Health Insurance Counseling and Advocacy Program (HICAP) provides unbiased information to help you make an informed decision for your individual health care needs.
Health Insurance Counseling and Advocacy Program (HICAP) provides individual counseling and assistance on all Medicare health insurance issues as well as community education services. HICAP does not sell, endorse, or recommend any specific insurance product.
A Medigap policy is health insurance sold by private insurance companies to fill gaps in original Medicare coverage and is designed to cover the Medicare co-payments, coinsurance, and deductibles.
Medicare Advantage Plans are health plan options like an (HMO or PPO) approved by Medicare and offered by private companies. These plans are part of Medicare and are sometimes called “Part C” or “MA plans.” Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans and they in turn are responsible for your health care. Medicare Plans include:
The different enrollment periods for Medicare are as follows:
Initial Enrollment Period begins three months before the month of the 65th birthday and ends three months after the month of the 65th birthday. The initial enrollment period is seven months, including the month of the person’s 65th birthday.
Special Enrollment Period (SEP) for Those Who Still Work begins the first day of the first month the person is no longer enrolled in the employer health plan, and ends eight months later (or six months in the case of people with disabilities whose group plan is involuntarily terminated.
General Enrollment Period is for those who miss their initial enrollment period. This may be done only during January – March of each year. If a person enrolls in a general enrollment period Medicare coverage will be effective July 1 of that calendar year.
Late Enrollment – An individual may enroll during her/his initial enrollment period or special enrollment period without penalty. Those who do not enroll during these specified periods, but enroll in a later general enrollment period, will have to pay a monetary penalty.
Medicare offers prescription drug coverage (Part D) for everyone with Medicare. To get Medicare 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 want Medicare drug coverage, you need to choose a plan that works with your health coverage.
In 2009, you entered the coverage gap when the total cost of your prescription drugs – including what you paid plus what was paid for your drugs by your Medicare drug plan on your behalf – exceeded $2,700. You remained in the coverage gap until what you spent out of pocket in 2009 – excluding what your Medicare drug plan paid on your behalf – reached $4,350. If your total out-of-pocket costs exceeded $4,350 in 2009, you entered catastrophic coverage. In 2012, the thresholds to enter and leave the coverage gap increased to $2,930 and $4,700 respectively. As a result of the Affordable Care Act, one no longer pays the full 100% of drug costs in the coverage gap. Instead, there is a 50% discount on brand name drugs and a 14% discount on generic drugs.
Help is available for people with lower incomes and limited savings. In 2012, individuals qualify if their income is below $16,755 and they have assets of less than $13,070. Couples qualify for extra help if their income is below $22,695 and assets are less than $26,120. Depending on the level of need, premiums, deductibles, co-insurance, and coverage gaps may be reduced or eliminated. Assets include items like checking, savings, CDs, IRAs, and 401Ks, but exclude items like houses and necessary cars.
Beneficiaries who have both Medicare and Medi-Cal are often referred to as “dual eligibles” or “Medi-Medi’s. Medicare is the beneficiary’s primary coverage. Medi-Cal acts as the secondary coverage and pays for Medicare co-payments and deductibles plus some benefits that Medicare does not cover. Med-Cal also pays the Medicare Part B premium for those with full Medi-Cal.
