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Medicare Advantage Plans (Medicare Part C)Medicare Advantage, also referred to as MedicarePart C, is a CMS-approved health coverage optionthat is provided by private insurance under contractwith CMS. Medicare Advantage plans include Part A(Hospital Insurance) and Part B* (Medical Insurance).Some Medicare Advantage plans also includePart D (Pharmacy).CMS must approve your enrollment into aCalPERS Medicare Advantage plan. If CMSdisenrolls or rejects your CalPERS MedicareAdvantage plan enrollment, your CalPERS healthcoverage may be cancelled.CMS requirements include the following: You must be enrolled in Part A and Part B* You must be eligible for Part D You must provide a residential address You must reside in the Medicare Advantageplans service area You may only be enrolled in one MedicareAdvantage plan at a time*Note: Kaiser members not eligible for premium-freePart A may enroll only in Part B and may still be eligibleto enroll in the Kaiser Permanente Senior Advantage plan.Medicare Part D (Prescription Drug)Medicare Part D is a voluntary federal outpatientprescription drug benefit available to everyone withMedicare. The Medicare Part D premium is paid toyour health carrier as part of the CalPERS healthpremium. As with Medicare Part B, if your incomeexceeds established thresholds, SSA will assess anadditional income-related monthly adjustment(IRMAA) amount that must be paid to SSA.Payment of this amount is mandatory to protectyour Medicare enrollment and eligibility to remainenrolled in a CalPERS Medicare health plan.If you are receiving SSA benefits, the additionalpremium will be deducted from your Social Securitybenefits. If not, you will be billed quarterly by SSA.Note: To be enrolled in a CalPERS Medicare healthplan, you cannot be enrolled in a non-CalPERS MedicarePart D plan. You may only be enrolled in one MedicarePart D plan at a time.4 CalPERS Medicare Enrollment GuideDo Not Enroll in a non-CalPERSMedicare Part D PlanYour CalPERS coverage includes enrollment in a Medicare Part D Plan. If you oryour dependents are covered by CalPERSand another health plan that includesMedicare Part D prescription drug benefits, you must cancel that Part D coverageto enroll in or continue enrollment in aCalPERS Medicare health plan.

When to Enroll in a CalPERS Medicare Health PlanIf you are retired, over age 65 and eligible forpremium-free Medicare Part A and premium-basedMedicare Part B, CalPERS requires you to enroll inboth Part A and Part B, and then transfer into aCalPERS Medicare health plan to continue CalPERShealth coverage.Eligibility Guidelines for CalPERS Medicare Health PlansIf you are currently enrolled in a CalPERS Basichealth plan, you and/or your dependents are eligibleto enroll in a CalPERS Medicare health plan underany of the following circumstances: You are age 65 or older, retired, and eligible forpremium-free Medicare Part A in your own rightor through the work history of a current, former,or deceased spouse (you must enroll and pay forMedicare Part B). You and/or your dependents are any age, haveEnd-Stage Renal Disease (ESRD) or AmyotrophicLateral Sclerosis (ALS), and have completed anyapplicable coordination periods with SSA. You are retired and you and/or your dependentshave a Social Security-qualified disability. You are retired from a California State Teachers’Retirement System (CalSTRS) employer and areeligible for the CalSTRS Medicare PremiumPayment Program. For more details, see page 8 ofthis booklet, visit www.calstrs.com, or callCalSTRS toll free at (800) 228-5453.Requirements to Continue CalPERS Health Coverage at Age 65 and OverYou will receive a notification from CalPERS fourmonths prior to the month you turn 65. Thisnotification informs you of CalPERS requirements tocontinue your health coverage, Medicare Enrollmentand Eligibility Information, Medicare Plan Options,and an Ineligibility of Medicare Certification form. Ifyou are eligible for premium-free Medicare Part A,you must enroll in Medicare Part A and Part B andtransfer to a CalPERS Medicare health plan.SSA allows you to enroll in Medicare Part A andPart B three months prior to your 65th birth month.By enrolling in Medicare Part A and Part B prior toyour 65th birth month, CalPERS will work with CMSto obtain your Medicare information and automatically transfer you to a CalPERS Medicare health plan.If you are ineligible for premium-free MedicarePart A or if you are deferring enrollment in MedicarePart B, you must complete the Ineligibility ofMedicare Certification form. To continue your healthcoverage, the form must be submitted to CalPERSwith copies of supporting documentation prior toyour 65th birth month to prevent cancellation ofyour CalPERS health coverage.If CalPERS is unable to obtain your Medicareinformation from CMS and cannot automaticallyenroll you in a CalPERS Medicare health plan or ifyou have not returned an Ineligibility of MedicareCertification form, you will receive a notification ofcancellation enclosed with a Certification of MedicareStatus form. CalPERS requires that you complete thisCalPERS Medicare Enrollment Guide 5

