NYC Medicare Advantage Plus Plan
The NYC Medicare Advantage Plus Plan (PPO) includes many health resources and benefits that Original Medicare does not offer, like:
• Flu and pneumonia vaccines, and most health screenings
• Inpatient hospital care and ambulance services
• Emergency and urgent care
• Skilled nursing facility benefits
• Complex radiology services and radiation therapy
• Diagnostic procedures and testing services received in doctor’s office
• Lab services and outpatient X-rays
• Home health agency care
• Routine hearing exams and hearing aid coverage
• Outpatient surgery and rehabilitation
• Non-emergency transportation
• Diabetes services and supplies
• Healthy meals
• Healthy pantry
• Durable medical equipment and related supplies
• Prosthetic devices
• Wearable health and fitness tracker
• 24/7 NurseLine
• SilverSnakers fitness program
• Medicare Community Resource Support
• Doctors available anytime, anywhere with LiveHealth Online
• Foreign travel emergency and urgently needed services
What is the new NYC Medicare Advantage Plus Plan ("The Plan")?
A unique, customized Medicare Advantage plan to provide better benefits for NYC retirees at lower costs.
When does the NYC Medicare Advantage Plus Plan go into effect? January 1, 2022.
How does The Plan work?
The Plan replaces both traditional Medicare and a Medicare Supplement plan with a single, integrated program administered by a Medicare-approved insurer. The Plan provides all health care services previously covered by Medicare and supplemented by the Senior Care plan. It adds important new benefits not covered by the current Senior Care plan, including: • Transportation costs for 24 one-way trips per year to doctors’ offices; • Home meal delivery for patients after being discharged from the hospital; • A fitness program & wellness rewards program; • $0 copay telemedicine with LiveHealth platform.
Is The Plan still premium-free? Yes.
Can I go to my current doctors and hospitals?
Yes. Retirees can go to any doctor or hospital that accepts Medicare. Providers not contracted with The Plan will bill The Plan for reimbursements. It does not make a difference if a provider is in the insurer’s network. As long as the provider takes payment from Medicare, they may bill the NYC Medicare Advantage Plus Plan and be paid the same amount as Medicare. This includes all hospitals in the NYC area, including Memorial Sloan-Kettering (MSK) and The Hospital for Special Surgery (HSS), almost all hospitals nationally, and 99.5% of all doctors.
What if the provider I see does not agree to accept payment from The Plan?
In the rare instance where a provider accepts Medicare and tells a retiree he will not accept payment from The Plan, the retiree must first contact The Plan’s concierge service. The Plan will make sure the provider understands it is the same payment schedule and billing protocol and answer other questions. If the provider still refuses, the member can pay the provider and then submit claims to The Plan for reimbursement. As long as the service is a Medicare-covered benefit and the Medicare fee schedule is followed, the member is only responsible for copays/co-insurance as defined by The Plan.
Who will provide the NYC Medicare Advantage Plus Plan?
An alliance between Empire BlueCross BlueShield and EmblemHealth .
What do I have to do?
If you are covered by a City retiree health plan, you will be automatically enrolled on January 1, 2022. However, you must be enrolled in Medicare Part A and Medicare Part B and continue to pay your Medicare Part B premiums.
Can I choose another plan or is the NYC Medicare Advantage Plus Plan my only choice?
You may choose to remain in your current plan by “opting out” of the NYC Medicare Advantage Plus Plan before Nov. 1, 2021. By opting out, you will be responsible for the premium share difference between the NYC Medicare Advantage Plus Plan and your selected plan’s cost.
Will this year be the only time I can opt in or out?
No. Every fall you will have the option to make changes to your coverage just like you do with the current system.
Will my co-pays remain the same?
The NYC Medicare Advantage Plus Plan will have $0 copays for primary care physician visits. Effective January 1, 2022, there will be $15 copays implemented for the Senior Care Plan, including primary care physician and specialist visits, and diagnostic tests, among other new copays.
Will the City reimburse my Medicare Part B premium?
Yes. The current reimbursement process for Medicare Part B premiums will continue.
In the Medicare Advantage Plus Plan, do I need a referral to see a specialist? No.
Do any services require preauthorization?
Yes, some medical procedures do require preauthorization. When you see an in-network provider, the doctor and the insurer will handle the preauthorization.
What if I live out of state?
The NYC Medicare Advantage Plus Plan includes a national network of doctors and hospitals.
What if the retiree or spouse/legal partner is under 65?
The retiree and spouse must choose an insurer that offers an over 65 option and an under 65 option. The over 65 members will be automatically enrolled in The Plan and the under-65 members in the Empire GHI/CBP plan, both at no cost to the retiree. For example, if the retiree chooses to pay monthly to remain in the HIP VIP plan, the under 65 spouse or legal partner will be enrolled in the HIP HMO for non-Medicare eligible participants at no cost. If the retiree chooses to pay monthly to remain in another plan, the under-65 spouse will pay up to remain with the same insurer.
If I have surgery scheduled for Jan. 3, 2022, with my current carrier, what should I do?
The Plan’s clinical transition team will work with you and your doctor to ensure continuity of care.
What happens if I go to the hospital in December and I’m not discharged until January?
The insurer that was in place at the time of the inpatient admission will be responsible for the entire inpatient stay.