How Does Medicare Work in California? 

California is home to a growing population of seniors. According to research published by the Public Policy Institute of California, the Golden State is poised to see a senior population of around 17% by the year 2030.

Additionally, it’s believed that some counties in California will see a 166% increase in their senior populations by 2060. Because Medicare insurance is relied upon by millions of seniors across America, including California, now may be a good time to take a closer look at how the program works.

Medicare benefits in California

Medicare insurance is a federal program that is managed by the Centers for Medicare & Medicaid Services (CMS). Different states can create regulations for insurance providers that partner with CMS to provide Medicare benefits, but the program is fundamentally the same in every state.

How Medicare covers inpatient care in California

In California, as across the United States, Medicare recipients receive coverage for inpatient care under Medicare Part A. This part of Medicare covers hospital admission and admission to skilled nursing facilities (SNFs).

Under the rules of Part A, Medicare recipients receive up to 60 days of full inpatient coverage per benefit period to be used in a Medicare-participating hospital. If inpatient care is required beyond 60 days, an additional 30 days can be used by paying a per-day coinsurance. 

Inpatient care in an SNF is limited to 20 days under Medicare Part A; however, this care can be extended for an additional 80 days each benefit period, making the full allotment of coverage 100 days in an SNF.

If care extends beyond the coinsurance limits in California, lifetime reserve days can be used to continue care. Once lifetime reserve days have been used up, Californians are responsible for the full cost of inpatient care.

How Medicare covers outpatient care in California

Outpatient care in California is covered by Medicare Part B. Services and care solutions like doctor visits, clinical and diagnostic testing, surgery and durable medical equipment (DME) are covered by Medicare benefits under Part B.

Medicare Part B recipients pay a coinsurance of 20%. Medicare insurance makes up the remaining 80%. In order to qualify for coverage, all outpatient services must be deemed medically necessary. This means that elective procedures, cosmetic surgery, weight loss treatment and similar medical care are not covered by Medicare in California, or in any state.

How Medicare covers prescription drugs in California

California’s seniors who take prescription drugs can turn to Medicare Part D for cost-saving benefits. Medicare Part D is optional coverage, and plans can cover a range of prescription drugs that are available for purchase from retail pharmacies.

Some medications covered under Medicare Part D require a co-pay at the time of purchase. Each Part D plan comes with its own monthly premium, and Medicare recipients must meet their plan deductibles before benefits apply toward the cost of prescriptions.

How does Medicare Advantage work in California?

Medicare Advantage plans are similar to Original Medicare; MA plans are provided by private insurers that can include added benefits. There are different types of Medicare Advantage plans offered in California, including the most common ones: health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

An HMO usually requires Medicare recipients to only see the doctors who are part of the plan’s network. Seeing a specialist requires a referral. A PPO allows Medicare recipients to see doctors outside of the plan’s network, but costs will be higher for doing so. PPOs usually do not require a referral to see a specialist. PPOs will have more flexibility, but will have higher costs than HMOs.

Options for Medicare recipients in California who meet the criteria may include Medicare Advantage special needs plans (SNPs). This type of plan is reserved for those who have been diagnosed with specific conditions or have certain needs. For instance, if you qualify for Medicare and Medicaid (Medi-Cal), you may be able to enroll in a Medicare Advantage Dual-eligible Special Needs Plan (D-SNP) if one is available in your area.