Medicare Advantage Plans in New York
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: November 18, 2020
Medicare Advantage, also known as Medicare Part C, is a privately run alternative to the federal government's Original Medicare program. Medicare Advantage plans are sold by insurance companies that contract with Medicare. These plans must provide the same basic benefits as Original Medicare — Part A (hospital insurance) and Part B (medical insurance) —, but they may cover extra services. Many Medicare Advantage plans include prescription drug coverage, and many offer coverage for dental, vision, and hearing care.
Key Point Module
- 1 In 2019, there were 173 Medicare Advantage plans available in New York.
- 2 39% of the total Medicare population in New York is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $10,464 per beneficiary in New York, which is 4% higher than the national average.
- 4 Available Medicare Advantage plans range from 18 to 97 across New York’s 62 counties.
When you start shopping for a Medicare Advantage plan, you’ll notice there are many types of plans to choose from. If you’ve had private health insurance in the past, you already may be familiar with one or more of these plan types. As you evaluate your options, keep your budget, preferences, and health needs in mind, as these factors will help you determine which plan type is best for you.
Medicare Advantage Plans in New York
Types of Medicare Advantage Plans
There are many different types of Medicare Advantage plans on the market. The type of plan you choose may affect how much you pay or how you receive care, so this is an important consideration. Some of the common types of plans in New York’s Medicare Advantage program include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-For-Service plans, and Special Needs Plans. Depending on your area, other types of plans may be available.
Health Maintenance Organizations (HMO)
Medicare Advantage Health Maintenance Organization (HMO) plans provide you with a network of doctors, specialists, and hospitals. For most services, you need to choose providers in your plan’s network. If you receive care outside of the network, you may be responsible for 100% of the cost.
If you join an HMO plan, you’ll be required to choose a primary care doctor. This doctor must participate in the plan’s network and be accepting new patients from the HMO. If you want to see specialists in the network, you’ll usually need a referral from your primary care doctor.
Preferred Provider Organizations (PPO)
Medicare Advantage Preferred Provider Organization (PPO) plans also have a network of doctors, specialists, and hospitals. Unlike with HMO plans, you aren’t required to use in-network providers. However, you’ll pay less if you get care from providers who are on the plan’s list.
PPO plans provide more flexibility than HMOs. If you join a PPO plan, you don’t usually need to choose a primary care doctor, and you generally don’t need a referral to see a specialist. For this flexibility, PPOs tend to have higher premiums than HMOs.
Private Fee-For-Service Plans (PFFS)
Private Fee-For-Service (PFFS) plans pay doctors, hospitals, and other health care providers a set fee for each covered service. You can see any provider who takes Medicare, as long as they agree to treat you and agree to the plan’s terms. Some PFFS plans have a network of providers who have agreed to always treat plan members.
PPFS plans are similar to PPO plans in that you don’t need to choose a primary care doctor, and specialist referrals aren’t required.
Special Needs Plans (SNP)
Medicare Advantage Special Needs Plans (SNPs) are only available to people with specific care needs, such as those who live in institutions, those who have both Medicare and Medicaid, and individuals with certain chronic health conditions, like diabetes or dementia. Each plan’s benefits and network are designed to meet the unique needs of the group it serves.
Like HMOs, these plans require members to choose a primary care doctor. Some plans may also require members to choose a care coordinator to help manage their care. For most services, you’ll need a referral to see a specialist.
Enrollment & Eligibility for Medicare Advantage Plans in New York
In general, you’re eligible for Medicare in New York if any of the following apply:
- You’re 65 years of age or older
- You have a disability and get Social Security Disability Insurance (SSDI) benefits
- You require dialysis or have had a kidney transplant
When it comes to Medicare Advantage plans in New York, there are some additional eligibility rules. You must be enrolled in both parts (A and B) of Original Medicare, and you must live in the area the plan serves. People with end-stage renal disease can’t usually join Medicare Advantage plans; however, insurers sell Special Needs Plans for people with this condition in some areas.
If you’re eligible to join a Medicare Advantage plan, you can only do it at certain times during the year.
Initial Enrollment Period
This seven-month period occurs when you first become eligible for Medicare. If you’re eligible based on your age, it starts three months before the month you turn 65 and ends three months after your birthday month. If you’re eligible because of a disability, the seven-month period starts three months before your 25th month of receiving SSDI benefits.
