offer better Part D plans for Robert’s needs. Robert checks the Medicare Plan Finder and finds a few Part D plans that sound good to him. He chooses one that isn’t too expensive and that covers the prescription drugs he needs.
Learning about WDP
Robert enrolls in Part D and is happy with his overall Medicare coverage, because it is pretty comprehensive and costs less than his old private insurance. Even so, he wishes it were cheaper. After a few months, he calls up the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222 to see if there’s any way for him to save some money.
They tell him that if he also qualifies for Medi-Cal health coverage or for a Medicare Savings Program, his total medical expenses go down. However, Robert knows he doesn’t qualify for those because his SSDI payments are too high. That’s when the HICAP counselor tells him about a special program called Medi-Cal's Working Disabled Program.
Robert qualifies for WDP if he starts working, because WDP has a higher income limit than standard Medi-Cal. And, it even pays his Medicare Part B premium and some of his Medicare co-insurance and deductibles!
Robert wants to go back to work part-time in the future, so he makes a note to himself that when he starts working, he’ll call his county social services agency about it.
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Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
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Frequently Asked Questions
How do I become eligible for Medicare?

If you or your spouse works enough time while paying Medicare taxes, you qualify for Medicare:
- When you turn 65
- After you get Social Security Disability Insurance (SSDI) benefits for two years, or
- If you have Lou Gehrig’s disease (amyotrophic lateral sclerosis, or ALS) or end-stage kidney disease (ESRD).
If your disability starts before you are 22 years old, you start getting Medicare if you get Childhood Disability Benefits (CDB) benefits for two years based on a parent’s work record.
Where can I sign up for Medicare?

You automatically get Original Medicare coverage if you get SSDI for two years or start getting Social Security retirement benefits before you turn 65. Otherwise, you may need to sign up.
If you have government-run Original Medicare, you have the options of also getting a privately managed Part D prescription drug policy and, if you are 65 or older, a privately run Medicare supplement policy (Medigap).
Or, you may decide that you want a privately run Medicare Advantage plan that includes all the benefits you need. Note: Most Medicare Advantage plans include prescription drug coverage, but some allow you to sign up for a separate Part D plan instead.
For all of these types of privately managed Medicare benefits, the signup process is basically the same:
- You decide which types of plans you want to sign up for.
- You research the private plans you are looking at. One way of comparing plans is by using the Medicare Plan Finder.
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You sign up:
- On Medicare.gov
- By calling Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY)
- By calling the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222
- By completing a paper application with the plan, or
- By contacting the plan directly.
Whom should I contact if I need help understanding Medicare?

For more help in understanding Medicare, you can:
- Call Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY), or
- Call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
How many parts does Medicare have?

Original Medicare has three main parts:
- Part A helps pay for medical care you get while you’re admitted in a hospital.
- Part B helps pay for outpatient medical care.
- Part D helps pay for prescription drugs.
Medicare Advantage is a way to get a single combined plan including Parts A, B, and D through a private company. With Medicare Advantage plans, you may have less flexibility, but your costs could be lower.
Should I get Original Medicare or Medicare Advantage?

Whether Original Medicare or Medicare Advantage is right for you depends on your situation and preferences. There is no answer that is right for everyone. In California, 48% of Medicare beneficiaries choose Original Medicare and 52% choose Medicare Advantage.
Learn more about the reasons one or the other might be right for you.
Will Medicare pay for all of my medical expenses?

No. Medicare only helps pay for care that it considers reasonable and necessary. If you need a service that Medicare doesn’t cover, you have to pay for it yourself, unless you have other coverage, such as Medi-Cal or employer-sponsored coverage.
For some services, you pay a deductible, copayment, or co-insurance before Medicare begins to help pay for that service. For Medicare Part B or Part D, or for Medicare Advantage, you may have to pay a monthly premium, unless you qualify to get help paying for your Medicare premiums, copayments, and deductibles through Medi-Cal, Medi-Cal's Working Disabled Program, a Medicare Savings Program, or the Low Income Subsidy (LIS).
How can I get help paying for Medicare?

