• Coverage Details

What Original Medicare covers and what not?

Medicare in California for 2026 follows federal guidelines but includes unique state-level protections and significant cost updates. Coverage is generally divided into what the government provides (Original Medicare) and what private plans offer.

What Original Medicare Covers (Parts A & B)

Part A (Hospital Insurance)

  • Inpatient Stays: Semi-private rooms, meals, general nursing, and drugs as part of your inpatient treatment.
  • Skilled Nursing Facility: Care after a qualifying 3-day inpatient hospital stay.
  • Hospice & Home Health: Limited medically necessary skilled care at home.

Part B (Medical Insurance)

  • Doctor Visits: Includes specialists and outpatient mental health services.
  • Preventive Services: Vaccines (Flu, COVID-19), screenings for cancer, and annual "Wellness" visits.
  • Durable Medical Equipment (DME): Walkers, wheelchairs, and oxygen equipment.

Unique California Protections & Programs

The "Birthday Rule"

Best for those who want to see any doctor in the U.S. that accepts Medicare and prefer predictable costs.

Medi-Medi Plans

For those eligible for both Medicare and Medi-Cal, California is expanding integrated plans to coordinate all benefits.

Acupuncture Coverage

While Original Medicare only covers acupuncture for chronic lower back pain, many CA Medicare Advantage plans include it as a standard benefit.

Key Cost Updates for 2026

  • Costs have adjusted for the new year, notably for prescription drugs.
Expense Type 2026 Amount Note
Part B Premium $202.90 Standard monthly amount for most Californians.
Part B Deductible $283 The amount you pay before Part B starts to cover 80%.
Part D Drug Cap $2,100 New for 2026: Maximum out-of-pocket limit for all covered drugs.
Part A Deductible $1,736 Per benefit period for hospital stays.
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Medicare in California generally follows federal guidelines

Services Not Covered by Original Medicare

Medicare in California generally follows federal guidelines, but there are specific "gaps" in coverage that are important to know for the 2026 plan year.
While Original Medicare (Parts A and B) covers medically necessary hospital and doctor services, it does not cover several common health needs unless you have a private Medicare Advantage (Part C) plan that explicitly includes them.

Category

What is Excluded

Exceptions / Options

Dental Care

Routine cleanings, fillings, extractions, and dentures.

Covered only if related to another medical procedure (e.g., jaw surgery or cancer treatment).

Vision & Hearing

Routine eye exams, glasses, contact lenses, and hearing aids.

Covered only after cataract surgery or if a doctor deems a hearing test medically necessary.

Long-Term Care

"Custodial care" (help with bathing, dressing, eating) in a nursing home or at home.

Medicare only covers Skilled Nursing (rehab) for up to 100 days following a 3-day hospital stay.

Prescription Drugs

Most outpatient medications are not covered by Parts A or B.

You must buy a standalone Part D plan or a Medicare Advantage plan.

Foot Care

Routine nail trimming, corn/callus removal.

Covered for people with specific conditions like diabetes or nerve damage.

Alternative Medicine

Most acupuncture (except for chronic low back pain), massage therapy, and chiropractic "maintenance."

Some California-specific Medicare Advantage plans add these as "extra" benefits.

Foreign Travel

Healthcare received outside the U.S. and its territories.

Some Medigap plans (like Plans G or N) provide limited foreign travel emergency coverage.