- Whom does HICAP serve?
- Who are the HICAP counselors?
- How is HICAP funded?
- How do I make an appointment?
1. Whom does HICAP serve?
HICAP services are available to current Medicare beneficiaries, those about to receive Medicare benefits, disabled adults, seniors and their families, and other representatives who want to learn more about buying health insurance or planning for their retirement. All HICAP services are offered at no cost to the client.
2. Who are the HICAP counselors?
HICAP counselors are volunteers, many of them retired, who have completed a comprehensive training program and are registered by the California Department of Aging.
3. How is HICAP funded?
HICAP is supported by a grant from the California Department of Aging. These funds are not tax dollars; HICAP is funded through fines and fees levied on health care insurance providers and their agents.
4. How do I make an appointment?
There are multiple in-person counseling sites throughout the county. For a listing of these sites you can contact the Orange County HICAP office at email@example.com or by calling (714) 560-0424 or (800) 434-0222.
- What is Medicare?
- What is the difference between Medicare and MediCal?
- What does Medicare cover?
- Are there services Medicare does not cover?
- Who is eligible for Medicare?
- How do I sign up for Medicare?
- When I enrolled in Medicare part A, I did not sign up for Part B. Is that coverage still available to me on the same terms?
- If I am not entitled to Medicare based on my employment, or the employment of my spouse, can I buy the coverage?
- Are there different health care systems Medicare beneficiaries can use to get their Medicare benefits?
- What is the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program?
1. What is Medicare?
Medicare is a federal health insurance program established in 1965 for individuals aged 65 or older, and anyone of any age with certain disabilities or permanent kidney failure. It is administered by the Center for Medicare Services (CMS) of the U.S. Department of Health and Human Services. Local Social Security Administration offices take applications for Medicare Part A and B enrollments.
Nationally, Medicare covers approximately 47 million persons, of whom about 7.2 million are disabled.
2. What is the difference between Medicare and Medicaid (Medi-Cal in California)?
Medicare is a federal health insurance program for older and disabled persons, regardless of income and assets. Medicaid, on the other hand, is a medical assistance program jointly financed by the State and Federal governments for eligible low-income individuals. Medicaid and CHIP provide health coverage to nearly 60 million Americans, including children, pregnant women, parents, seniors and individuals with disabilities. In order to participate in Medicaid, Federal law requires States to cover certain population groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). States set individual eligibility criteria within federal minimum standards.
3. What does Medicare cover?
Medicare has four parts: Hospital Insurance (Part A) and Medical Insurance (Part B) Medicare Advantage (Part C) and Prescription drug coverage (Part D).
Hospital Part A helps pay for inpatient care in a hospital or skilled nursing facility, or for care from a home health agency or hospice. If you are admitted to a hospital, Medicare provides coverage for a semi-private room, meals, regular nursing services, operating and recovery room costs, intensive care, drugs, lab tests, X-rays, and all other medically necessary services and supplies. Covered services in a skilled nursing facility include a semi-private room, meals, regular nursing services, rehabilitation services, drugs, and medical supplies and appliances.
Part B helps pay for limited physician services, outpatient hospital care, clinical laboratory tests, and various other medical services and supplies, including durable medical equipment. Physician services are covered any where you receive them in the U.S. Other covered services include surgical, diagnostic tests and X-rays that are part of treatment, medical supplies furnished in a doctor's office, and drugs which cannot be self-administered, but are part of the treatment plan. Medicare pays only for care that it determines is medically necessary.
Medicare Advantage (MA) plans are also known as Medicare Part C. An MA plan is an alternative to Original fee-for-service Medicare. MA plans are sponsored by Medicare, which pays private insurance companies to provide health services to beneficiaries who enroll in these plans. In order to join an MA plan, you must be enrolled in both Medicare Part A and Part B, and you must continue to pay the Part B premium. If you join an MA plan, you are still on Medicare and retain the full rights and protections entitled to all beneficiaries.