Regardless of whether you have Original Medicare or Medicare Advantage, you may qualify for help paying for Medicare. There are two main types of help:
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Medicare Savings Programs (MSPs) help people with low income and low resources pay Medicare premiums. Depending on the MSP, it may also help with other expenses, such as copayments, co-insurance, and deductibles.
- For people with Original Medicare, MSPs can help with Parts A and B.
- MSPs can help with any Medicare Advantage plan.
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The Low Income Subsidy (LIS), also known as Extra Help, helps pay premiums, copayments, co-insurance, and deductibles for prescription drug coverage.
- For people with Original Medicare, the LIS can help with Part D plan expenses.
- The LIS can help with Medicare Advantage plans that include prescription drug coverage, sometimes call MA-PD plans.
Note: If you have both Medi-Cal (or Medi-Cal's Working Disabled Program) and Medicare coverage, your Medi-Cal coverage may also help pay for your Medicare expenses or you may automatically get help from an MSP and the LIS.
If you have any questions about Medicare Savings Programs and the LIS, call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222
Learn more about getting help paying for Medicare and how to apply for it.
What is a Medigap policy (Medicare Supplement Insurance)?

A Medigap policy (also called Medicare Supplement Insurance) is a private plan that helps cover some Original Medicare expenses, such as copayments and deductibles. In California, you cannot sign up for a Medigap policy if you are less than 65 years old.
Medicare.gov lists the most common levels of Medigap plan and what benefits they provide.
Should I opt out of Part B coverage?

You should only opt out of Part B coverage if you both:
- Have an employer-sponsored insurance policy and your employer or insurer says it's safe for you to opt out of Part B, and
- Do not qualify for Medi-Cal, WDP, or a Medicare Savings Program.
If you opt out of Part B coverage, you may have to pay monthly penalties if you want Part B later. If you qualify for Medi-Cal or an MSP, they help pay for your Part B expenses and you are better off overall with Part B.
Should I sign up for Part D coverage?

If you have Original Medicare, you should sign up for Part D unless you both:
- Have creditable coverage that pays for your medications, and
- Do not qualify for Medi-Cal or the Low Income Subsidy (Extra Help).
If you do not have creditable coverage, you have to pay a monthly penalty if you want Part D later. If you qualify for Medi-Cal or the Low Income Subsidy, they help pay your Part D costs and you are better off overall with Part D.
Note: If you have Medicare Advantage, it may already include prescription drug coverage. Check with your plan. (The LIS also helps pay for Medicare Advantage plans that cover prescription drugs.)
Can I be on Medicare and another form of health coverage at the same time?

Yes. Other types of coverage that you can have with Medicare include:
- Medi-Cal
- Medi-Cal's Working Disabled Program
- Employer-sponsored coverage
- Continued coverage from a former employer through COBRA
- Retirement plans
- Veterans (VA) benefits
- Military (TriCare for Life) benefits, or
- Individual health insurance.
Learn more about how Medicare interacts with other types of coverage.
Does Medicare pay for long-term care coverage?