form and provide supporting documentation tocontinue your CalPERS health coverage.The Certification of Medicare Status must bereceived by CalPERS with documentation certifyingone of the following choices: Enrollment in Medicare Part A and Part B (submita copy of your Medicare card or SSA documentation that includes your Medicare BeneficiaryIdentifier (MBI)) Ineligible for Medicare in your own rightand not eligible through the work history of acurrent, former, or deceased spouse (submitSSA documentation) Deferred enrollment in Medicare Part B due toyour or your spouse’s employment (submit proofof enrollment in an active Employer Group HealthPlan (EGHP) through current employer)To ensure timely processing of any documentsmailed to CalPERS, please note your CalPERSIdentification number (CID) number on allpages submitted.If you are retired, turning age 65, and you do notcomplete and return the Certification of MedicareStatus form as instructed above, you will receive anotice of cancellation informing you that healthcoverage for yourself and all enrolled dependentswill be automatically cancelled the first day of themonth after you turn 65.If you need assistance completing theforms, contact CalPERS toll free at 888 CalPERS(or 888-225-7377).Important Note: Your CalPERS Medicare health planwill become effective on your Medicare effective date asdetermined by SSA or the first day of the month following CalPERS receipt of the Certification of MedicareStatus form, whichever is later.6 CalPERS Medicare Enrollment GuideIneligibility for MedicareIf you are ineligible for premium-free MedicarePart A, you must complete and return theIneligibility of Medicare Certification form or theCertification of Medicare Status form with thereason for your ineligibility: Do not have 40 quarters in Social Security/Medicare-covered employment Do not qualify through the work history of acurrent, former, or deceased spouseThe reason for your ineligibility must includesupporting documentation from the SSA such as acopy of the Social Security statement or letter fromthe SSA indicating that you are not eligible forMedicare based on your work record and/or the workhistory of a current, former, or deceased spouse.Once this information is received and confirmedby CalPERS, you may remain in a CalPERS Basichealth plan.Not Qualified for Medicare Part AIf you do not qualify for premium-freeMedicare Part A based on your SocialSecurity/Medicare work record or therecord of your current, former, ordeceased spouse, you may remain in aCalPERS Basic health plan. If you laterqualify for Medicare Part A at no cost, youmust enroll in Medicare Part B and in aCalPERS Medicare health plan. If you are aCalSTRS retiree and need to determineyour eligibility for their Medicare PremiumPayment Program, contact CalSTRS tollfree at (800) 228-5453.

Note: If you are not currently eligible for premium-freeMedicare Part A in your own right, you may beeligible for it when your spouse turns 62. To findout if you are eligible through a spouse, contactthe SSA at (800) 772-1213 or TTY (800) 325-0778,or visit their website at www.ssa.gov. If you become eligible and delay enrollment, youmay be subject to a federal late enrollment penalty.Deferred Enrollment in Medicare Part BYou or your spouse can defer enrollment inMedicare Part B if either of the following apply: You are still working and enrolled in anactive EGHP Your spouse is still working and you arecovered under his or her active EGHPIf you plan on deferring enrollment in MedicarePart B you must contact SSA to inform them first.After completing this step, you must complete andreturn the Ineligibility of Medicare Certification formor the Certification of Medicare Status form withsupporting documentation showing proof of enrollment in an active EGHP through the currentemployer. Once this information is received andapproved by CalPERS, you may remain in a CalPERSBasic health plan until retirement or until you loseyour active coverage in the EGHP.Note: The option to defer your enrollment in Part Bdoes not apply to workers in the California StateUniversity (CSU) System Faculty Early RetirementProgram (FERP). If you are working under a FERPcontract and are eligible for premium-free MedicarePart A, you must enroll in Medicare to retain yourCalPERS health coverage.Cancellation of CalPERS Health CoverageYour action is necessary to ensure a successful transition from a CalPERS Basic health plan to a CalPERSMedicare health plan. Carefully review and followinstructions provided in the letter received fromCalPERS four months prior to your 65th birth month.CalPERS is unable to keep members enrolled in aCalPERS Basic health plan for the following reasons: You are Medicare eligible and you did not enrollin Medicare Part A and/or Part B You did not provide proof of Medicareineligibility; or You did not notify CalPERS of MedicarePart B deferment due to having EGHPthrough active employmentIf your health plan coverage is terminated, youmay request re-enrollment through the request foradministrative review process within 90 days of thedate the coverage is cancelled by writing to:CalPERS Health Account Management DivisionMedicare AdministrationP.O. Box 942715Sacramento, CA 94229-2715The request for administrative review must statethe grounds on which it is requested, the relief thatis sought, and include any supporting evidence.You will receive a determination within 60 days ofCalPERS’ receipt of all pertinent information informing you if your coverage will be reinstated. If yourcoverage is not reinstated, you may re-enroll duringCalPERS annual Open Enrollment period by providing a completed Certification of Medicare Status formwith the required supporting documentation.CalPERS Medicare Enrollment Guide 7

