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Understanding Medicare in California
As a healthcare provider serving communities across California, BASS Medical Group regularly helps patients navigate Medicare questions, especially as coverage options, plan availability, and costs change from year to year.
California has nearly 7 million Medicare beneficiaries, the largest Medicare population in the United States. With 2026 bringing updated premiums, plan offerings, and enrollment considerations, understanding how Medicare works — and how it may interact with other coverage — remains essential.
What Is Medicare?
Medicare is a federal health insurance program for:
- Adults age 65 and older
- Certain individuals under 65 with qualifying disabilities
- People of any age with End-Stage Renal Disease (ESRD) or ALS
Although Medicare is federally administered, plan availability, provider networks, and supplemental options vary by state and county, including throughout California.
The Four Parts of Medicare
Part A — Hospital Insurance
Part A generally helps cover:
- Inpatient hospital stays
- Skilled nursing facility care (after a qualifying hospital stay)
- Hospice care
- Limited home health services
Most beneficiaries do not pay a monthly premium for Part A if they or a spouse paid Medicare taxes while working.
Part B — Medical Insurance
Part B covers many outpatient and preventive services, including:
- Doctor visits and specialist care
- Preventive screenings and wellness visits
- Diagnostic tests and imaging
- Durable medical equipment
Part B requires a monthly premium, which is set annually and may be higher for individuals with higher reported incomes.
Part C — Medicare Advantage
Medicare Advantage (Part C) plans are offered by private insurers approved by Medicare. These plans must provide at least the same coverage as Parts A and B and often include:
- Prescription drug coverage
- Dental, vision, and hearing benefits
- Wellness or fitness programs
In 2026, California beneficiaries continue to have access to a wide range of Medicare Advantage plans, though benefits, premiums, and provider networks vary by county and plan.
Part D — Prescription Drug Coverage
Part D helps cover prescription medications and is available through:
- Stand-alone prescription drug plans, or
- Medicare Advantage plans that include drug coverage
Because formularies and pharmacy networks change annually, reviewing Part D coverage each year remains important.
Medicare Enrollment Periods
California beneficiaries may enroll or make changes during:
- Initial Enrollment Period (IEP): Around your 65th birthday
- Annual Election Period (AEP): October 15 – December 7
- General Enrollment Period (GEP): January 1 – March 31 (if you missed IEP)
- Special Enrollment Periods (SEPs): Triggered by qualifying life events
Coverage choices and penalties may apply if enrollment deadlines are missed.
California’s Medigap “Birthday Rule”
California offers additional consumer protections through its Birthday Rule, allowing Medigap beneficiaries to switch to a comparable plan around their birthday without medical underwriting, subject to specific timelines and conditions.
Medi-Cal, Dual Eligibility, and ACA Transitions
Some Medicare beneficiaries in California may also qualify for Medi-Cal, the state’s Medicaid program. Individuals enrolled in both programs are often referred to as dual-eligible or “Medi-Medi” beneficiaries.
Additionally, some adults transition to Medicare after previously receiving coverage through the Affordable Care Act (ACA) marketplace. In these cases:
- ACA premium tax credits generally end once Medicare eligibility begins
- Timing enrollment correctly can help avoid coverage gaps or penalties
Eligible dual-eligible patients may qualify for Dual Eligible Special Needs Plans (D-SNPs), which coordinate Medicare and Medi-Cal benefits under a single plan.
Medicare Costs in California
Medicare costs vary by individual circumstances and plan selection:
- Part A: Often premium-free
- Part B: Monthly premium, adjusted annually and income-based
- Part C & Part D: Vary by plan, county, and coverage level
Because benefits and costs change from year to year, reviewing coverage annually is strongly encouraged.
When to Talk With a Healthcare Provider
Understanding insurance coverage is an important part of managing your health. You may benefit from a discussion with a healthcare provider if you:
- Are new to Medicare or approaching age 65
- Are transitioning from employer or ACA coverage
- Have Medicare Advantage or Medi-Cal questions
- Want to confirm provider participation or referrals
At BASS Medical Group, our teams are happy to help patients understand how their Medicare coverage fits into their care and how to plan visits accordingly.
To learn more or to schedule an appointment, visit bassmedicalgroup.com or contact your local BASS office.
