Medicare Advantage (Part C) replaces Original Medicare (Part A & B), but must offer at least the same Part A and B benefits or coverage as Original Medicare .
Along with receiving Part A and B benefits, Medicare Part C often bundles additional services like dental, hearing, vision and prescription drug coverage.
Medicare Advantage beneficiaries often have provider networks they must choose from. These are groups of doctors their insurance company has agreed to pay for services. Seeing out-of-network doctors could mean higher costs.
Medicare Advantage plans generally have out-of-pocket maximums. After a beneficiary reaches this spending limit, their health insurance company covers the rest of their costs for the year.
Whether you live upstate or in one of the five boroughs, the state of New York has several health care options available for residents aged 65 and older. One of those is Medicare Advantage (Part C). To know if Part C is right for you, you’ll want to answer some basic questions: What are the Medicare Advantage plans NY residents can choose from? How much do they cost, and how do they work?
To help find answers, here is GoHealth’s guide to Medicare Advantage in New York.
Find a local Medicare plan that fits your needs
To understand what’s covered by Medicare Advantage plans, NY residents should know the basics of Original Medicare (Parts A and B). Even though it’s changed over the years, this traditional form of Medicare provides the minimum framework for how Medicare Advantage (Part C) plans cover their beneficiaries. In other words, Medicare Advantage plans must provide at least the same coverage as Original Medicare.
Original Medicare consists of two Parts: A and B. Medicare Part A provides hospital coverage by helping pay for inpatient care. Part B helps cover outpatient care like doctor’s visits and therapies, and even medically necessary durable medical equipment. Original Medicare also covers preventive services like screenings and behavioral therapy for weight loss. However, you must purchase additional policies if you need services like dental, vision, hearing, and prescription drugs.
Medicare Advantage replaces Original Medicare (Part A & B) but offers the same Part A and B benefits or coverage as Original Medicare. You’ll have at least the same access to inpatient, outpatient and preventive care. Along with receiving Part A and B benefits, Medicare Part C often bundles additional dental, hearing, vision, and prescription drug coverage.
What doctors are covered with Medicare Advantage?
Medicare Advantage plans generally use a primary care physician to manage your care and other specialists to treat any issues that come up along the way. These doctors are part of your provider network, or a group of doctors and other qualified providers the health insurance company has contracted to treat its customers. Depending on the type of Medicare Advantage plan you have, you may have the option of seeing out-of-network doctors for a higher fee, or not at all.
Here are four common types of Medicare Advantage plans NY state has to offer:
- Health Maintenance Organization (HMO) : These plans feature primary care physicians who manage your care and refer you to other doctors in your provider network.
- Preferred Provider Organization (PPO): PPOs use primary care physicians but allow you the freedom to see in-network providers without referrals.
- Private Fee-for-Service (PFFS): PFFS plans pay your providers each time you receive a service.
- Special Needs Plans (SNP): condition-specific plans designed for beneficiaries with certain diseases or health issues. D-SNP assists dual eligible individuals, and C-SNP is for people with chronic diseases.
If you have a plan that does not allow you to see out-of-network doctors, you may still receive care. If you do, you’ll probably be stuck paying full price for your service. If you’re unsure whether your doctor or specialists are in-network, make sure to verify your coverage with your doctor’s office.
Medicare Advantage plans do not have standard rates they must charge. That means the cost of Medicare Advantage plans in NY comes down to your specific needs, and which plan you choose. If you or a loved one are budgeting for health care costs, here are some key things to know about the cost of Medicare Advantage plans in New York:
- Premiums: The monthly cost of a Part C plan can vary greatly; some plans offer no-cost premiums while others may charge the standard Part B premium plus their monthly amount. You may also have to pay a Part A premium if you didn’t work long enough to qualify for a no-cost premium.
- Deductible: this is the amount you must pay before your coverage kicks in. Like premiums, the amount of your deductible depends on your plan. Some offer no-cost deductibles for medical and dental coverage. Others may charge the standard deductibles from Part A and Part B — or more.