Enrolling in a CalPERS MedicareHealth Plan Apply for Medicare Parts A and B threemonths before you turn 65 by contacting the SSA toll free at (800) 772-1213or TTY (800) 325-0778. Be preparedto provide your and your spouse’sSocial Security numbers. CalPERS will work with CMS to obtainyour Medicare information and automatically transfer you to a CalPERSMedicare health plan. You may request a change in healthplans within 60 days of enrollmentin a Medicare health plan. To find CalPERS health plansavailable in your area, utilize theHealth Plan Search by Zip Codetool on the CalPERS website.8 CalPERS Medicare Enrollment GuideNote for CalSTRS RetireesIf you do not qualify for premium-freeMedicare Part A, please contact CalSTRSabout their Medicare Premium PaymentProgram to determine if you can obtainMedicare Part A at no cost. To determineyour eligibility for this program, visitwww.calstrs.com, or call (800) 228-5453.MovingContact your health plan and CalPERS ifyou move. Medicare health plans havespecific rules associated with changinghealth plans due to a move. NotifyingCalPERS of your change of address andinquiring about potential health planchanges will allow for a smooth transitionof your health coverage. Contact CalPERSto change your address at 888 CalPERS(or 888-225-7377).

CalPERS Medicare Health Plan Enrollment ExceptionsYou may be ineligible to enroll in a CalPERSMedicare health plan due to Medicare exemptionreasons. Following are examples of circumstancesthat may allow you to remain enrolled in a CalPERSBasic health plan: Neither you nor your spouse qualifies forpremium-free Medicare Part A. You or your spouse works past age 65and are enrolled in an active EGHP throughthat employment and have deferred your or yourspouse’s enrollment in Medicare Part B. You were eligible for Medicare Part A andPart B before January 1, 1998, but you did notenroll in Part B. You retired from the California State University(CSU) system and qualified for Medicare Part Aand Part B before January 1, 2001, but you did notenroll in Part B. This does not apply to participantsin the CSU system’s FERP. You were eligible for Medicare because of adisability, but the SSA determined you are nolonger disabled and you no longer qualify forpremium-free Medicare Part A. You moved permanently outside of theUnited States.Return the Ineligibility of MedicareCertification Form or the Certificationof Medicare Status FormIf you do not return the properdocumentation prior to the last day ofthe month you turn 65 your CalPERShealth coverage will automatically becancelled the first day of the monthfollowing your 65th birthday.Continuing to Work After RetirementIf you are working after retirement from CalPERSemployment, your health plan options depend uponwhether you and/or your spouse are covered by anactive EGHP.You Are Not Enrolled in An Active EmployerGroup Health PlanIf you are working after retirement and not enrolledin an active EGHP (your own or your spouse’s), youmay continue your CalPERS health coverage bycertifying your Medicare status. If eligible forMedicare, you must enroll in Medicare and transferinto a CalPERS Medicare health plan. If you are ineligible for Medicare, you must provide documentssupporting your ineligibility.You Are Enrolled in An Active EmployerGroup Health PlanIf you are working after retirement and are enrolledin Medicare Part A and Part B, CalPERS will transferyour health plan enrollment from a CalPERS Basichealth plan to a CalPERS Medicare health plan.CalPERS is unable to maintain your enrollment in aCalPERS Basic health plan if you are enrolled in PartA and Part B with SSA.If you or your spouse are working and enrolled inan active EGHP through current employment, youmay remain in a CalPERS Basic health plan if youcontact SSA and defer enrollment in Medicare Part B.When you retire or lose coverage through theactive EGHP, immediately enroll in Medicare Part Band contact CalPERS to transition into a CalPERSMedicare health plan.If you are ineligible for Medicare, you mustprovide documents supporting your ineligibility.CalPERS Medicare Enrollment Guide 9

Medicare Enrollment (Under Age 65)If a member or a dependent is enrolled inMedicare Parts A and B, they may be eligible toenroll in a CalPERS Medicare health plan. If themember is retired, they may provide their and/ortheir dependents Medicare Part A and Part B information to CalPERS by submitting a copy of theirMedicare card and elect to transfer to a CalPERSMedicare health plan. Enrollment into a CalPERS10 CalPERS Medicare Enrollment GuideMedicare health plan will be processed and effectivethe first of the month following receipt of all necessary documentation. For active employees and theirdependents, federal law limits enrollment into aCalPERS Medicare health plan to those diagnosedwith Amyotrophic Lateral Sclerosis (ALS) orEnd-Stage Renal Disease (ESRD) that havecompleted any applicable coordination periods.

