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Note: A previous version of this article misstated the out-of-pocket expenses for TotalCare. According to Linda Gorman, Marketing and Communications Director for Central California Alliance for Health, “TotalCare members will have $0 out-of-pocket costs for most routine and covered services, except for a nominal copayment for certain prescription drugs.”
Seniors on Medicare have until Dec. 7 to make changes to their coverage during the annual enrollment period starting on Oct. 15. However, with a host of competing choices—six prescription drug plans, 10 supplemental “Medigap” plans, and four Medicare Advantage plans—discerning the best combination of services can be confusing.
However, the volunteer-based Health Insurance Counseling and Advocacy Program (HICAP), operated by the state-funded Senior Network Services, can help seniors and their families make informed decisions through in-person workshops and phone consultations.
“A lot of seniors just don’t know how Medicare works,” HICAP Program Manager Bill Proulx said. “That’s what we’re here for. One benefit to you is that we can tell you the good, the bad, and the ugly.”
To help local seniors navigate the complexity of Medicare coverage, in-person assistance from HICAP is available at both the Pauline Valdivia Memorial Community Center in Hollister and the Mary Velasco Sullen Senior Center office in San Juan Bautista on designated days and times (see below).
According to Britt Bassoni, Director of Special Projects at the Seniors Council of Santa Cruz & San Benito Counties, no other organization does “anything remotely like what they do for seniors.”
“Covered California,” he said, “can give you a list of your plans, but they’re not walking you through why one plan might be a better fit for you than another. Unless you were going to pay a financial counselor, you’re not going to get this information anywhere else.”
According to Proulx, everyone with Medicare automatically receives Parts A (hospital insurance) and B (medical insurance), but for most people, this coverage is insufficient to meet their basic health needs. (Supplemental Part D plans cover prescription drugs.)
“The big expense with Medicare is the 20% co-insurance,” Proux said. “There are about 400,000 knee replacements every year in America, costing on average, $50,000. If somebody’s paying 20% of that, it’s $10,000 out of their pocket.”
That is where the web of other plans that may help with the coverage at an extra cost comes into play.
Proulx said there are two options. One is to enroll in a Medicare Advantage plan, which provides Part A and B benefits through a private insurance company approved by Medicare. This plan combines hospital, medical, and Part D benefits into one, and many also include extra benefits such as dental, vision, and fitness programs.
“If you ever see that commercial,” Proulx said, “where you can get everything for this low, low price? That’s what part C is. It’s your A, your B, and your D all rolled into one. They set up contracts with providers, and then you’re required to use those providers.”
Larger counties have more plan options available, like Fresno County, which offers 40. San Benito County is limited to four plans: three from Imperial Insurance and one from the Central California Alliance for Health (Total Care).
The differences between plans, Proulx said, come down to which specific medical needs are covered and at what price or co-pay. One plan may cover procedures that another may deny.
| Original Medicare | Medicare Advantage | |
| Basics | You get Parts A & B from the government. You can add private Medigap and Part D plans. | A private company provides your A, B, and D benefits as an all-in-one plan. |
| Provider | You can go to any doctor or hospital that accepts Medicare. No referrals needed for specialists. | You must use network-based doctors, specialists, and hospitals within the plan’s local network. |
| Costs | Higher, predictable monthly premiums. Lower, predictable costs when you need care. | Lower monthly premium, but there are co-pays and co-insurance for services. Yearly maximum out-of-pocket limit. |
| Drugs | Covered by purchasing a separate, standalone Part D plan. | Usually included in the plan. |
| Benefits | Does not cover dental, vision, or hearing. | Limited coverage for dental, vision, and hearing. |
One catch, according to Proux, is that coverage is complicated by some parts of it being federal, some parts state-specific, and some parts county-specific, but then your doctor may or may not take that insurance.
“It becomes a problem in Aromas,” he said. “Because it is in three counties, someone may be talking to their neighbor across the street who’s in Monterey County, but they reside in San Benito County and have different options.”
The other option is to enroll in a combination of a Part D plan (for prescriptions) and a Medigap plan, which helps cover some of the out-of-pocket costs for approved care not covered by original Medicare, such as deductibles, copayments, and coinsurance. There are eight different plans, including two legacy plans which are no longer available to new enrollees.
“These pay the co-pays, the co-insurances, and deductibles of parts A and B,” Proulx said, “The government doesn’t care if you have Medigap or not, but your doctor probably does because they don’t want to chase you for your 20%.”
As an example, Proulx said, some Medigap plans cover the first three pints of blood a patient might need. Without the insurance, the blood would cost anywhere from $350 to $1,000 per pint, depending on what kind of blood somebody needs and where that facility is getting the blood.
One advantage to Medigap plans, Proulx said, is that once a patient signs onto a particular coverage, the costs might go up but “neither the government nor the insurance company can change the benefits for life of the enrollee.”
Proulx said that people considering changes to their plan can start by looking at their Part D coverage, which is as easy as logging into www.medicare.gov and entering their prescriptions to compare their costs across various plans and pharmacies, as well as what tier their prescriptions fall under.
The tiers are:
Tier 1: Preferred generics (lowest co-pay/co-insurance)
Tier 2: Non-preferred generics
Tier 3: Preferred brand-name drugs
Tier 4: Non-preferred brand-name drugs
Tier 5: Specialty drugs (highest co-pay/co-insurance)
“No company or plan covers every drug on the market,” Proulx said. “Insurance companies decide which drugs they want to cover, and these various tiers can change. One company could list ibuprofen as a Tier 1, while another lists it as a Tier 2.”
The website will analyze an enrollee’s prescriptions and return details on 12 plans, ordered from least expensive to most expensive. The results include the monthly premiums and co-pays for the entire year, providing a lump sum for comparison of the plans.
Although unable to handle enrollments in any of the Medicare options, HICAP can still help residents understand the plans, out-of-pocket costs, coverage needs, and low-income assistance.
(Proulx suggests that those thinking about a change first talk to their doctor to make sure they accept whatever plan is being considered.)
The current enrollment period, from Oct. 15 to Dec. 7, allows for changes to your Medicare plan, such as switching from original Medicare to a Medicare Advantage plan, changing your Part D prescription plan, or moving to a Medigap plan.
In-person Medicare Enrollment assistance from HICAP is available at the Pauline Valdivia Memorial Community Center, 300 West Street, Hollister, from 9:30 a.m. to 1 p.m. on Wednesdays and at the Mary Velasco Sullen Senior Center office, 301 The Alameda, Suite 5B, San Juan Bautista, from 9:30 a.m. to 1 p.m. on Fridays.
San Benito County-specific information is available by phone at (831) 637-0630.
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