Medicare beneficiaries living in New York and enrolled in Original Medicare, Part A and Part B, have various coverage options available through the Medicare Advantage (Medicare Part C) program, depending on the zip code in which they live. Medicare Advantage is required by law to offer at least the same benefits as Original Medicare, except for hospice care, which is still covered through Part A of the federal program. Like residents of other states, New York residents enrolled in Medicare Part C get their benefits directly through their individual Medicare Advantage plan instead of through the government-run program.
How Medicare Advantage works in New York
New York beneficiaries are eligible for Medicare Advantage coverage if they:
- Are enrolled in Medicare Part A and Part B.
- Live in the service area of a Medicare Advantage plan.
- Do not have end-stage renal disease (with some exceptions).
Original Medicare consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). In New York, as in other states, you can sign up for Original Medicare starting three months before you turn 65, during your birthday month, and in the three months after the month you turn 65. This is your seven-month Medicare Initial Enrollment Period (IEP). Be aware that if you don’t sign up for Original Medicare during your IEP, you can still enroll during the General Enrollment Period, which runs from January 1 to March 31 each year, but you may have to pay a late-enrollment penalty for Part A and/or Part B in the form of higher premiums. Once they’re enrolled in Original Medicare, New York Medicare beneficiaries can sign up for Medicare Advantage plans as an alternative way to get their Original Medicare coverage. Offered by Medicare-approved private insurance companies in New York, Medicare Advantage plans cover the same hospitalization and medical benefits offered by Original Medicare. New York Medicare Advantage plans may offer additional benefits such as routine vision, hearing, routine dental, and/or prescription drug coverage.
You’re first eligible for Medicare Part C during your Initial Coverage Election Period (ICEP), which typically coincides with the same seven-month period as your Initial Enrollment Period for Part B (starting three months before you turn 65, including your birthday month, and ending three months after that). If you delay enrollment in Part B, your ICEP is the three-month period before your Part B coverage starts.
After your Initial Coverage Election Period passes, you’ll generally have to wait until certain times of the year to enroll in or make changes to your Medicare Part C coverage. If you’re already enrolled in a Medicare Advantage plan and wish to change plans, or if you’re enrolled in Original Medicare and want to enroll in a Medicare Advantage plan for the first time, the best time to do so is during Fall Open Enrollment, also known as the Annual Election Period (AEP), which runs from October 15 to December 7 each year. In New York, as in other U.S. states, if you change Medicare plans during the AEP, your new coverage generally begins on January 1 of the following year. You can also use this period to disenroll from your Medicare Advantage plan and return to Original Medicare.
In certain special circumstances during the year, you may be able to change Medicare plans during Special Election Periods (SEPs). Some examples of qualifying situations include moving to a new address where your Medicare Advantage plan isn’t offered, losing your current coverage (for example, losing Medicaid eligibility), or qualifying for other coverage (such as becoming eligible for the Extra Help program). The duration and details of your Special Election Period may vary, depending on the reason you qualify for one.
If you’re enrolled in a Medicare Advantage plan and want to switch plans, you can do so during the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31 each year. You can also switch back to Original Medicare, Part A and Part B, at this time. Then you can use this period to enroll in a stand-alone Medicare Prescription Drug Plan to go alongside your Original Medicare.
Types of Medicare Advantage plans in New York
Medicare Advantage plan options in New York include, among others, Health Maintenance Organizations (HMOs), Preferred Provider Organization (PPO) plans, Special Needs Plans (SNPs), Private Fee-for-Service (PFFS) plans, and Medical Savings Account (MSA) plans.
If you select an HMO plan, you are required to visit doctors, health-care providers, and hospitals in the health plan’s provider network to be covered (with the exception of emergency or urgent care). You’re also usually required to have a primary care physician, and you may also need a referral from your primary care doctor to receive coverage for certain specialist health services. If you want more flexibility, you can opt for an HMO Point-of-Service (HMO-POS) plan. HMO-POS plans allow you to go out of network for certain health services, but at a higher cost.
PPO plans* are another type of Medicare Advantage plan that may be available to Medicare beneficiaries in New York. These types of plans let you choose doctors, health-care providers, and hospitals outside of the plan’s provider network, but you may end up paying more by exercising this option.
If you have special health needs, you may be eligible for Medicare Special Needs Plans, which generally limit enrollment to people with certain chronic or disabling conditions; those living in an institution (such as nursing homes); or those who also qualify for Medicaid. Medicare SNPs offer customized coverage to meet these specific conditions. For example, a SNP that targets people with diabetes may have provider networks with doctors who specialize in treating patients with diabetes or may have certain services to help its members better manage their condition.
You may also opt for a Medicare PFFS (Private Fee For Service) plans, where the PFFS plan decides how much it will pay for your doctor, health-care provider, and hospital visits, and also determines your share of each expense. These plans generally allow you to see any provider that will accept the plan’s terms and conditions and agree to treat you; you’ll have to find providers that will contract with the plan on a case-by-case basis. Some PFFS plans have provider networks of doctors and hospitals that have signed a contract agreeing to always treat you.
MSA plans are another option for Medicare Advantage beneficiaries in New York. MSA plans generally combine a high deductible with a savings account that beneficiaries can use to pay for their health-care expenses.
Many Medicare Advantage plans include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug plans, and they combine health and prescription drug coverage (Medicare Part D) into one insurance plan. Most of the above types of Medicare Advantage plans may cover prescription drugs, with the exception of MSA plans and some PFFS plans. Be aware that regardless of whether you choose to enroll in a Medicare Advantage or Medicare Advantage Prescription Drug plan, you must remain enrolled in Original Medicare and continue paying your Medicare Part B premiums in order not to lose your health coverage.
Comparing Medicare Advantage plans in New York
Medicare-contracted private health insurance companies across the state of New York offer a variety of Medicare Advantage plans for Medicare beneficiaries. Each Medicare Advantage plan may charge different costs and may have different rules regarding services, and these rules may change on a yearly basis, so it’s important for beneficiaries to compare available Medicare Advantage plan options based on their own unique location and health needs.
The availability and cost of Medicare Advantage plans varies depending on your service area. Premiums for a Medicare Advantage plan with the same coverage and benefits can vary between different service areas within the state of New York. Some Medicare Advantage plans in New York may offer premiums as low as $0, but do keep in mind that you must continue paying your Medicare Part B premiums, even if your Medicare Advantage plan has a $0 premium.
Medicare Advantage plans may offer additional benefits beyond what is included in Original Medicare coverage. You also need to decide whether or not you want prescription drug coverage with your Medicare Advantage plan through a Medicare Advantage Prescription Drug plan and whether you want a plan that covers additional benefits (such as hearing or wellness programs). With all these options, you can see why it can be important to compare plans with the benefits and costs best suited to your specific health needs.
You might also want to read more on Medicare Supplement (Medigap) Plans in New York.
*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.