Eligibility and Enrollment

Medicare is a federal health insurance program regulated by the Centers for Medicare and Medicaid Services (CMS). Medicare is for individuals:

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

Medicare consists of four parts, each covering specific services:

  • Medicare Part A (Hospital)
  • Medicare Part B (Medical)
  • Medicare Part C (Medicare Advantage plans)
  • Medicare Part D (Prescription drugs)

The Social Security Administration (SSA) oversees Medicare eligibility and enrollment.

The SSA has three Medicare enrollment periods:

  1. Initial Enrollment Period - When you're turning 65, you have a seven-month period to sign up for Part A and/or Part B. This Initial Enrollment Period begins three months prior to the month you turn 65, and ends three months after the month you turn 65.

    The date you sign up determines the effective date your Medicare coverage starts.

    If you sign up: Your Part A and/or Part B effective date is:
    One to three months before you turn 65 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 after the month you sign up
    One month after you turn 65 Two months after the month you sign up
    Two months after you turn 65 Three months after the month you sign up
  2. General Enrollment Period - If you're not enrolled in Medicare, you have the opportunity to sign up for Part A and/or Part B during a three-month period each year. The General Enrollment Period begins January 1 and ends March 31. Your coverage begins the following July 1.

  3. Special Enrollment Period - If you and/or your spouse are currently working and covered by an employer group health plan from that current employer, you may be eligible to sign up for Part A and/or Part B during a Special Enrollment period. Contact the SSA for more information.

Continuing CalPERS Health Coverage After Age 65

A few months before you turn 65, CalPERS will send you notifications of the requirements to continue your health coverage. The notifications request information about your eligibility or ineligibility to enroll in Medicare.

Before you turn 65, you must meet these requirements to continue your CalPERS health coverage:

  1. Apply for Medicare by contacting the Social Security Administration (SSA). If you qualify for Medicare Part A at no cost because either you or your qualified spouse worked for 40 quarters in Social Security/Medicare-covered employment, you must also enroll in Medicare Part B as soon as you're first eligible.

    When you enroll in Medicare Part A and Part B two to three months prior to your 65th birth month, CalPERS will work with the CMS to obtain your Medicare information and automatically transfer you from a CalPERS Basic (non-Medicare) health plan to a CalPERS Medicare health plan. If CalPERS is unable to obtain your Medicare information from CMS, you'll need to complete and submit the Certification of Medicare Status (PDF) form to CalPERS with copies of supporting documentation for manual processing.

  2. If you're ineligible for Medicare Part A at no cost, or if you're deferring enrollment in Medicare Part B due to current working status and covered under an employer group health plan, you must complete the Ineligibility of Medicare Certification (PDF) form.

    Submit the Ineligibility of Medicare Certification form to CalPERS with copies of supporting documentation prior to your 65th birth month to prevent cancelation of your CalPERS health coverage. You may remain in a Basic (non-Medicare) health plan if you're ineligible for Medicare.

  3. Review your CalPERS 2017 Medicare Plan Options (PDF) or 2018 Medicare Plan Options (PDF). Transitioning from a Basic (non-Medicare) health plan into a Medicare health plan is an opportunity to change health plans. Not all Basic (non-Medicare) health plans have a corresponding Medicare health plan available. You may request to change health plans when you provide your Medicare eligibility information. If you do not choose a Medicare health plan, CalPERS will automatically enroll you in a Medicare health plan.

For next steps, view the Transitioning to a Medicare Health Plan section below, and visit Medicare Plan Changes.

If CalPERS is unable to obtain your Medicare information from the CMS and cannot automatically enroll you in a CalPERS Medicare health plan, you must certify your Medicare status to continue your CalPERS health coverage.

Complete and submit the Certification of Medicare Status (PDF) form with supporting documentation certifying one of the following choices:

  • Enrolled in Medicare Part A and Part B (Submit a copy of your Medicare card or SSA documentation.)
  • Ineligible for Medicare either in your own right and/or through the work history of a current, former, or deceased spouse (Submit SSA documentation.)
  • Deferring enrollment in Medicare Part B due to your or your spouse’s employment (Submit proof of active group health insurance through current employer.)

If you do not meet these requirements, you'll receive a notice of cancelation of health coverage for yourself and all enrolled dependents the month you turn 65. Your CalPERS health coverage will automatically be canceled the first day of the month after you turn 65.

See Cancelation of CalPERS Health Coverage for information on reinstating your health coverage.

