- In 2019, there were 173 Medicare Advantage Plans available in New York.
- 39% of the total Medicare population in New York was enrolled in Medicare Advantage Plans as of 2018.
- In 2018, Original Medicare spent an average of $10,464 per beneficiary in New York, which is 4% higher than the national average.
- Available Medicare Advantage Plans range from 19 to 97 across New York’s 62 counties.
Every Original Medicare beneficiary needs to decide if they will remain with their original program or select a Medicare Advantage Plan. You can choose from four types of Medicare Advantage Plans. If you received health care coverage from your employer in the past, you’ll recognize the way Medicare Advantage works in terms of selecting in-network or out-of-network medical care and the benefits offered like prescription drugs, vision, dental, or hearing.
Medicare Advantage Plans in New York
Types of Medicare Advantage Plans
Not every Medicare Advantage Plan is available in every New York county. It’s essential to consider the factors of each plan offered through the New York Medicare Advantage program. Each plan offers different benefits, and you should look at the pros and cons of each to find one that best suits your health care needs and finances.
These plans offer services from a list of specific providers in the HMO’s network. Many, but not all of these plans, provide prescription drug coverage. You’ll need to choose a primary care physician, and if you want a specialist, you generally need a referral. These plans have the lowest costs, and many don’t require extra premiums. However, if you see a doctor outside your plan’s network, you’ll be responsible for the full costs of the service unless it’s an emergency.
While Medicare Advantage PPO plans work with a network of health care providers, you can use doctors and hospitals from outside the network. However, these providers charge higher fees than in-network ones. You won’t need a primary care physician, nor do you need a referral to see a specialist in most cases. PPO New York Medicare Advantage Plans offer extra benefits not available under Original Medicare, but may carry an extra fee.
A Medicare Advantage PFFS plan sets limits on how much it will pay health care providers and what your share of the cost will be. In some cases, these plans will work with a network of providers who will only see members of that PFFS plan. It’s always less expensive to visit an in-network doctor, and some out-of-network providers may not accept the PFFS plan. (All health care professionals must treat emergencies.) Some, but not all, of these plans provide prescription drug coverage. If not, you can join a separate Medicare Part D prescription drug plan.
These plans are designed for people with specific health conditions or living arrangements. If you qualify for an SNP, you need to look for plans that provide the best coverage for your specific situation. You must use health care providers in the plan’s network, with exceptions made for emergency care or out-of-area dialysis. You will need to select a primary care physician, and referrals are necessary for specialists. All SNPs provide prescription drug coverage with formularies tailored to their clientele.
Enrollment and Eligibility for Medicare Advantage Plans in New York
- You need to be 65 years old or older or suffer from a disability to qualify.
- You need to be enrolled or eligible to be enrolled in Original Medicare’s Part A and Part B and not enrolled in Medigap.
- You must live in the county in which the Medicare Advantage Plan you select is provided.
- You must be a U.S. citizen or a permanent resident for longer than five years.
- For the first time in 2021, a senior with End-Stage Renal Disease (ESRD) can join a Medicare Advantage Plan.
- Initial Enrollment makes up the three months before you turn 65, the month you turn 65, and three months after you turn 65.
- October 15 to December 7 is the Open Enrollment window. During this time, you can switch from Original Medicare to a Medicare Advantage Plan or vice versa. You also can switch between Medicare Advantage Plans.
- Medicare Advantage Open Enrollment lasts from January 1 to March 31. During this time, you can switch Medicare Advantage Plans or return to Original Medicare. You cannot move from Original Medicare to a Medicare Advantage Plan. If you selected Medicare Part B for the first time during Open Enrollment, you can switch to a Medicare Advantage Plan from April 1 to June 30. Your coverage starts on July 1 that year.
- Special Enrollments apply if you move out of your coverage area or leave a job and lose employer-sponsored health care.
Prescription drug coverage
Medicare Part D pays for prescription drugs. If you have Original Medicare and wish to have drug coverage, you’ll need to sign up for a separate Part D plan. Many HMO and PPO Medicare Advantage Plans include prescription drug coverage as part of the benefits package, but you may need to pay a separate premium. Members who belong to HMO and PPO plans that do not include this coverage aren’t permitted to sign up for a separate Part D plan. If you’re enrolled in one of these plans and sign up for a Part D plan, you will be expelled from your Medicare Advantage Plan and placed back into Original Medicare. Many PFFS plans include prescription drug coverage, but you can sign up for a Medicare Part D plan if not. All SNP plans include prescription drug coverage
Medicare Advantage Resources in New York
Choosing a Medicare Advantage Plan is a little bit like selecting the perfect pair of jeans. You can like a lot of jeans, but you need to find a pair that’s just right for you. There are many Medicare Advantage Plans, but it’s important to find a plan that meets your treatment, cost, and location needs. Here are some resources to help you make that decision.
Department of Financial Services, New York
New York’s DFS offers details on Original Medicare, Medigap, Medicare Advantage Plans and open enrollment. The site includes several links to obtain further information along with a FAQ section. Visitors can file a complaint or email with any questions not already addressed by the department.
Contact Information: Website | 800-342-3736
Health Insurance Assistance/New York City Department of Aging
This division of the state’s Department of Aging offers a wealth of information for senior New Yorkers. You can speak over the phone with a trained expert who can provide details about the various plans. Free monthly orientation sessions are offered to help you understand your options.
Contact Information: Website | 212-244-6469
State Office for the Aging
New York’s State Health Insurance Assistance Program (SHIP) oversees trained Medicare counselors who work at each of the state’s Area Agencies on Aging. Seniors can get help with choosing plans, filing claims, and finding low-income assistance. The volunteers are completely unbiased and receive no reimbursement from any insurance provider.
Contact information: Website | 800-701-0501
Learn More From Our Sources
- Medicare.gov | Medicare Advantage HMO Plans | Last accessed June 2021
- Medicare.gov | Medicare Advantage PPO Plans | Last accessed June 2021
- Medicare.gov | Medicare Advantage PFFS Plans | Last accessed June 2021
- Medicare.gov | Medicare Advantage SNP | Last accessed June 2021
- Medicare.gov | Who can join a Medicare Advantage plan? | Last accessed June 2021
- Medicare.gov |Joining a Health or Drug Plan | Last accessed June 2021