Protections For Medicare Beneficiaries Residing in New York State
Improvements to Medicare's Preventative Care Coverage
Medicare beneficiaries pay nothing for most preventive services if the services are received from a doctor or other health care provider who participates with Medicare (also known as accepting assignment). For some preventive services, the Medicare beneficiary pays nothing for the service, but may have to pay coinsurance for the office visit to receive these services.
Medicare covers two types of physical exams; one when you're new to Medicare and one each year after that. The Welcome to Medicare physical exam is a one-time review of your health, education and counseling about preventive services, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months of enrolling in Part B. You will pay nothing for the exam if the doctor accepts assignment. When you make your appointment, let your doctor's office know that you would like to schedule your Welcome to Medicare physical exam. Keep in mind, you don't need to get the Welcome to Medicare physical exam before getting a yearly Wellness exam. If you have had Medicare Part B for longer than 12 months, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. Again, you will pay nothing for this exam if the doctor accepts assignment. This exam is covered once every 12 months.
Medicare Supplement "Medigap" Insurance
Medicare Supplement (Medigap) insurance is health insurance sold by private insurance companies to cover some of the "gaps" in expenses not covered by Medicare.
For policies sold before June 01, 2010, there are fourteen standardized plans A through L. For policies sold on or after June 01, 2010, there are 11 standardized plans A through N. Each standardized Medigap policy must provide the same basic core benefits such as covering the cost of some Medicare copayments and deductibles. Some of the standardized Medigap policies also provide additional benefits such as skilled nursing facility coinsurance and foreign travel emergency care. However, in order to be eligible for Medigap coverage, you must be enrolled in both Part A and Part B of Medicare.
As of June 1, 2010, changes to Medigap resulted in modifications to the previously standardized plans offered by insurers. Medigap plans H, I, and J, which contained prescription drug benefits prior to the Medicare Modernization Act, were eliminated. Plan E was also eliminated as it is identical to an already available plan. Two new plan options were added and are now available to beneficiaries, which have higher cost-sharing responsibility and lower estimated premiums:
- Plan M includes 50 percent coverage of the Medicare Part A deductible and does not cover the Part B deductible
- Plan N does not cover the Part B deductible and adds a new co-payment structure of $20 for each physician visit and $50 for each emergency room visit (waived upon admission to hospital)
Certain Medigap benefits were also be modernized. The At-Home Recovery benefit, which was previously offered in only Plans D, G, I, and J was eliminated. In its place, a new Hospice Care benefit was created and was added as a basic benefit available in every Medigap plan. The under-utilized Preventive Care Benefit, which was previously only offered in Plans E and J, was eliminated. The 80 percent Medicare Part B Excess benefit, available in Plan G, was changed to a 100 percent coverage benefit. Insurers are also now required to offer Plans A and B, as well as either Plan C or Plan F. Previously insurers only had to offer Plans A and B.
Individuals enrolled in plans with an effective date prior to June 01, 2010 have the right to keep their existing policies in force. Medicare supplement insurance is guaranteed renewable.
As of January 1, 2020, the Medicare Access and CHIP Reauthorization Act (MACRA), which the federal government enacted in 2015, resulted in modifications to the availability of certain Medigap plans. On or after January 1, 2020, insurers may not offer plans C, F, or high-deductible plan F to newly eligible Medicare beneficiaries. “Newly eligible” is defined as those individuals who first become eligible for Medicare due to age, disability, or end-stage renal disease, on or after January 1, 2020.
Existing insureds covered under plans C, F, or high-deductible plan F prior to January 1, 2020 may continue to renew their coverage due to guaranteed renewability. All three of these Medigap plans cover the Medicare Part B (medical insurance) deductible. On or after January 1, 2020, insurers are required to offer either Plan D or G in addition to A and B. The MACRA changes also created a new high-deductible Plan G that may be offered starting January 1, 2020.
For more information on Medicare supplement insurance plan design/benefits, please see the Benefit Chart of Medicare Supplement Plans.
New York State law and regulation require that any insurer writing Medigap insurance must accept a Medicare enrollee's application for coverage at any time throughout the year. Insurers may not deny the applicant a Medigap policy or make any premium rate distinctions because of health status, claims experience, medical condition or whether the applicant is receiving health care services. However, eligibility for policies offered on a group basis is limited to those individuals who are members of the group to which the policy is issued.
While every Medigap insurer offers both plan A and B for policies sold before June 01, 2010, plans A, B and either C or F for policies sold on or after June 01, 2010, and plans A, B and either D or G for policies sold on or after January 1, 2020, not every company offers all standardized plans.