Prescription drug coverage (Part D) helps pay for medications doctors prescribe for treatment. Anyone who has Medicare hospital insurance (Part A), medical insurance (Part B) or a Medicare Advantage plan (Part C) is eligible for prescription drug coverage (Part D). Joining a Medicare prescription drug plan is voluntary and you pay an additional monthly premium for the coverage.
4. Are there services Medicare does not cover?
While Medicare helps pay a large portion of your medical expenses, there are various health care services and products for which Medicare will not pay. These generally include custodial care; eye-glasses, hearing aids, and examinations to prescribe or fit them. Medicare also does not pay for cosmetic surgery, dental care and routine foot care. Although some personal care services (for example: bathing assistance, eating assistance, etc.) can be covered as part of any skilled care, they are never covered alone except under the hospice benefit.
5. Who is eligible for Medicare?
Generally, individuals age 65 and over can get Part A benefits if they can establish their eligibility for monthly Social Security or Railroad Retirement benefits on their own or their spouse's work record. In addition, certain government employees whose work has been covered for Medicare purposes, and their spouses, can also have Part A. In rare cases, involving individuals who became age 65 in 1974 or earlier, Part A may be available if they meet certain United States residence and citizenship or legal alien requirements.
Part A is also available to most individuals with permanent kidney failure, those who have been entitled to Social Security disability benefits or Railroad Retirement disability benefits for more than 24 months, and to certain disabled government employees whose work has been covered for Medicare purposes. Any person who is eligible for Part A is also eligible to enroll in Part B.
6. How do I sign up for Medicare?
If you are already getting Social Security or Railroad Retirement benefit payments when you turn 65, you will automatically get a Medicare card in the mail. The card will usually show that you are entitled to both Part A and Part B and indicate the beginning dates of your entitlement to each. If you do not want Part B, you can refuse it by following the instructions that come with the card. If you are not receiving Social Security or Railroad retirement benefits when you turn 65, you may have to apply for Medicare coverage. Check with Social Security Administration to see if you are able to get Medicare under the Social Security system or based on Medicare covered government employment; check with the Railroad Retirement office if you are able to get Medicare under the Railroad Retirement system. If you must file an application for Medicare, you should do so during your initial seven-month enrollment period. That period starts three months before the month you first meet the requirements for Medicare.
7. When I enrolled in Medicare Part A, I did not sign up for Part B. Is that coverage still available to me on the same terms?
You may still enroll in Part B during the annual general enrollment period from January 1 to March 31, and your coverage will begin on July 1 of the year you enroll. Your monthly premium will likely be higher than it would have been had you enrolled in Part B when you enrolled in Part A. Generally, if you defer your enrollment in Part B, you must pay a monthly premium surcharge. The surcharge is 10 percent for each 12-month period in which you could have been enrolled but were not. The surcharge generally does not apply if you delayed enrolling in Part B because you were covered by an employer health plan based on your (or your spouse's) current employment once you first became eligible for Medicare. In that case, you would be allowed to enroll in Part B during a special 7-month enrollment period. The period begins with the month the employer group health plan ends, or with the month the employment on which it is based ends, whichever is earlier. In the case of certain disability beneficiaries, the special period begins when Medicare replaces the employer group health plan as the primary payer of the beneficiary's covered medical services.
8. If I am not entitled to Medicare based on my employment, or the employment of my spouse, can I buy the coverage?
Individuals age 65 or over who are United States residents and either United States citizens, or aliens who have been lawfully admitted for permanent residence and have resided in the United States for at least five years at the time of filing, can purchase both Part A and Part B, or just Part B.
9. Are there different health care systems Medicare beneficiaries can use to get their Medicare benefits?
Yes. You can receive services covered by Medicare either through the traditional fee-for-service (pay-as-you-go) delivery system or through coordinated care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), which have contracts with Medicare.
10. What is the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program?
The Medicare Modernization Act of 2003 established requirements for a new program in which DME suppliers had to compete to become Medicare contract suppliers by submitting bids to furnish certain DME items. This competitive bidding lowered the payment amounts to the suppliers, resulting in savings to the Medicare Program. This program was implemented in 10 regions, including Riverside and San Bernardino Counties, in 2011. The second round of DMEPOS was implemented in Orange County July 1, 2013. Medicare beneficiaries with Original Medicare, residing in one of the implementation regions of the United States (known as a Competitive Bidding Areas), will have to use a contract supplier to obtain supplies that are included under this program. To get more information or to find a contract supplier in your area, please visit www.medicare.gov/supplierdirectory/search.html
- How Much Does it Cost?
