Statewide program helps explain Medicare complexities

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Many of the decisions older workers have to make when considering retirement are so daunting that coping with them can feel like more work than staying at work. But Medicare doesn’t have to be one of them.

Should you enroll in Original Medicare or Medicare Advantage? Can you get a Medicaid supplement? What exactly will be covered and how can you compare different offers? A good first decision might be to throw away all the inevitable mail and electronic solicitations from medical and insurance providers touting their plans. You need unbiased, plain-language advice on which plan best suits your needs.

Californians can take advantage of the statewide Health Insurance Counseling and Advocacy Program (HICAP), a project of the nonprofit Self-Help for the Elderly, which aims to help older adults maintain their independence.

HICAP aims to help people nearing retirement, as well as those already on Medicare, understand their benefits, options, and rights. Services range from online presentations to communities to in-person appointments at local offices with trained volunteer counselors registered with the California Department of Aging, which administers HICAP.

HICAP’s services are free, and perhaps most importantly, scrupulously objective. It does not sell or endorse specific plans.

Social Security Administration: 1-800-772-1213, 8 a.m.-7 p.m., Monday through Friday. Wait times are generally shorter from 8am to 10am and 4pm to 7pm, and during the last half of the week and month.

Health Insurance Counseling and Advocacy ProgramCalifornia Department of Aging: 800-434-0222

Alameda County HICAP: 333 Hegenberger Rd, Suite 850, Oakland, 510-839-0393

Contra Costa County HICAP: 400 Ellinwood Way, Pleasant Hill, 800-510-2020 (within Contra Costa from landline), 925-655-1393

Sonoma County HICAP: 1129 Industrial Ave, Suite 201, Petaluma, 707-526-4108

San Francisco HICAP: 601 Jackson St., 2nd Floor, San Francisco, 415-677-7520

San Mateo County HICAP: 1710 S. Amphlett Blvd., Suite 100, San Mateo, 650-627-9350

Santa Clara County HICAP: 3100 De La Cruz Blvd., Suite 310, San Jose, 408-350-3200, option 2


“There are big differences between … original Medicare and Medicare Advantage plans, but SF HICAP needs to give beneficiaries an overview of both and let the beneficiary decide,” said Jane Blonien, program specialist for San Francisco HICAP. “We, as staff and volunteers, must remain neutral.”

The first step is to contact the Social Security Administration when retirement is on the horizon. They will verify eligibility and help determine which forms to submit for enrollment in Medicare Parts A (covering hospitalization) and B (outpatient care).

If you have internet access, create an online account at www.ssa.gov, if you don’t already have one. Not only will applying for benefits almost certainly be faster than calling, but logging into the website also allows you to view your Social Security account, estimate future benefits, check the status of a claim, or to schedule appointments if necessary.

After enrolling in the program, “Medicare.gov is a great way to start navigating the Medicare system,” Blonien said. “The beneficiary can access available Medicare Advantage plans, Medigap plans and premiums, and standalone Part D plans (which work with Original Medicare).”

Then it’s time to call your local HICAP office for a “new to Medicare” counseling appointment. Every county in the state has one.

The confusing tangle of pros and cons involved in choosing between original federally-run Medicare and Medicare Advantage or similar health plans offered by private companies that provide Medicare Parts A and B under contract with Medicare is a good example of how HICAP advisors can help you sort it out. out.

A major difference between the plans is that a Medicare Advantage plan generally limits members to its network; the member will have to pay for outpatient care himself or pay the scheme high “out-of-network” co-insurance costs. But the advisor will also point out that Medicare Advantage offers benefits that original Medicare does not, such as limited eye care, dental and hearing coverage, gym and exercise club memberships, and generally coverage. Medicare Part D drug plan. It’s up to you whether this outweighs the restrictions.

Another difference: “Original Medicare covers 80% (of the cost of care) and there is 20% co-insurance,” Blonien said. That means a beneficiary without Medicare supplemental insurance, aka Medigap, could face huge but unknown costs.

“On the other hand, Medicare Advantage plans have a maximum Out-of-Pocket (MOOP), and the beneficiary knows what the eventual price limit might be if they get sick,” Blonien said.

Other issues HICAP counselors can explain include health insurance terminology, billing and claims procedures, coordinating Medicare with any retiree insurance plans or COBRA coverage you may have, healthcare insurance long-term care and programs such as Medi-Cal’s Medicare savings programs and Medicare Supplemental Assistance that reduce costs for low-income beneficiaries. Advisors can also help with choosing a Medigap policy, maintaining medical records, legal issues, and dealing with health care providers.

HICAP will also present one of its free educational programs, upon request, to groups of Medicare beneficiaries, their families and/or providers.

HICAP has the Bay Area well covered with offices in San Francisco, San Mateo, San Jose, Oakland, Pleasant Hill, and Petaluma (which also serves Marin, Napa, Mendocino, Lake, and Solano counties). Although head office is in these cities, counseling may take place in local offices scattered throughout their respective communities. Whether you have a question about the Medicare benefits you already receive or wondering how to get started, reliable, free help is just a phone call or a click away.

About Irene J. O'Donnell

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