Medicare Parts A & B (a.k.a. “Original Medicare”) aims to be comprehensive – but it unfortunately doesn’t cover 100% of your medical needs. There are little-known out-of-pocket expenses which can become expensive if you don’t have a good Medicare supplement insurance policy to protect you. One of the more popular supplements, Medicare Part C (or “Medicare Advantage), is the focus of this particular article.
Federal Regulations for Medicare Advantage
Medicare Advantage may also be referred to as a Medicare “Replacement” insurance policy. This is because signing up for Medicare Advantage involves replacing your federal Medicare benefits with a different insurance policy from a private company. However, there are laws in place to make sure that your Advantage plan is at least identical to – if not better than – Original Medicare. These laws are in place to protect you, the consumer.
Medicare Advantage Enrollment In Yew York
New Yorkers are some of the biggest fans of Medicare Advantage in the country. A significant 38% – which is more than one-third of Medicare-qualified seniors – are signed up for a plan. And in the chart below, you can observe which Advantage plans are more popular than others:
|Plan Type||Enrollment Percentage|
|Local PPO Plans||13%|
|Special Needs Plans||11%|
|Regional PPO Plans||9%|
|Private Fee-For-Service Plans||5%|
|Other (Cost Plans, MSA’s, etc.)||3%|
Plan Coverage & Cost
Many different factors, such as age and tobacco use, will influence your monthly premium. But there are ways to gather data and come up with a close estimate. Below, you can take a look at some of the estimated costs near you:
Most Popular Medicare Advantage Plans in New York
If you are looking for the best Medicare Advantage plan in New York, you can turn to Medicare’s opinion. Medicare established the Overall Star Rating system as a way for consumers to see a third-party evaluation of every company that offers Medicare services or products. Medicare gathers information and surveys users of every company they deal with. For companies providing health care, like Medicare Advantage providers, Medicare rates them on use of preventive medicine strategies, management of chronic diseases, membership experiences, complaints and changes in performance, and customer service. The more stars the better. You can use this annual report to help evaluate a company you are interested in.
Helpful Medicare Advantage Tips & Tricks
Doctor/Provider Network Restrictions
The provider network is the group of doctors and facilities from which your Advantage plan will allow you to receive medical care. If you want to see a doctor or use a facility which is outside of your provider network, your plan’s network restrictions may make that difficult or impossible without paying out-of-pocket. Make sure you check with your preferred doctor(s) and facilities before you decide on an Advantage plan.
Where you generally need to get your care and services from for:
- HMO Plans – Medicare advantage programs that operate on the HMO model restrict your choice of physicians, hospitals, clinics, etc. to those that belong to a specific network. There are exceptions for emergency care, out of area urgent care, and out of area dialysis. Some plans have a Point of Service (POS) option that allow you to go outside of the network but typically, these services cost you more than staying in the network.
- PPO Plans – PPOs also have extensive networks but, unlike HMOs and SNPs, they do not limit your choice of providers to those that are members of their network. You can use any physician in the service area so long as they accept Medicare and your insurance plan. Using out-of-network resources normally requires a higher copay and deductible.
- PFFS Plans – With a Private Fee-For-Services (PFFS) plan, you can use any healthcare provider who accepts Medicare and the plan. Not all will. Most of these types of plans provide a directory of providers who do accept the plan simplifying the search for healthcare services. However, be sure to confirm your doctor accepts your coverage each time you make an appointment.
- Special Needs Plans – If you belong to a Special Needs Plan you generally need to use the healthcare providers that are in your group. They will all be members of the Medicare’s SNP network. Typically these plans have specialists that can treat the diseases or conditions of the members. There are two exceptions to seeking medical care outside the network; emergency or urgent care required by a sudden onset of illness or injury, and End Stage Renal Disease dialysis outside the area.
Finding a doctor who accepts your Medicare Advantage plan:
- HMO Plans – With an HMO Medicare Advantage plan you won’t have to worry about finding a healthcare provider that accepts your plan. That’s because the only physicians you can use are those in the HMOs network. You might be able to select your own HMO member primary physician, but if you need additional services, your primary will select them and refer you to them.
- PPO Plans – PPOs allow you to see any healthcare provider who accepts Medicare and the plan. However, your copay for services is significantly lower if you use a provider that is in the PPO’s network. Typically, these plans have a directory of member providers and preferred pharmacies.
- PFFS Plans – Private-Fee-For Service Plans place no restrictions on the healthcare providers and facilities that you can use providing they accept Medicare and the PFFS plan terms. However, not all providers will accept the PFFS plan even if they do accept Medicare. PFFS plans pay the provider directly and if the provider finds the rates unacceptable, they will not provide service. It is important that you verify a provider will accept your plan before making any appointment even if they have in the past.
- Special Needs Plans – If you are a member of a Special Needs Plan, the physicians that will treat you are limited to the specialists in your group. All of them are members of the Medicare SNP Network. There are exceptions. If you need emergency care due to a sudden onset of illness or injury and End Stage Renal Disease dialysis outside the area.
The Medicare’s physician search tool makes finding doctors who accept Medicare easy. Most Medicare Advantage plan companies have similar online tools. Finding providers is easier than you might think.
Drug, Vision and Dental Coverage
Vision coverage is offered by many Medicare advantage plans and typically includes a regular yearly eye exam, lenses and contacts. These services are often restricted to specific providers. Check your plan to find participating optical shops. In addition, Medicare advantage plans have to provide for all vision care benefits available under original Medicare like exams for diabetic retinopathy and age-related macular degeneration.
Dental care is not a benefit that Original Medicare provides. However, many Medicare Advantage plans offer their members limited dental services. Benefits can vary greatly from plan to plan; however, at a minimum most provide a routine annual exam (including x-rays and cleanings). Additional dental care like filings, periodontal care, even dentures may be available from some plans.
Enrollment Options & Best Time To Enroll
By far, the best time to enroll is during your 6 month IEP (see below) once you turn 65 and enroll in the federal Medicare program. Some companies may even approve you automatically without asking any questions about your health if you first qualify for federal Medicare benefits. If you wait, however, or if you are struggling with a serious health condition (such as End Stage Renal Disease), you may have to seek help from your local insurance agent or your state department of insurance. You can also take a look at our Medicare Advantage Enrollment Options page for more information.
- Initial Enrollment Period: 6-month timeframe when you first enroll in Medicare to purchase a Medicare Advantage plan.
- Annual Enrollment Period (AEP): This timeframe runs from October 15th through December 7th every year, and during this time you can change or cancel your Medicare Advantage and part D drug plan.
- Special Enrollment Period (SEP): During special circumstances, you may be eligible to purchase/change a plan outside of the Annual Enrollment Period. Things such as moving out of the plans’ service area, losing group health or employer coverage, a company no longer offering plans in the area, etc. are all events that could trigger a SEP.
What Medicare Advantage Plan Is Best For Me?
If you have a primary care doctor and specialists that you like and trust, then the best New York Medicare Advantage plan is one that includes your existing healthcare providers in their network. If the plan offers Part D drug coverage, make sure it stocks the medications that you use. As you get older, wellness will become more important. The perfect plan will offer useful wellness programs like home checkups, transportation to medical appointments, discount fitness clubs and more.
Of course, premiums are important, but also take into consideration the company’s reputation, time in the business, financial stability, and ease of use. Most importantly, the best Medicare Advantage plan is one you fully understand and have confidence in. Changing plans can be problematic because of open enrollment limitations. Make certain you’re satisfied before you make a selection.