General Medicare Information

Medicare is a federal health insurance program that covers millions of Americans. This basic health insurance provision is a part of Social Security. Medicare is regulated by the Centers for Medicare and Medicaid Services (CMS), and Medicare eligibility and enrollment is overseen by the Social Security Administration (SSA). Medicare is for individuals:

  • Age 65 and older
  • Under age 65 with certain disabilities
  • With End-Stage Renal Disease (ESRD)

For retirees who don't have access to private health insurance, Medicare is a value. However, Medicare doesn't cover all medical costs.

Knowing the different parts of Medicare and how they work together will help you make the best choice. The table below is a brief summary of the different parts of Medicare:

Medicare:

Part A

Part B

Part C

Part D

Description:

Inpatient Care

Outpatient Care

Medicare Advantage Plans (MA Plans)

Prescription Drug Coverage

Examples of coverage:

Inpatient hospital care, skilled nursing facility, hospice, lab tests, surgery and home health care.

Doctor and other health care providers’ services, outpatient care, durable medical equipment, home health care and some preventive services.

MA Plans, offered through private insurance companies, cover all services of Medicare Part A and B, and most offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most are offered as PPO’s or HMO’s.

Most MA Plans include Part D coverage for your prescriptions with their own formulary, or list of covered drugs. If you decide to opt out of Part C and use traditional Medicare (Part A and B only), Part D plans can be purchased standalone.

Is there a premium?

(See below for detailed information)

Generally, no.

Yes.

Generally, yes. Varies by plan.

If paired with a MA plan, usually included with your plan premium.

Do I have to sign up for the coverage?

Generally, enrollment is automatic.

Generally, yes.

Yes.

Yes.

 

Medicare Enrollment Periods

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If you retired before you turned 65, your 7-month Initial Enrollment Period for Medicare Part A and B is:

3 months before your 65th birthday

Month of your 65th birthday

3 months following your 65th birthday

 

To sign up for Medicare during the IEP, it is advisable to contact Social Security 3 months before your 65th birthday for the smoothest transition. You may also apply for Part A and Part B online at the following link. 

When you sign up for Part A or B will determine the effective date of the coverage:

If you sign up for Medicare:

Your Part A and/or B effective date is:

1 to 3 months before your 65th birthday

The first day of your 65th birth month

Or

The first day of the month prior to your 65th birth month, if your birthday is on the first day of the month

The month you turn 65

One month following the month you sign up

1 month after you turn 65

2 months after you sign up

2 months after you turn 65

3 months after the month you sign up


 

If you do not sign up for Medicare during the Initial Enrollment Period, you can sign up for Part A and B during the General Enrollment Period between January 1 – March 31 of each year, with an effective date of July 1.

If you did not sign up for Part A or Part B during the Initial Enrollment Period and you were eligible for the coverage, the following late enrollment penalties may apply:

Part A

Part B

Your monthly premium may be 10% higher for twice the number of years you could have had Part A, but did not sign up.

Your monthly premium may be 10% higher for as long as you have Part B coverage for every 12-month period that you could have had Part B, but did not sign up for it.


 

If you did not sign up for Medicare during the Initial Enrollment Period, you may be eligible to sign up for Part A and B during the Special Enrollment Period if the following conditions are met:

  • You or your spouse are currently working.
  • You’re covered by a group health plan through an employer that is considered “active” coverage.

If you qualify for enrollment in Part A and Part B during this Special Enrollment Period, you will have 8-months to enroll, beginning (whichever event occurs first):

  • The month after you (or your spouse) retire.
  • The month after the “active” group health plan coverage ends.

For more information on Special Enrollment Periods and their exceptions, please visit the Social Security site.


Medicare Premiums

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Generally, you will not have to pay a premium for Part A if you, your spouse, former spouse or deceased spouse paid Medicare taxes while working. Typically, you can get premium-free Part A at 65 if:

  • You already get retirement benefits from Social Security or the Railroad Retirement Board.
  • You’re eligible to get Social Security or Railroad benefits but haven’t filed for them yet.
  • You or your spouse had Medicare-covered government employment.

The following is a general breakdown of premiums for Part A:

Medicare Taxes Paid

Standard Premium

Less than 30 quarters:

$437 per month

30-39 quarters:

$240 per month

40+ quarters:

$0 per month

 

For more information on Part A Premiums, please click here.


Social Security establishes a Medicare Part B premium amount annually. Each month you must pay the monthly Medicare Part B premium to Social Security to remain enrolled in Part B. If you receive Social Security benefits, the Part B premium will be deducted from your Social Security benefits. Otherwise, you will be billed quarterly by Social Security.

You will pay the following standard premiums for Medicare Part B for 2019 if you meet the following criteria:

  1. You enroll in Part B for the first time in 2019.
  2. You don’t get Social Security benefits.
  3. You’re directly billed for your Part B premiums.
  4. You have Medicare or Medicaid, and Medicaid pays for your premiums. (Your state will pay the standard premium amount of $135.50)
  5. Your modified adjusted gross income as reported on your IRS tax return from 2017 is above a certain amount. If so, you’ll pay the standard premium amount and an Income Related Monthly Adjusted Amount (IRMAA). IRMAA is an extra charge added to your premium.