If you're ineligible for Medicare Part A at no cost, you must complete and submit the Ineligibility of Medicare Certification (PDF) form or the Certification of Medicare Status (PDF) form with the reason for your ineligibility:

  • Did not work in employment covered by Social Security/Medicare
  • Do not have 40 quarters in Social Security/Medicare-covered employment
  • Do not qualify through the work history of a current, former, or deceased spouse

You must include supporting documentation such as a copy of the Social Security statement or letter from the SSA indicating that you're not eligible for Medicare based on your work record and/or the work history of a current, former, or deceased spouse.

You may remain in a CalPERS Basic (non-Medicare) health plan until you later become eligible for Medicare Part A at no cost. If you later become eligible for Medicare Part A at no cost, you'll no longer be eligible to remain in a Basic (non-Medicare) health plan. To continue CalPERS health coverage, enroll in Medicare Part A and Part B, provide documentation of enrollment to CalPERS, and transition to a CalPERS Medicare health plan.

If you're deferring enrollment in Medicare Part B, you must complete and submit the Ineligibility of Medicare Certification (PDF) form or the Certification of Medicare Status (PDF) form indicating the reason for deferral:

  • You're still working and have active employer group health coverage.
  • Your spouse is still working and you're covered under their active employer group health coverage.

You must provide supporting documentation showing proof of enrollment in an active employer group health plan through the current employer.

Once this information is received, you may remain in a CalPERS Basic (non-Medicare) health plan until retirement or until you lose your active coverage in the employer group health plan. If you later retire or lose your employer group health coverage through active employment, you'll no longer be eligible to remain in a CalPERS Basic (non-Medicare) health plan. To continue CalPERS health coverage, enroll in Medicare Part A and Part B, provide documentation of enrollment to CalPERS, and transition to a CalPERS Medicare health plan. The SSA will allow you to enroll in Medicare Part B without a late-enrollment penalty if you're eligible to enroll during a Special Enrollment period.

If your CalPERS Basic (non-Medicare) health plan coverage is canceled because you did not provide supporting documentation to meet the requirements to continue your CalPERS health coverage after age 65, you can request reinstatement of your health coverage within 90 days of your cancelation. In your request for reinstatement, you must provide supporting documentation from the SSA.

You may also request re-enrollment through an administrative review process after 90 days of the date the coverage is canceled.

Submit your request for reinstatement of health coverage to:

CalPERS Health Account Management Division
Attention: Medicare Administration
P.O. Box 942715
Sacramento, CA 94229-2715

If your coverage isn't reinstated, you may re-enroll during the annual Open Enrollment period by providing a completed Certification of Medicare Status (PDF) form along with the required supporting documentation.

Medicare Premiums

The SSA establishes a Medicare Part B premium amount annually. Each month you must pay the monthly Medicare Part B premium to the SSA to remain enrolled in Part B. If you receive SSA benefits, the Part B premium will be deducted from your SSA benefits; otherwise, the SSA will bill you quarterly.

The standard Part B premium amount applies to most people; however, you may pay an Income Related Monthly Adjustment Amount (IRMAA) if your modified adjusted gross income reported on your IRS tax return is above a certain amount.

Once you're enrolled in a CalPERS Medicare health plan, you must continue to pay the SSA for Part B and maintain enrollment in Part B to remain enrolled in the CalPERS health program.

If you're Medicare eligible and terminated from Medicare Part B by CMS, you'll be disenrolled from a CalPERS Medicare health plan and you may not be enrolled in a CalPERS Basic (non-Medicare) health plan; therefore, you may lose your CalPERS health coverage.

If you're terminated from Medicare Part B, you must contact CalPERS immediately to resolve any enrollment issues and overpayments for Medicare Part B reimbursements.

When you turn 65, you're eligible to enroll in Medicare Part B. If you do not enroll in Part B when you're first eligible, you may be subject to the federal late enrollment penalty. The late enrollment penalty is added to your monthly Part B premium for as long as you have Part B. You may also be subject to the late enrollment penalty if you voluntarily terminate your enrollment from Part B and enroll in Part B at a later date.

State & CSU

If you're a state or California State University (CSU) retiree (some exceptions apply), you may be eligible for a reimbursement of all or part of your Medicare Part B premium. If you're eligible for a Part B reimbursement, the amount is limited to the difference between your employer contribution and the cost of your plan's premium, up to the amount of the standard Part B premium. Your reimbursement will be automatically calculated and will appear on your retirement warrant as a credit.