- Copayments and coinsurance: these are the payments you make out of pocket. Instead of the percentage-based coinsurance model Original Medicare uses, many Part C plans charge copayments. These are flat-rate payments you make to your doctor or provider when you receive a service. While it’s difficult to know exactly how many of these you’ll need to pay, it’ll have a significant impact on your bottom line.
- Out-of-pocket maximum: Many beneficiaries are drawn to Medicare Advantage because many of these plans will cover all costs after you reach a specific annual spending limit. Known as the out-of-pocket maximum, this feature is a crucial difference between Part C and Original Medicare, which does not offer such a cap on your costs.
- In-network vs. out-of-network: We’ve discussed it already, but it’s worth repeating here; sticking to in-network doctors can often save you money if you have Medicare Advantage. Depending on the type of Part C plan you’re enrolled in, you may have to pay full price for any services you receive outside your plan.
Are you eligible for cost-saving Medicare subsidies?
To be eligible for Medicare Advantage in New York, you must be a legal U.S. citizen. You’re typically first eligible to enroll in Medicare the year you turn 65, but you may be able to enroll early if:
- You have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease.
- You’ve received disability-based Social Security benefits.
- You’ve drawn Railroad Retirement Board benefits for 24 months.
How to enroll in Medicare Advantage Plans: NY edition
There are several opportunities to enroll in Medicare Advantage once you turn 65. The first thing to do is enroll in Parts A and B when you’re first eligible; this will not only allow you to switch to a Part C plan, but will ensure you won’t have to account for any late enrollment penalties. After you’re enrolled in Parts A and B, you can switch to Medicare Advantage at several different points.
Initial Enrollment Period (IEP)
Once you first enroll in Parts A and B, you can switch over to a Medicare Advantage plan while your seven-month IEP window is still open. If you choose a Part C plan without prescription drug coverage, you can add a Part D plan at this time, too.
Medicare Open Enrollment Period
Medicare beneficiaries enrolled in Parts A and B can switch to Medicare Advantage each year from Oct. 15 to Dec. 7. If you already have Medicare Advantage, this is the window when you can switch plans, join a Medicare drug plan if you need it, and even drop your coverage altogether. Changes made during Annual Enrollment take effect on Jan. 1.
Special Enrollment Period
Certain life events can throw your health coverage up in the air. When this happens, you may qualify for a Special Enrollment Period. These are enrollment windows that will open to allow you to make changes to your health insurance. Common reasons for an SEP for older adults include moving to a new area or losing other coverage. If you qualify, you can enroll in Medicare Advantage as you would during your Initial Enrollment Period.
Can I change Medicare Advantage plans before next year?
Suppose you don’t qualify for a SEP but aren’t satisfied with the Part C plan you chose during your Open or Initial Enrollment Periods. In that case, you can make a one-time switch during the Medicare Advantage Open Enrollment Period. This window opens on Jan. 1 and lasts until March 31. Changes take effect July 1.
Yes, many of the Medicare Advantage plans NY has to offer include prescription drug coverage into their benefits. You won’t need to add and pay for a Part D plan separately with one of these plans. To choose a plan that fits your needs, you’ll want to find your medications in the health insurance company’s drug formulary. This is a list of the medications it covers, which have been classified into several tiers. This can help you understand what it will charge for your medications. As a guide, cost-effective generics are often found in lower tiers, while pricey name-brand drugs are in the top tiers.
What extra benefits and savings do you qualify for?
Before 65 Guide
Understanding health insurance before age 65, especially when considering early retirement
Medicare Plans Guide
Costs, coverage and enrollment details for each Medicare plan
Medicare Beneficiary Guide
For those currently enrolled in Medicare
Low Income and Medicare Guide
For individuals with a qualifying income status
A Caregiver’s Guide
For individuals with a qualifying income status