Medicare and Your Benefits

All retired SFHSS members and their dependents are required to enroll in Medicare Part A and Part B as soon as they are eligible.

What Is Medicare?

Medicare is a federal health insurance program for people age 65 years or older and for people under age 65 with a Social Security-qualified disability or End Stage Renal Disease. Medicare has three parts. Medicare Part A is hospital insurance. Part B covers the physician and outpatient services. Medicare Part D provides prescription drug coverage.

Retiree Members, Enrolled Dependents and Medicare

Retiree members and their dependents must enroll in premium-free Medicare Part A and Medicare Part B as soon as they are eligible. Once enrolled, all Medicare premium payments must be made to the federal government as required, in order to maintain continuous Medicare enrollment. Most people pay a premium for Medicare Part B. Based on income, some individuals also pay a premium for the group Medicare Part D that is part of SFHSS-administered retiree medical coverage. Failure by a retired member or an enrolled dependent to comply with SFHSS rules regarding Medicare enrollment will mean a change in, or loss of, medical plan coverage.

Active Employee Members, Enrolled Dependents and Medicare

If you are working and eligible for SFHSS health coverage at age 65 or older, the federal government and SFHSS do not require that you enroll in Medicare. However, even though it is not required, you are eligible for Medicare at age 65 and can enroll if you choose to do so. These same rules apply to a spouse covered on a member's HSS-administered medical plan. Unlike a spouse, a domestic partner (of either gender) of an active employee must enroll, and remain enrolled, in premium-free Medicare Part A and Medicare Part B upon reaching age 65, or sooner, if eligible for Medicare due to disability. Proof of Medicare enrollment, such as a copy of the Medicare card, must be provided to HSS. A domestic partner who is age 65 or older and eligible for Medicare Part A and Part B, but is not enrolled in Medicare, cannot be enrolled in SFHSS coverage.

How do I know if I am eligible for Medicare?

If you are receiving Social Security benefits, the Social Security Administration will notify you prior to your 65th birthday regarding your eligibility for Medicare. For information about Medicare eligibility and enrollment, call the Social Security Administration, the federal agency responsible for handling Medicare. You can reach them at (800) 772-1213 (TTY: (800) 325-0778) or visit them at the office most convenient for you. You can also obtain information from the Social Security Administration’s official website at www.ssa.gov. If you are under age 65, but have a Social Security-qualified disability or kidney disease requiring hemodialysis or transplant, you must contact the Social Security Administration to apply for Medicare.

What if I’m not eligible for Medicare Part A?

Some individuals only qualify for Medicare Part B. In that case, you must submit a statement to SFHSS from the Social Security Administration indicating that you’re not eligible for premium-free Medicare Part A coverage. If SFHSS Rules require your Medicare enrollment, you must still you enroll in Medicare Part B, regardless of eligibility status for Medicare Part A.

What if I didn’t enroll in Medicare Part B when I was originally eligible?

If you are a retiree, or the domestic partner of an active employee when you turned age 65, but neglected to enroll in Medicare Part B, you may be assessed a penalty by the Social Security Administration for each year in which you failed to enroll when eligible. Nevertheless, you are still required to enroll in Medicare in accordance with the Health Service System Rules.

What if I don’t enroll in Medicare despite SFHSS Rules?

If an SFHSS member or dependent is eligible for Medicare, and is required to enroll by SFHSS rules, but does not enroll, that individual will lose his or her current medical plan coverage. SFHSS members will automatically be enrolled in the City Health Plan 20 until they provide proof of Medicare enrollment to SFHSS. Under the City Health Plan 20 out-of-pocket costs significantly increase. You will be responsible for paying the 80% that Medicare would have paid for any Medicare eligible claims, plus any amounts above usual and customary fees. In addition, your yearly out-of-pocket limits will increase to $10,950. If a dependent is eligible for Medicare, and required to enroll in Medicare per SFHSS Rules, but does not provide proof of Medicare enrollment to SFHSS, medical plan coverage for that dependent will be terminated.

What about Medicare Part D?

There are two types of Part D coverage - individual and group. The retiree medical plans offered through SFHSS include group Part D prescription drug coverage. Retirees and their dependents should not enroll in any individual Medicare Part D plan offered through a pharmacy, organization or other insurer. If the member or dependent enrolls in an individual Medicare Part D plan that is not part of SFHSS coverage, HSS medical coverage may be terminated.

Retiree Members

Upon becoming Medicare-eligible, a retiree member must enroll in the Kaiser Permanente Senior Advantage plan or Medicare Advantage PPO offered by UnitedHealthcare. Members currently enrolled in Blue Shield of California's Access+ HMO or Trio HMO who are becoming Medicare-eligible and electing to enroll in the New City Plan have the option of enrolling their non-Medicare dependents in the City Plan or allowing them to remain in Blue Shield until they become Medicare-eligible.