FAQs - Understanding CalPERS Sponsored Medicare Health Benefits

Understanding your CalPERS health benefits and how they work in coordination with Medicare is important to make sure you receive complete health coverage. When are you eligible for Medicare? Which CalPERS Medicare health plan should you choose? How do you coordinate the benefits? These questions, and more, are often asked of us and we want to be sure you have all the information you need to make good health plan choices.

What is Medicare?

Medicare is a federal health insurance program established by Congress to help people 65 and older, some disabled people under 65 years of age, and people with End-Stage Renal Disease (kidney failure treated with dialysis or a transplant) to receive health care benefits. Medicare helps pay for some health care costs. The major difference between what you have now in CalPERS and what you'll have with Medicare has to do with how payments are made and the cost of services.

For specific details about benefits and services covered by Medicare, call (800) 633-4227, or visit Official U.S. Government Website for People with Medicare, or the Official Website of the U.S. Social Security Administration.

What is the Original Medicare Plan?

The Original Medicare Plan is a fee-for-service arrangement. This means you can go to any doctor, hospital, or other health care provider who accepts Medicare. Medicare-covered services are subject to a Medicare deductible, which is the Medicare beneficiary's responsibility. Then Medicare pays its share of the claims costs. You are responsible for the balance of the claim (coinsurance). Generally, the Medicare coinsurance and deductibles are covered by your CalPERS health benefits. Refer to the Medicare & You Handbook issued by the Centers for Medicare & Medicaid Services (CMS) for detailed facts on Medicare benefits and costs. CMS is the Official U.S. Government Site for People with Medicare.

Does Medicare cost me money?

CMS sets the premium amounts, deductibles, and coinsurance rates for the Federal Medicare health insurance program. To determine your costs for Medicare, contact the Social Security Administration at (800) 772-1213, or visit the Official U.S. Government Website for People with Medicare.

To determine your costs for enrolling in a CalPERS Medicare health plan, check out the 2009 Health Plan Rates page on our Website. If you are a Public Agency retiree, contact your employer's Benefits or Payroll Office, and if you are a State retiree, call CalPERS at 888 CalPERS (or 888-225-7377).

If you enroll in a CalPERS health plan, you will not have to pay a separate premium for Part D. You will only pay the premium for your CalPERS health plan.

If I wait and enroll in Medicare after I first become eligible and then enroll in Medicare, will it cost me more?

The Social Security Administration determines your Medicare costs. Generally, if you enroll in Medicare after you are first eligible to do so, you may pay more to enroll.

Am I eligible for Medicare?

The Social Security Administration determines eligibility for federal Medicare health insurance benefits. To find out about your eligibility based on your or your spouse's Social Security and Medicare programs work record, call your local Social Security office at (800) 772-1213, or you can view your Social Security Statement online.

Can I keep the Basic health plan I've always had?

State law specifies that if you are eligible for Medicare Part A and Part B, you cannot be enrolled in a Basic health plan. You must enroll in a Medicare health plan.

What does this mean to me?

If you are retired and/or eligible for Medicare for Part A, you must enroll in Part B and transfer to a CalPERS sponsored Medicare health benefits plan. There are few exceptions to this rule.

Exceptions to Medicare Plan Enrollment

You may remain in a Basic health plan if you:

  • Did not work in employment covered by Social Security-Medicare programs
  • Do not have enough Social Security-Medicare work credits
  • Do not quality through a current, former, or deceased spouse.
  • Are eligible for Medicare prior to January 1, 1985, but did not enroll in Medicare.
  • Are retired from the California State University system, and were eligible for Medicare prior to January 1, 2001, but did not enroll in Part B. You and your eligible dependents are not required to enroll in a Medicare health plan, but can choose to enroll.
  • Are working and are eligible for Medicare based on End-Stage Renal Disease (ESRD). Please contact CalPERS Medicare Administration Representative to discuss your specific situation.

If you voluntarily cancel your Medicare benefits, you are no longer eligible for CalPERS health coverage.

Deferred Enrollment in Medicare Part B

If you are age 65 and are working and covered by yours or your spouse's Employer Group Health Plan (EGHP); you may defer your Medicare enrollment. Contact the CalPERS Medicare Administration Representative to discuss your specific situation.

Why do I also need a CalPERS health plan?

Medicare covers many but not all of your health care costs. In addition to Medicare's monthly premium and annual deductible, there may be co-payments, and some services are not covered at all.

To reduce your Medicare out-of-pocket costs, CalPERS Medicare health plans provide coverage that supplements your Medicare benefits. Enrolling in a Medicare health plan is not automatic. After you enroll in Medicare, you must contact CalPERS to request a change from your Basic plan to a CalPERS sponsored Medicare health plan. The effective date of enrollment will be the first of the month following the date CalPERS receives the information.

How and when do I enroll in Medicare?

To find out how to enroll and when to enroll in Medicare, contact the Social Security Administration at (800) 772-1213 or visit The Official Website of the U.S. Social Security Administration.

Most retirees should enroll immediately at age 65. However, retirees under age 65 who are eligible for Medicare due to Social Security disability should enroll when they are first eligible for Medicare benefits. Do not delay or refuse your Medicare benefits. Doing so may cost you more when you enroll later after your initial eligibility, and your CalPERS basic health plan will be canceled until you enroll in Medicare.

I'm a Medicare eligible CalPERS member. What should I do to enroll in Part D?

You should not enroll in Medicare Part D Prescription Drug Plan outside of the CalPERS Health Program. If you have been automatically enrolled in a Medicare Part D plan by a non-CalPERS state or federal program or employer, you must disenroll from that plan. Do not delay your non-CalPERS Part D disenrollment or your CalPERS health plan will be canceled.

Dated: 03-16-2009