Each year when the federal government announces the standard Part B premium, CalPERS will reset the standard Part B premium for the new year based on the standard amount established by the federal government. Each year your Part B reimbursement will be adjusted based on the new year's standard Part B premium. If you disagree with the Part B reimbursement, you will need to provide to CalPERS supporting documentation from the SSA that confirms the amount that you pay for the standard Part B premium (not including any late enrollment penalties, fees, or interest). CalPERS will review the SSA documentation to make a determination of the correct Part B reimbursement.

If you're terminated from Medicare Part B and no longer paying Part B premiums to the SSA, you must contact CalPERS immediately regarding your termination. If you receive reimbursement for Part B premiums on your retirement warrant for months that you did not pay Part B premiums to the SSA, CalPERS will invoice you for the overpayment of Medicare Part B reimbursements.

Public Agency

California law does not provide for reimbursement of Medicare Part B premiums for retirees of contracting public agencies. If you're retired from a contracting public agency, you may contact your former employer to ask if this benefit is provided to you.

Income Related Monthly Adjustment Amount (IRMAA)

If you're paying an increased Medicare Part B premium (IRMAA) due to your income level, send a copy of the entire Social Security notice showing your increased Medicare Part B premium. If there are funds available, you'll see an increased reimbursement credit on your retirement warrant. Send the copy of your notice to:

CalPERS Health Account Management Division
Attention: Medicare Administration
P.O. Box 942715
Sacramento, CA 94229-2715

If you pay an IRMAA for Part B, you may also pay an IRMAA for Part D. California law does not provide for reimbursement of Medicare Part D premiums.

Transitioning to a Medicare Health Plan

When you retire, become Medicare eligible, and enroll in Medicare Part A and Part B, you'll have the option to choose a new Medicare health plan. If you do not choose one, CalPERS will enroll you in a CalPERS Medicare health plan.

If... Then...
Your current health carrier offers a CalPERS-sponsored Medicare health plan CalPERS will enroll you in your current health carrier's Medicare health plan
Your current health carrier does not offer a CalPERS-sponsored Medicare health plan CalPERS will enroll you in the UnitedHealthcare (UHC) Group Medicare Advantage PPO Plan.

CalPERS requires all family members to have the same health carrier. A combination plan means at least one family member is enrolled in a Medicare health plan and at least one family member is enrolled in a Basic (non-Medicare) health plan through the same health carrier.

Consider your family's needs when determining which Medicare health plan is right for you. If you or your family member become eligible for Medicare and enroll in a CalPERS Medicare health plan, all members of your family will be impacted by the Medicare member's change in health plans.

For example:

  • If the Medicare member enrolls in the UHC Group Medicare Advantage (PPO) Plan, the other family members must move to the UHC Basic Plan, SignatureValue Alliance (HMO).
  • If the Medicare member enrolls in another available Medicare plan, such as Kaiser Permanente Senior Advantage, the other family members will be enrolled in the Kaiser Permanente Basic Plan.

If your current health carrier does not offer a CalPERS-sponsored Medicare health plan, and you do not choose one when transitioning to Medicare, CalPERS will enroll you in a combination plan based on your ZIP code. Refer to the table below:

If... Then...
Your health eligibility ZIP code area is within UHC's service area Your family will be enrolled in the UHC combination plan:
  • Medicare members will be enrolled in UHC Group Medicare Advantage (PPO) Plan.
  • Family members enrolled in a Basic (non-Medicare) health plan will be enrolled in UHC SignatureValue Alliance HMO Basic Plan.
Your health eligibility ZIP code area is outside UHC's service area Your family members in Medicare and Basic (non-Medicare) health plans will be enrolled in PERS Choice PPO Plan.

Search the UHC SignatureValue Alliance HMO Network or call (877) 359-3714 to find out if UHC accepts your or your dependent's current providers. If not, and it's a priority to keep your or your family members' current providers, you may consider enrolling in one of CalPERS PPO Plans (PERSCare, PERS Choice, or PERS Select). Both the Medicare and Basic Plans are PPOs, which will allow all family members to retain their current providers but may result in higher costs.

You can log in to my|CalPERS and use the CalPERS Find a Medical Plan tool to compare the costs and benefits of different plan options.

If you're currently ineligible for Medicare Part A without cost in your own right, you may be or become eligible through a current, former, or deceased spouse's work history. If you're eligible through a spouse, you may apply when your spouse is first eligible to receive Social Security benefits, generally at age 62. Contact the Social Security Administration at (800) 325-0778 or TTY (800) 325-0778 to clarify your Medicare eligibility through a spouse.