- What’s covered?
- What’s the Deductible?
- What’s the Co-Payment?
- What Is A “Donut Hole”?
- What about my Medigap Policy?
- What if I already belong to an HMO?
- What about my retiree coverage?
- When can I sign up for Medicare Part D?
1. How Much Does it Cost?
Private insurance companies and HMOs offer part D. You may have to pay a premium ranging from $0 to $114.90. Some plans may offer richer benefits (smaller deductible, co-pays, or “donut hole”) depending on the type of plan and the premium.
Many plans offer a “tiered” system of costs for covered medications. Generally, there are 4 or 5 tiers with the preferred brands in the lowest cost tier (tier 1) and non-preferred brand medication on the more expensive, higher tiers.
Finally, if your drug is not covered by your plan, you will have to pay for it yourself, and this will not count towards your co-payment and deductible requirements.
2. What’s Covered?
Each plan has a “formulary” – a list of covered drugs. Formularies are not standardized and will vary from plan to plan. You should check to see if a plan covers your medication before enrolling.
3. What’s the Deductible?
There is a $320 (2012) annual deductible.
4. What’s the Co-Payment?
After meeting the deductible, you are required to pay 25% of the cost for the next $2,610 in drugs.
5. What Is A “Donut Hole”?
Part D covers most people on Medicare by insuring drug costs up to about $2,930 a year. Prior to the Affordable Care Act, there was no coverage after $2,930 until your costs exceed $6,658 per year. In 2012, when an individual enters the “Donut Hole,” they pay 50% of the cost for brand medication and receive a 14% discount on generic medications. Discounts only apply to medications that are on the plans formulary. After the total cost of the medications reaches $6,658 the “donut hole” ends and catastrophic coverage begins: you pay only 5% of costs and Medicare pays the rest. The “donut hole” is the coverage gap between $2,930 and $6,658 where you must still pay a premium and the cost of drugs, but receive reduced benefits.
6. What about my Medigap Policy?
Some Medigap policies sold prior to 2006 offer drug coverage. If you have one of these policies, you should have received a letter from your insurance company telling you that your current coverage is not considered “at least as good as Part D coverage.” In this case, you can consider enrolling in a Part D plan, during the Annual Enrollment Period (October 15 – December 7), but you will face a late enrollment penalty when your Part D plan becomes effective.
7. What if I already belong to an HMO?
Some HMO plans may include the Part D benefit; others may charge you for it. You will need to check with your plan.
8. What about my retiree coverage?
If you have drug coverage through a union or company retirement plan, you will receive a letter from the plan, each year, telling you how the plans benefits will change and whether they are considered “at least as good as Part D coverage.” If they are not, you should consider enrolling in the Medicare prescription drug benefit.
9. When can I sign up for Medicare Part D?
The initial enrollment period for Medicare Part D is a seven-month enrollment period. That period starts three months before the month that your Part A becomes effective and ends three months after. If you decide to enroll in Part D after that date, there may be a lifetime premium penalty of 1% for each month you delayed enrollment.
Information and Resources
1) Health Insurance Counseling and Advocacy Program (HICAP)
A network of 24 local, community-based programs throughout California that provide free counseling and education on Medicare and related issues.
To reach the program nearest you, call
In Orange County, call
In the Inland Empire, call
In Inyo and Mono Counties, call
2) Web Sites
The official government website for Medicare.
California Health Advocates, the California HICAP Association site.
A consumer-oriented web site sponsored by California Health Advocates that provides easy to understand information about Medicare and offers several dozen Medicare fact sheets in English, Chinese, Spanish and Vietnamese.
Offers a simple tool that will help you find a discount card or drug plan that is right for you, and other prescription assistance programs for which you may be eligible.