Medigap policies may contain up to a six (6) month waiting period before pre-existing conditions are covered. A pre-existing condition is a condition for which medical advice was given or treatment was recommended or received from a physician within six months before the effective date of coverage. However, under New York State regulation, the waiting period may be either reduced or waived entirely, depending upon your individual circumstances. Medigap insurers are required to reduce the waiting period by the number of days that you were covered under some form of "creditable" coverage so long as there were no breaks in coverage of more than 63 calendar days. Coverage is considered "creditable" if it is one of the following types of coverage:
- A group health plan
- Health insurance coverage
- Medicare (Credit for the time a person was previously covered under Medicare is required only if applicant submits an application for Medigap insurance prior to, or during, the six month period beginning with the first day of the first month in which an individual is both 65 years of age or older and is enrolled for benefits under Medicare Part B.)
- CHAMPUS AND TRICARE health care programs for the uniformed military services
- A medical care program of the Indian Health Service or of a tribal organization
- A State health benefits risk pool
- Federal Employees Health Benefits Program
- A public health plan (any plan established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country that provides health coverage to individuals who are enrolled in the plan
- A health benefit plan issued under the Peace Corps Act
- Medicare supplement insurance, Medicare select coverage or Medicare Advantage plan (Medicare HMO Plan)
NOTE: New York's Open Enrollment and Portability provisions protect you whether you are Medicare eligible by reason of age or disability. The provisions also apply to Medicare beneficiaries with end stage renal disease.
Medicare Select is a type of Medigap policy that requires insureds to use specific hospitals and in some cases specific doctors (except in an emergency) in order to be eligible for full benefits. Other than the limitation on hospitals and providers, Medicare Select policies must meet all the requirements that apply to a Medigap policy. Medicare Select policies may have lower premiums because of this requirement.
When you use the Medicare Select network hospitals and providers, Medicare pays its share of approved charges and the insurance company is responsible for all supplemental benefits in the Medicare Select policy. In general, Medicare Select policies are not required to pay any benefits if you do not use a network provider for non-emergency services. However, Medicare will still pay its share of approved charges no matter what provider you use.
Currently no insurers are offering Medicare Select insurance in New York State.
Medicare Advantage Plans Offered in New York State
Medicare Advantage Plans are approved and regulated by the federal government's Centers for Medicare and Medicaid Services (CMS). For information regarding which Plans are available and the Plan's benefits and premium rates, please contact CMS directly or visit CMS Medicare web site.
Medicare Open Enrollment
During the federal Open Enrollment period, current or newly eligible Medicare beneficiaries, including people with Original Medicare, can review current health and prescription drug coverage, compare health and drug plan options available in their area, and choose coverage that best meets their needs. This is the time when Medicare eligible individuals can enroll in Medicare Advantage and Medicare Part D prescription drug plans.
People with Medicare, their families and other trusted representatives can review and compare current plan coverage with new Medicare Advantage and Medicare Part D plan offerings. The following resources may be helpful in comparing plan offerings:
- www.medicare.gov, which allows individuals to get a comparison of costs and coverage of the plans available in their area using the Medicare Plan Finder and Medicare Options Compare tools.
- 1-800-MEDICARE (800) 633-4227 for assistance to find out more about coverage options. TTY users should call (877) 486-2048.
- Medicare and You Handbook.
- One-on-one counseling assistance from the New York State Office for Aging Health Information Counseling and Assistance Program (HIICAP). Call (800) 342-9871 to be directed to your local office.
- A listing of national stand-alone prescription drug plans and state specific fact sheets can be found at www.cms.gov
Medicare Prescription Drug Coverage (Part D)
Medicare Part D is prescription drug coverage that is partially subsidized by the federal government. To be eligible, you must be entitled to benefits under Medicare Part A and/or enrolled under Part B. You must choose a plan, enroll, and pay a monthly premium to get the coverage. If you have limited income and resources, you may get this coverage for little or no cost by applying for the Low Income Subsidy.
To take advantage of this coverage, you may join a Medicare Prescription Drug Plan that covers prescription drugs only and keep Original Medicare (Medicare Part A and B) or you can join a Medicare Advantage Plan that also offers prescription drug coverage.
- For a listing of available Medicare Part D Plans, please use the Medicare Plan Finder available on the CMS website.
- If you have prescription drug coverage through an employer or union, check with your benefits administrator to discuss your options. The prescription drug coverage under your employer/union plan may be equal to or better than Medicare prescription drug coverage and you may not need to enroll in Medicare Part D.
- If you have prescription drug coverage under the Elderly Pharmaceutical Insurance Coverage (EPIC) Program, contact EPIC for more information about your options.
- If you have a Medicare supplement insurance plan with prescription drug coverage (Plans H, I, or J), you will receive a letter from your carrier describing your prescription drug options. If you need additional assistance contact the Health Insurance Information Counseling & Assistance Program (HIICAP) at (800) 701-0501.
For more information about Medicare prescription drug coverage, see the federal Centers for Medicare and Medicaid Services (CMS) publication Medicare and You Handbook. For more information about the Medicare Advantage Plans or Medicare Prescription Drug Plans available in your area, visit the federal Medicare website or call 1-800-MEDICARE (800) 633-4227. TTY users should call (877) 486-2048.