Medicare FAQ — Medicare 65 California

Question 1

What is Medicare and who is eligible?

Accepted Answer

Medicare is the federal health insurance program primarily for people 65 and older. You're eligible if you're a U.S. citizen or permanent legal resident who has lived in the U.S. for at least 5 years. You may also qualify under 65 if you have certain disabilities or end-stage renal disease (ESRD).

Question 2

Do I automatically get Medicare when I turn 65?

Accepted Answer

It depends. If you're already receiving Social Security or Railroad Retirement Board benefits, you'll be automatically enrolled in Part A and Part B and receive your Medicare card about 3 months before your 65th birthday. If you're not yet receiving those benefits, you need to actively sign up through Social Security — online at ssa.gov, by phone, or in person.

Question 3

What's the difference between Original Medicare and Medicare Advantage?

Accepted Answer

Original Medicare (Parts A and B) is the traditional government-run program. You can see any doctor or hospital that accepts Medicare nationwide, but you pay 20% of most costs with no out-of-pocket maximum. Medicare Advantage (Part C) is offered by private insurers — it bundles Parts A and B (usually with Part D drug coverage) into one plan, often with extra benefits like dental and vision, but typically limits you to a network of providers. In 2026, the Medicare Advantage out-of-pocket maximum for in-network services is $9,350.

Question 4

What does Medicare NOT cover?

Accepted Answer

Original Medicare does not cover most dental care, routine vision exams and glasses, hearing aids, long-term custodial care (nursing home), or care received outside the U.S. Some Medicare Advantage plans do cover dental, vision, and hearing. For long-term care, you'd need separate long-term care insurance or Medi-Cal if you qualify.

Question 5

When should I sign up for Medicare?

Accepted Answer

Your Initial Enrollment Period (IEP) is a 7-month window: 3 months before your 65th birthday month, your birthday month itself, and 3 months after. For the earliest possible coverage start date, enroll in the 3 months before your birthday month. If you're still working and covered by an employer plan, you may be able to delay without penalty — but rules are specific, so verify before assuming.

Question 6

Can I delay Medicare if I'm still working?

Accepted Answer

Yes — if you (or your spouse) are actively employed and covered by an employer group health plan, you can delay Part B without penalty. You'll have a Special Enrollment Period (SEP) that lasts 8 months after your employment or employer coverage ends. Important: COBRA and retiree coverage do NOT count as employer coverage for this purpose. Once those begin, your SEP clock starts.

Question 7

What happens if I miss my enrollment window?

Accepted Answer

If you miss your Initial Enrollment Period and don't qualify for a Special Enrollment Period, you'll have to wait for the General Enrollment Period (January 1 – March 31 each year). Coverage begins the first day of the month after you enroll. You may still face permanent late enrollment penalties: 10% added to your Part B premium for each 12-month period you were eligible but didn't enroll, and 1% per month for Part D.

Question 8

Do I need to enroll in Part A if it's free?

Accepted Answer

Most people should enroll in Part A when first eligible — it's free if you have 40+ work quarters, and there's little reason to delay. The main exception: if you have a Health Savings Account (HSA) through a high-deductible employer plan, enrolling in Part A makes you ineligible to continue contributing to the HSA. In that case, you may want to delay Part A enrollment until you stop contributing.

Question 9

How much does Medicare cost in 2026?

Accepted Answer

Part A is free for most people. Part B has a standard premium of $185.00/month in 2026 (higher earners pay more via IRMAA). The Part B annual deductible is $257 in 2026. The Part A hospital deductible is $1,757 per benefit period. If you add a Medigap plan, expect $100–$300+/month depending on the plan and your age. Medicare Advantage plans often have $0 or low premiums but may have copays and network restrictions.

Question 10

What is IRMAA?

Accepted Answer

IRMAA stands for Income-Related Monthly Adjustment Amount. If your income exceeds certain thresholds, you pay a surcharge on top of the standard Part B and Part D premiums. It's based on your tax return from 2 years prior. For 2026, the surcharge kicks in for individuals with income above $106,000 (or $212,000 for married couples filing jointly). You can appeal if your income has dropped significantly since then.

Question 11

What is a Medigap plan and do I need one?

Accepted Answer

Medigap (Medicare Supplement) plans are sold by private insurers to cover the out-of-pocket costs Original Medicare doesn't pay — like the 20% coinsurance, deductibles, and hospital copays. They're standardized by letter (Plan G, Plan N, etc.) so benefits are identical across insurers; only the premium differs. If you choose Original Medicare, a Medigap plan can make your costs much more predictable. The best time to enroll is during your 6-month Medigap Open Enrollment Period, which starts when you're 65 and enrolled in Part B — during this window, insurers cannot deny you or charge more based on health.

Question 12

What is the Part D out-of-pocket cap?

Accepted Answer

Since 2025, Part D has a $2,000 annual out-of-pocket cap on covered prescription drugs. Once you reach $2,000 in out-of-pocket drug costs, you pay $0 for covered drugs for the rest of the year. This cap remains in effect for 2026. The Medicare Prescription Payment Plan also lets you spread your out-of-pocket costs across monthly payments throughout the year.

Question 13

What is HICAP and how can it help me?

Accepted Answer

HICAP (Health Insurance Counseling and Advocacy Program) is California's free Medicare counseling service. Trained volunteer counselors can help you understand your Medicare options, compare plans, review your current coverage, and navigate enrollment — all at no cost and with no sales pressure. You can find a local HICAP counselor through the California Department of Aging at aging.ca.gov/HICAP or by calling 1-800-434-0222.

Question 14

What is California's Medicare Birthday Rule?

Accepted Answer

California's Birthday Rule is a unique consumer protection that lets you switch to a Medigap plan with equal or lesser benefits during the 30 days following your birthday each year — without medical underwriting. This means you can switch to a lower-cost plan from a different insurer even if your health has changed, as long as the new plan has equal or lesser benefits than your current one. No other state offers this exact protection.

Question 15

What is Medi-Cal and how does it interact with Medicare?

Accepted Answer

Medi-Cal is California's Medicaid program for low-income residents. If you qualify for both Medicare and Medi-Cal, you're considered 'dual eligible.' California offers Dual Eligible Special Needs Plans (D-SNPs) that coordinate both programs, often with $0 premiums and minimal cost-sharing. Medi-Cal may also help pay your Medicare premiums, deductibles, and copays through Medicare Savings Programs.

Question 16

What is Extra Help and do I qualify?

Accepted Answer

Extra Help (also called the Low Income Subsidy or LIS) is a federal program that helps people with limited income and resources pay for Part D prescription drug costs. In 2026, individuals with income up to about $23,340 and limited assets may qualify. Extra Help can reduce your Part D premium to $0, lower your deductible, and cap your copays. Apply through Social Security at ssa.gov or call 1-800-772-1213.

Frequently Asked Questions

Medicare Basics

Enrollment & Timing

Costs & Coverage

California-Specific Questions

Still Have Questions? Let's Talk.