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.

The bottom line: Both Original Medicare and Medicare Advantage have advantages and are good ways to get Medicare benefits. In California, 44% of Medicare beneficiaries choose Original Medicare and 56% 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.

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.

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.

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 $9,350 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.
• With both Medicare Advantage and Original Medicare, there is a $2,000 out-of-pocket maximum for prescription drugs covered by your plan.

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 ($1,761 per month, $2,380 for couples).

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 ($1,305 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 ($1,565 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 ($1,761 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.

Your Countable Income:

Your Monthly Earned Income	$
Your Monthly Unearned Income (not including SSI)	$
Your Monthly Impairment Related Work Expenses (IRWEs)	$
	$1,305
	$20
	$65
	$967
Your Monthly Countable Income
Your Annual Countable Income
	$15,650
Federal Poverty Guideline
Your Countable Income as a Percent of FPG

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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 you are in one of these situations:

• You also get Medi-Cal coverage
• You are in a Medicare Savings Program (MSP), or
• You have countable income below $23,475 per year if you are single ($31,725 for couples) and resources less than $16,100 if you are single ($32,130 for couples). Not all of your income and resources are counted when you apply for the Low Income Subsidy. You can apply even if you don’t think you qualify.

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.

You can apply for the Low Income Subsidy online or at your local Social Security office.

Note: Before 2024, there used to be a "Partial LIS" that didn't help as much. Now, everybody who qualifies for the LIS gets the full subsidy.

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 ($2,609 per month or less if you live alone).
  • 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 $518 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.

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 $185.00 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.

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:

1. You decide which types of plans you want to sign up for.
2. 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)
3. 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:

1. 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.
2. 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.
3. 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.
4. If you're already in a Medicare Advantage plan, there is another open enrollment period from January 1 to March 31. You can switch plans or go back to Original Medicare with a separate Part D plan.

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.

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 $185.00 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 $9,350 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 $185.00 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.