Yearly income in 2017 is the following:

In 2019 you pay the following:

File individual tax return:

File joint tax return:

File married & separate tax return:

IRMAA Amount

Total monthly premium

Less than or equal to $85K

Less than or equal to $170K

Less than or equal to $85K

$0.00

$135.50

Greater than $85K and less than or equal to $107K

Greater than $170K and less than or equal to $214K

N/A

$54.10

$189.60

Greater than $107K and less than or equal to $133.5K

Greater than $214K and less than or equal to $267K

N/A

$135.40

$270.90

Greater than $133K and less than or equal to $160K

Greater than $267K and less than or equal to $320K

N/A

$216.70

$352.20

Greater than $160K and less than or equal to $500K

Greater than $320K and less than or equal to $750K

Greater than $85K and less than or equal to $415IK

$297.90

$433.40

$500K and above $750K and above $415K and above $325.00 $460.50
 

If you currently receive Social Security benefits, you will pay less than the amounts listed above ($130 on average). However, you may receive an IRMAA depending on your income from your 2017 tax return. Please contact Social Security for more information on the exact premium you will pay in 2019.

For more information on Part B premiums, please click here.


The premium you pay for Part C depends on the plan you enroll in. Plans establish the amounts they charge for premiums, deductibles and services annually. The plan you enroll in decides how much you pay for the covered services you get and the network of providers.

If your district does not offer benefits past 65 year old, CSEBO's current medical providers Anthem Blue Cross and Kaiser Permanete offer individual plans for direct purchase. Please visit their websites or contact a health benefit broker for more information.


To get Part D, you must join a Medicare Advantage (MA) Plan that includes prescription drug coverage or join a separate Medicare Prescription Drug Plan. These plans are administered by insurance companies and private companies approved by Medicare. Each plan can vary in cost and drugs covered.  

By law, MA Plan insurers must provide coverage that is equivalent to or better than the standard Part D benefit. The benefit of pairing a MA Plan with Part D coverage is these plans are able to enhance the standard Part D benefit by either or both of these means:

  • Removing the deductible.
  • Including cost shares that are different from, but are equivalent to or better than, the standard benefit.

Generally, the coverage you receive with a MA Plan paired with a Part D prescription drug plan will be richer than if you were to get a Part D plan on its own.

The standard Part D premium is typically paid through your MA Plan premium. If your income exceeds a federal threshold as determined by the SSA, you may be subject to an additional Income Related Monthly Adjustment Amount (IRMAA) for Part D prescription drug premiums. You'll either receive an invoice for the additional amount, or it will be deducted from your Social Security benefits. The chart below shows the IRMAA based on your income:

If you filed an individual tax return and your income in 2017 was:

If you were married but filed for a separate tax return and your income in 2017 was:

If you filed a joint tax return and your income in 2017 was:

This is the 2019 monthly cost of your extra Part D amount (to be paid in addition to your premium):

Less than or equal to $85K

Less than or equal to $85K

Less than or equal to $170K

Your plan premium

Greater than $85K and less than or equal to $107K

N/A

Greater than $170K and less than or equal to $214K

$12.40 + Your plan premium

Greater than $107K and less than or equal to $133.5K

N/A

Greater than $214K and less than or equal to $267K

$31.90 + Your plan premium

Greater than $133.5K and less than or equal to $160K

N/A

Greater than $267K and less than or equal to $320K

$51.40 + Your plan premium

Greater than $160K and less than or equal to $500K

Greater than $85K and less than $415K

Greater than $320K and less than or equal to $750K

$70.90 + Your plan premium

Above $500K Above $415K Above $750K $77.40 + Your plan premium

 

For more information on Part D, please visit the following link.


 

Additional Resources

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When you have other insurance (such as an employer group health coverage) paired with Medicare, who pays first varies depending on your situation. The first coverage to pay your claims is known as the primary payor, and the second coverage to pay claims is known as the secondary payor. Coordination of Benefits (COB) will vary depending on who is the primary payor and who is the secondary payor, which can sometimes affect your cost share for services.

Below is a list of common scenarios and who is the primary or secondary payor:

If you have retiree insurance (insurance from your or your spouse’s former employment):

Medicare pays first (primary payor).

If you’re 65 or older, have group health plan coverage based on you or your spouse’s current employment, and the employer has 20 or more employees:

Your group health plan pays first (primary payor).

If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has less than 20 employees:

Medicare pays first (primary payor).

If you’re under 65 and disabled, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees:

Your group health plan pays first (primary payor).

If you’re under 65 and disabled, have group health plan coverage based on your or a family member’s current employment, and the employer has less than 100 employees:

Medicare pays first (primary payor).

If you have Medicare because of End-Stage Renal Disease (ESRD):

Your group health plan will pay first (primary payor) for the first 30 months after you become eligible to enroll in Medicare. Medicare will pay first (primary payor) after this 30-month period.


Resource

Website

Phone Number

Additional Info

U.S. Medicare Site

https://www.medicare.gov/

1-800-633-4227

2017 Medicare & You

Centers for Medicare & Medicaid Services

https://www.cms.gov/

1-877-267-2323

Part B Enrollment Form

Social Security Administration

https://www.ssa.gov/medicare/

1-800-772-1213

Office Locator

MyMedicare

https://www.mymedicare.gov/

1-877-607-9663

 

Benefits Coordination & Recovery Center

Link

1-855-798-2627

 

HealthCare.gov

https://www.healthcare.gov/

1-800-318-2596

 

Health & Human Services https://www.hhs.gov/ 1-877-696-6775  
Ventura County Area Agency on Aging http://www.ventura.org/vcaaa 1-805-477-7300  
CalPERS https://www.calpers.ca.gov 1-888-225-7377  
CALSTRS www.calstrs.com 1-800-228-5453