Frequently Asked Questions - HICAP

Medicare is the Federal health insurance program established in 1965 which is administered by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health Services. Medicare is health insurance for the following people:

  • Age 65 or older;
  • Under age 65 with certain disabilities who qualify for disability benefits from Social Security or Railroad Retirement Board (RBB);
  • Any age with End-Stage Renal Disease (ESRD) - permanent kidney failure requiring dialysis or a kidney transplant;
  • Diagnosed with ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig's Disease) the month your disability benefits begin.
  • If you aren't getting Social Security or Railroad Retirement (RRB) benefits, you will need to sign up in one of three ways: 1) online at; 2) call Social Security at 1-800-772-1213; or 3) visit your local Social Security Office.
  • In most cases, if you're already getting benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month.
  • If you're under 65 and disabled, you automatically get Part A and Part B after you get Social Security disability benefits (SSDI) or certain disability benefits from the RRB for 24 months.

Medicare Part A (Hospital) covers the following services:

  • Inpatient care in hospitals;
  • Inpatient care in a skilled nursing facility (not custodial or long-term care);
  • Home health care services;
  • Hospice care services;
  • Blood.

Medicare Part B (Medical) covers:

  • Doctor's services and tests;
  • Outpatient care;
  • Home health care services;
  • Durable medical equipment and other medical services;
  • Ambulance services;
  • Chiropractic services;
  • Diabetes supplies;
  • Preventive services.

Medicare doesn't cover everything. If you need certain services that Medicare doesn't cover, you will have to pay for them yourself unless you have other insurance to cover the costs. Even if Medicare covers a service or item, you generally have to pay deductibles, coinsurance, and copayments. Some of the items and services that Medicare does not cover include the following:

  • Long-term care;
  • Routine dental care;
  • Cosmetic surgery;
  • Acupuncture;
  • Hearing aids;
  • Exams for fitting hearing aids.


Medicare Advantage plans are offered by private insurance companies that contract with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. MA plans in Lake, Mendocino, Marin, Napa, Solano and Sonoma counties may include Health Maintenance Organizations (HMO's), Preferred Provider Organizations (PPO's); Private Fee for Service (PFFS); and Special Needs Plans (SNP's). For more information about which companies and plans are offered in your county, a brief description of benefits, and the rules for joining, changing, or disenrolling from a plan, call the HICAP office at 1-800-434-0222.

Definitions of Medicare Advantage (MA) Plans:
Beginning January 1, 2012, there are 2 (two) different Medicare Advantage plans available. When you
sign up for a Medicare Advantage plan, you assign your Medicare Part A and Part B over to the plan.
Your plan determines what is covered and what is not covered. The definition for each of these
plans is below:

1.  Health Maintenance Organization (HMO) plan: HMO Plans must cover all Medicare Part A and Part B
health care. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can
only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs
may be lower than in the Original Medicare Plan.

2.  Special Needs Plan (SNP): Medicare Special Needs Plans’ (SNP) are specially designed for people
with certain chronic diseases and other specialized health needs. These plans are only available
for specific groups of people, such as people living in certain long-term care facilities (like a
nursing home), people eligible for Medicare and Medicaid (Medi-Cal in California), or people with
certain chronic or disabling conditions. All Medicare SNPs provide Medicare prescription drug
coverage (Part D).

All Medicare Advantage (MA) plans must adhere to the guidelines established by the Centers for
Medicare & Medicaid Services (CMS) and must provide all of the benefits covered under Original

MA plans are Individual Plans for people who do not qualify for an Employer Group Health Plan
(EGHP).  Converting an EGHP from actively working to a retiree plan, and going on Medicare may
change your benefits and premiums.
HICAP provides one-on-one counseling to help you compare your current EGHP plan with individual
Medicare Advantage plans (HMO and PPO) and Medicare Supplement (Medigap) plans.


NEW: In the fall of 2011, the beginning of the Annual Enrollment Period (AEP) will change to October 15, 2011 and end on December 7, 2011. If you make a change during this period, your new coverage will begin on January 1, 2012.



Medicare offers prescription drug coverage to everyone with Medicare. Even if you don't take a lot of prescriptions now, you should still consider joining a Medicare Prescription Drug Plan (PDP). To get Medicare prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. If you decide not to join a Medicare drug plan when you are first eligible, and you don't have other creditable prescription drug coverage, you will likely pay a late enrollment penalty. For a list of the stand-alone PDP plans in your county, call HICAP at 1-800-434-0222.

NEW: In the fall of 2011, the beginning of the Annual Enrollment Period (AEP) will change to October 15, 2011 and end on December 7, 2011. If you make a change during this period, your new coverage will begin on January 1, 2012.

You may qualify for "Extra Help", also called the low-income subsidy (LIS), from Medicare to help pay prescription drug costs if your yearly income and resources are below the following limits in 2011:

  • Single person: Monthly income less than $1,361 and resources less than $12,640;
  • Married person living with a spouse and no other dependents: Monthly income less than $1,839 and resources below $25,260.

The local HICAP office can assist you by completing an online application through Social Security's website. Call HICAP at 1-800-434-0222 to have a counselor help explain the "Extra Help" program and complete the online application or call Social Security at 1-800-772-1213.

You may qualify for the Medicaid (Medi-Cal in California) program or any of the Medicare Savings Programs (MSP) if you meet certain monthly income and asset levels. To find out more information about these programs, call HICAP at 1-800-434-0222 or go to this website's resource page for available programs in your county.

A Medigap policy, sold by private insurance companies, can help pay some of the health care costs ("gaps") that Original Medicare doesn't cover, like copayments, coinsurance and deductibles. Some Medigap policies also offer coverage for services that Original Medicare doesn't cover, like medical care when you travel outside the U.S.. If you have Medicare Parts A and B and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs; then your Medigap policy pays its share. Medicare doesn't pay any of the premiums for a Medigap policy. For more information on what companies sell Medigaps and the benefits for each of the ten plans available, call HICAP at 1-800-434-0222 and ask for the Medicare Supplement (Medigap) packet.

For Medigap companies and plans

Do you have, or are you eligible for other types of health insurance or prescription drug coverage (like from a former or current employer or union)? If so, read the materials from your insurer or plan, or call them to find out how the coverage works with Medicare. If you have coverage through a former or current employer or union or other source, talk to your benefits administrator, insurer or plan before making any changes to your coverage. If you drop your coverage, you may not be able to get it back.

One of the best resources for answers to your Medicare questions is review is the Medicare & You publication that you receive each year in September or October. You can pick one up at your local Social Security office or call Medicare at 1-800-MEDICARE (1-800-633-4227) to order a copy. See our Resource Page for other informational websites and their phone numbers.