CalPERS Medicare Health Plan OptionsCalPERS offers several Medicare health plans.When you retire, become Medicare eligible, andenroll in Medicare Part A and Part B, CalPERS willenroll you in a CalPERS Medicare health plan of yourchoice that is available to you. If you do not choose anew health plan, CalPERS will automatically transferyou into a CalPERS Medicare health plan.Your current CalPERS Basic health plan may notoffer a CalPERS sponsored Medicare health plan,therefore a health plan change is required.There are three types of Medicare plans available: A Medicare Advantage (MA) Health MaintenanceOrganization (HMO) plan provides health carefrom specific doctors and hospitals under contractwith the plan. You pay copayments for someservices, but you have no deductible, no claimforms, and a geographically restricted service area. A MA Preferred Provider Organization (PPO)allows you access to all providers in the U.S. thataccept Medicare. You pay less if you use doctors,hospitals, and other health care providers thatbelong to the plan's network. If you use doctors,hospitals, and providers outside of the networkyou may do so at an additional cost to you. A PPO Supplement plan is similar to a traditional“fee-for-service” plan, but you must use doctors inthe PPO provider network or pay higher co-insurance (percentage of charges). You must usuallymeet an annual deductible before some benefitsapply. You’re responsible for a certain co-insuranceamount and the plan pays the balance up to theallowable amount.For more information on transitioning to aMedicare health plan and Combination plans, visitwww.calpers.ca.gov.CalPERS Medicare Enrollment Guide 11

To Compare Benefits Between Health PlansCalPERS PPO Health PlansCalPERS offers PPO Medicare Supplemental plans.Most benefits in these plans are Medicare-approvedservices with Medicare payment supplemented bythe plan. However, the plans provide coverage forsome benefits not covered by Medicare (e.g.,acupuncture). Furthermore, the plans also providecoverage for medically necessary services andsupplies when benefits under Medicare areexhausted or when charges for certain services andsupplies exceed amounts covered by Medicare.CalPERS Medicare Advantage Health PlansCalPERS offers multiple Medicare Advantage plansthat cover all Medicare Parts A and B benefits aswell as Part D prescription drug benefit. Additionalbenefits beyond those covered under the originalMedicare program include acupuncture,chiropractic, and hearing aid services.To compare benefits between health plans,refer to the Health Benefit Summary available atthe CalPERS website at www.calpers.ca.gov.You can also check the availability of health plansin a specific ZIP code on the CalPERS website atwww.calpers.ca.gov, through myCalPERS atmy.calpers.ca.gov, or by calling CalPERS toll freeat 888 CalPERS (or 888-225-7377).You may make changes to your health plan in anyof the following ways: Through myCalPERS at my.calpers.ca.gov By completing a Health Benefits Plan Enrollmentform and mailing it to CalPERS at P.O. Box 942715,Sacramento, CA, 94229-2715 or faxing it to(800) 959-6545 By calling CalPERS toll free at 888 CalPERS(or 888-225-7377).Combination EnrollmentsA combination enrollment means at leastone family member is enrolled in a CalPERSMedicare health plan and at least onefamily member is enrolled in a CalPERSBasic health plan. CalPERS requires that allcovered family members are enrolled withthe same health carrier.Note: If a Medicare eligible member enrolls ina CalPERS Medicare health plan, it may requirea change in the health carrier which may impactfamily members enrolled in a Basic health plan.Medicare Advantage HMO PlanWith a Medicare Advantage HMO plan, you workclosely with your PCP to get the care you need.You pay no additional costs, other than applicablecopayments, when you receive services from theplan’s network of providers. If you go to out-ofnetwork doctors or hospitals, you will have to payfor all services (except for emergency or out-of-areaurgent care services). A Medicare Advantage HMOplan has been approved by CMS and receives amonthly payment directly from CMS to provideyour Medicare benefits.12 CalPERS Medicare Enrollment GuideMedicare Advantage HMO Requireme

CalPERS Medicare Health Plan Enrollment . Medicare is a federal health insurance program . for individuals: Age 65 and older . hospice care, and some home health care. You or your dependents may become eligible . for p