Medicare Open Enrollment
Also known as the annual election period or the annual enrollment period, Medicare open enrollment takes place between October 15 and December 7 every year. At this time, people with Original Medicare can switch to a Medicare Advantage plan. Any changes you make during this period will take effect on January 1.
Medicare Advantage Open Enrollment Period
The Medicare Advantage open enrollment period takes place between January 1 and March 31. At this time, people who already have Medicare Advantage can switch to another Medicare Advantage plan. If you have Original Medicare, you can’t switch to Medicare Advantage during this period.
General Enrollment Period
If you didn’t get Medicare when you first became eligible for coverage, you can enroll during the general enrollment period. This annual period runs from January 1 to March 31. If you get Medicare during the general enrollment period, you may qualify for a special enrollment period for Medicare Advantage. The special enrollment period starts April 1 and ends June 30.
Prescription Drug Coverage
Prescription drug coverage, known as Medicare Part D, is an optional Medicare benefit. If you don’t want or need drug coverage, you can join a Medicare Advantage plan that doesn’t include this benefit, though many Medicare Advantage plans offer prescription drug coverage.
Plans that include Part D provide a list of covered drugs, known as the formulary. Insurers can choose which drugs to add to the formulary, but in each commonly prescribed category, they have to include at least two drug options.
Separate Part D plans are available for people with Original Medicare. People with Medicare Advantage usually can’t buy these standalone plans. There are some exceptions, such as if you’re enrolled in a Medicare Advantage Private Fee-For-Service plan.
Medicare Advantage Resources in New York
With so many Medicare Advantage plans in New York, narrowing down your options can be confusing or overwhelming. When choosing coverage, there are many things to keep in mind, from premiums and out-of-pocket costs to covered services and provider networks. Seniors don’t need to navigate Medicare on their own. If you need help choosing the right plan for your needs, or if you have questions about a specific plan, there are many resources you can turn to.
Office for the Aging
Through its Health Insurance Information Counseling and Assistance Program (HIICAP), the Office for the Aging helps New Yorkers navigate Medicare. Trained HIICAP counselors can answer any questions you may have about New York Medicare, including Medicare Advantage plans. The program offers in-person counseling by appointment at local offices across the state. You can also call HIICAP’s toll-free helpline to receive counseling by phone. For seniors who prefer online resources, the HIICAP Notebook has a chapter about Medicare Advantage health plan options.
Contact Information: Website | (800) 701-0501
NYC Department for the Aging
The New York City Department for the Aging acts as the Area Agency on Aging (AAA) for the city. It provides a vast array of services for the approximately 1.64 million seniors living in New York City. Every month, the department hosts a free orientation session for seniors who are new to Medicare. These sessions provide information about the types of Medicare coverage, including Medicare Advantage plans. The department also has nearly 250 senior centers throughout the city, and some centers provide benefits screenings. These screenings help seniors learn if they’re eligible for Medicare, Medicaid, and other programs. Each senior center has its own schedule of activities and services, so contact your local center to learn more.
Contact Information: Website | (212) 244-6469
The Legal Aid Society
The Legal Aid Society is a nonprofit organization that provides legal assistance to low-income people in New York City. The organization can help with a wide variety of civil legal matters, including government benefits. New Yorkers who need help getting or keeping Medicare coverage can call the organization’s Access to Benefits helpline. This helpline is available on weekdays from 10:00 a.m. to 3:00 p.m.
Contact Information: Website | (888) 663-6880
Community Service Society
The Community Service Society is a nonprofit organization that provides many services for low-income New Yorkers. Through its Facilitated Enrollment for the Aged, Blind, and Disabled Program (FE-ABD), it helps seniors and younger adults with disabilities enroll in Medicare and other public health insurance options. The program provides in-person, one-on-one benefits counseling at meeting sites throughout the state. These in-person services are available in 38 of New York’s counties. If you can’t travel to a meeting site, the organization also provides at-home assistance with applying for Medicare.
Contact Information: Website | (212) 254-8900
- Sources [-]
https://aging.ny.gov/system/files/documents/2021/08/21mod5f.pdf Last accessed August 2021
https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp Last accessed April 2021
https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html Last accessed April 2021
https://www.medicare.gov/manage-your-health/i-have-end-stage-renal-disease-esrd Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan Last accessed April 2021
https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods Last accessed April 2021
Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.