CalPERS participates in a Medicare Part D prescription drug plan for members enrolled in a CalPERS Medicare health plan.

The standard Part D premium is paid through your CalPERS health insurance 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'll be deducted from your Social Security benefits. Non-payment of the additional prescription drug premium will result in cancelation of your CalPERS health coverage.

If you enroll in a CalPERS-sponsored Medicare Advantage Plan that includes Part D prescription drug coverage in its benefit package and you are subject to an additional Medicare Part D premium, you must pay the additional Medicare Part D premium, or your health coverage will be canceled. If you re-enroll at a later date, you may incur a federal late enrollment penalty.

If you enroll in a CalPERS-sponsored Medicare Supplement Plan and a Medicare Advantage Plan that does not include Medicare Part D prescription drug coverage in its benefit package, you'll also be enrolled in a CalPERS-sponsored Medicare Part D prescription drug plan unless you notify the Medicare Part D prescription drug plan that you wish to opt-out of prescription drug coverage. If you decline coverage, you'll be responsible for all of your prescription drug costs. If you re-enroll at a later date, you may incur a federal late enrollment penalty.

Do not enroll in a non-CalPERS Medicare Part D plan. If you do so, CMS will disenroll you from your CalPERS-sponsored Medicare Advantage Plan or Medicare Part D prescription drug plan resulting in cancelation of your CalPERS health coverage and you'll be responsible for your prescription drug costs.

If you're Medicare eligible and you lose your Part A and/or Part B, you'll be disenrolled from the CalPERS Medicare health plan. Your disenrollment from Part A and/or Part B may result in cancelation of your CalPERS health coverage.

CMS requires members to live in the approved plan service area and list a residential address. Post Offices Boxes are not permitted. If CalPERS is unable to verify your permanent residential address, your enrollment may be subject to cancelation, or you may be administratively enrolled in a Medicare Supplement plan to continue your CalPERS health coverage.

CMS must approve your enrollment in a Medicare Advantage plan and Medicare Part D plan. CalPERS and/or your CalPERS Medicare health plan may contact you to obtain additional information required by CMS to complete your enrollment. If you're contacted for additional information, respond immediately to protect your health coverage.

You may be enrolled in only one Medicare Advantage plan at one time, as well as one Medicare Part D plan at one time. If you're enrolled in a CalPERS Medicare health plan and later enroll in another Medicare health plan, you'll be disenrolled from the previous Medicare health plan.

United Healthcare

UnitedHealthcare (UHC) offers two health plan options for Medicare retirees from contracting agencies: a PPO plan with dental and vision, and a PPO plan without dental and vision. The PPO with dental and vision coverage is available to Medicare-eligible members not covered under their retirement benefits for an additional premium per Medicare member, per month. UHC will bill you directly for this amount.

Kaiser Permanente Senior Advantage

Kaiser Permanente Senior Advantage also offers two health plan options for Medicare retirees from contracting agencies: an HMO plan with a dental option and an HMO plan without a dental option. The plan with the dental option has an additional premium per Medicare member, per month. Delta Dental will bill you directly for this amount.

You can make changes to your health plan outside of Open Enrollment due to a qualifying event, such as adding a dependent child, registered domestic partner, or new spouse.

For more information about special enrollment opportunities, visit Retiree Plans & Rates or review the Health Program Guide (HBD 120) (PDF).

Medicare Part B Coverage for Diabetic Supplies

The Centers for Medicare & Medicaid Services (CMS) has a National Mail Order Program for diabetes testing supplies that requires Medicare Part B members to use a Medicare contracted supplier. OptumRx Home Delivery Pharmacy is not one of the Medicare National Mail Order contract suppliers. This applies to diabetes testing supplies only and will not affect other items and prescriptions you currently fill through OptumRx Home Delivery Pharmacy, including oral medications for treating diabetes.

If you have questions regarding your Medicare Part B coverage for diabetic supplies, call OptumRx Member Services at (855) 505-8106 (TTY users call 711). Representatives are available 24 hours a day, 7 days a week.

Download the Printable Version of the OptumRx Letter (PDF).

Want to Learn More?

Read our Medicare Enrollment Guide (PDF) for more information about eligibility. Learn why you need to enroll in a CalPERS Medicare health plan and find answers to frequently asked questions.



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