No, Medicare does not generally pay for long-term care. Medi-Cal may help pay for some of these costs.
Learn more
Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
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Common Pitfalls
Not understanding the expenses involved with Medicare
When making decisions about Medicare, make sure you understand its costs, which can include:
- Premiums, a monthly amount that has to be paid whether or not you use medical services. Medicare premiums may be deducted directly from your Social Security Disability Insurance (SSDI) or Social Security retirement benefits.
- Copayments, a set amount you have to pay for a medical visit or service. The exact amount of the copayment depends on the service you get: Medications, visits to specialists, lab tests, X-rays, emergency room visits, and other services can all have different copayment amounts.
- Co-insurance, a set percentage of the cost of a visit or service that you must pay.
- A deductible, a set amount of money that you pay out of your own pocket each year before Medicare begins to pay for certain expenses. Once you have paid the deductible, you do not have to pay it again until the next calendar year.
Opting out of Part B and Part D without checking if you'll have to pay penalties later
For most people who get Original Medicare, Part B has a $164.90 monthly premium (it could be a bit less; the amount depends on your situation) and Part D prescription drug coverage also has a premium (the amount depends on the Part D plan).
You may want to opt out of Part B and Part D to save money on monthly premiums, especially if you have other coverage and don’t think you need the sorts of medical services and prescription drugs they cover. However, if you decide you don’t want Parts B and D and you change your mind later, you might have to pay large penalties.
You should only think about opting out of Part B or D if you have other coverage that covers the same types of things that Parts B and D cover:
- For Part B, that means you should have an employer-sponsored insurance policy. If you do, make sure to check with your employer or insurer whether it's safe for you to opt out of Part B.
- For Part D, that means you should have creditable coverage. Creditable coverage means that your prescription drug coverage is as good as Part D. Not all plans are considered creditable by Medicare; you have to check with the plan administrator.
Even if you have other coverage, it might still make sense to keep Parts B and D if you also qualify for Medi-Cal, Medi-Cal's Working Disabled Program, a Medicare Savings Program, or the Part D Low Income Subsidy (also called Extra Help). They may help you pay for Part B and Part D and so your overall coverage is better.
Not applying for a Medicare Savings Program and the Low Income Subsidy (Extra Help)
Medicare Savings Programs (MSPs) help people with low income and low resources pay Medicare premiums. Depending on the MSP, it may also help with other expenses, such as copayments, co-insurance, and deductibles.
- For people with Original Medicare, MSPs can help with Parts A and B.
- MSPs can help with any Medicare Advantage plan.
The Low Income Subsidy (LIS), often called Extra Help, helps people with low income and low resources pay premiums, copayments, co-insurance, and deductibles for Medicare prescription drug coverage:
- For people with Original Medicare, the LIS can help with Part D plan expenses.
- The LIS can help with Medicare Advantage plans that include prescription drug coverage, sometimes called MA-PD plans.
You may qualify for an MSP or the Low Income subsidy and not know. Many people who qualify for them never apply. Even if you think you won’t qualify, make sure to apply! They can be a big help. Note: If you have both Medi-Cal and Medicare coverage, you may automatically get help from an MSP and the LIS.
If you have any questions about Medicare Savings Programs and the LIS, call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222.
Learn more about getting help paying for Medicare and how to apply for it.
Not seeing how your other health coverage interacts with Medicare
If you have more than one type of coverage, one coverage may pay for costs that your other coverage doesn't pay for, meaning you have to pay less out of your own pocket.
Other types of coverage that you can have with Medicare include:
- Medi-Cal
- Medi-Cal's Working Disabled Program
- Employer-sponsored coverage
- Continued coverage from a former employer through COBRA
- Retirement plans
- Veterans (VA) benefits
- Military (TriCare for Life) benefits, or
- Individual health insurance.
Learn more about how Medicare interacts with other types of coverage.
Learn more
Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.
Try It
Next Steps
Learn more about Medicare
- Visit Medicare.gov.
- Use the Medicare Plan Finder to compare Part D and Medicare Advantage plans.
- See how Medicare interacts with private health coverage in How Medicare works with other insurance.
- Read Medicare & You, Medicare’s official handbook, which explains benefits, costs, services, health plans, and prescription drug plans.
- Call Medicare at 1-800-633-4227 or 1-877-486-2048 (TTY). The line is open 24 hours a day, 7 days a week.
- Call the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222. They have offices in every California county.
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California Health Advocates has information on all aspects of Medicare, including a specific section on Medicare for people with disabilities.
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The Health Consumer Alliance has brochures in 18 languages on Medicare, Medi-Cal, and other health care topics.
Getting Help with Your Benefits
If you get Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Childhood Disability Benefits (CDB), and you're looking for a job, a trained Benefits Planner can help you avoid problems with your job plan. If you need help or have questions about your situation, you can call the Ticket to Work Help Line at 1-866-968-7842 or 1-866-833-2967 (TTY), Monday through Friday.
View DB101's full list of experts who can help you understand different benefits.
Community-Based Organizations
Various community-based organizations guide people through state, federal, public, and private health and income programs. Some organizations may work with specific populations while others work with people with any type of disability. Here are a few examples
Goodwill Industries services range from personal evaluation and office skills training to career counseling, childcare, and transportation. Some Goodwill Industries centers also do benefits planning for people who get SSI, SSDI, and Medicare. Find locations at www.Goodwill.org, or by calling (voice) 1-800-466-3945.
The California Foundation for Independent Living Centers lists centers serving people with all disabilities. Many of these centers do benefits planning for people who get SSI, SSDI, and Medicare. If they don't offer benefits planning themselves, Independent Living Centers can refer you to local benefits planners. Find the list of independent living centers at www.CFILC.org, or by calling (voice) 1-916-325-1690 or (TTY) 1-916-325-1695.
The California Department of Public Health's Office of AIDS lists 1,300 organizations offering HIV/AIDS services throughout California. Some of these organizations provide case management, benefits planning, and benefits counseling services that can include help with public and private benefits programs. You can search the list online, or call (voice) 1-800-367-AIDS (2437) or (TTY) 1-888-225-AIDS (2437).
Disability Rights California provides representation for consumers of public programs who are disabled. Website publications include topics on health care, benefit programs, and In-Home Supportive Services.
Learn more
Social Security Disability Insurance (SSDI)
SSDI helps people with disabilities who worked and paid Social Security taxes.
Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Benefits and Work Estimator
Got a work plan? See how it would help your situation.