Page Reviewed / Updated - May 18, 2020
Medicare Advantage, which is also known as Medicare Part C, provides an all-in-one alternative to traditional Medicare, bundling Part A and Part B benefits, often together with prescription drug coverage. Medicare Advantage plans are available through private-sector insurers who contract with Medicare to provide benefits to eligible seniors. Although costs and coverage levels vary from carrier to carrier, Medicare Advantage plans may offer recipients additional benefits that aren’t available through the federal program, such as vision, dental and hearing. Seniors may also find out-of-pocket costs to be lower through Medicare Advantage.
Although an average of 34% of all Medicare beneficiaries opt for a Medicare Advantage plan, the number of participants choosing private-sector coverage over traditional Medicare varies widely by state. New York has a higher-than-average Medicare Advantage enrollment, with 39% of Medicare recipients choosing a private plan. In more rural states, enrollment in Medicare Advantage is typically lower, and in Wyoming and Alaska, less than 3% of beneficiaries select this alternative.
New York seniors who are considering a Medicare Advantage plan can choose from a variety of options. The most common types of programs are HMO, PPO, PFFS and SNP plans, but less common options include HMO-POS and MSA plans. This guide helps seniors navigate the differences between plans and options for prescription drug coverage, and it provides an overview of how to enroll in the program. We’ve also included several online resources for New Yorkers who need additional assistance choosing appropriate coverage or completing the enrollment process.
Depending on their county of residence, seniors who qualify for Medicare Advantage can choose among six types of plans: Health Maintenance Organizations (HMOs), HMO Point-of-Service (HMO-POS) plans, Preferred Provider Organizations (PPOs), Medical Savings Account (MSA) plans and Special Needs Plans (SNPs).
Although most options offer the same basic benefits package, different rules for referrals, network services and the availability of prescription medication coverage may apply.
Health Maintenance Organizations (HMOs)
Health Maintenance Organizations provide services through a network, requiring plan participants to choose a primary care physician and to receive most of their care through participating providers. However, members may be able to go out of network for emergency care and out-of-area dialysis and urgent care services. Enrollees who choose to receive other services from an out-of-network provider may be responsible for the entire cost. Plan participants are also required to get a referral from their PCP in order to see a specialist or undergo testing. Although seniors who opt for an HMO plan may have more limited care options, prescription drugs are usually covered, and premiums may be lower than other Medicare Advantage plans.
HMO Point-of-Service (HMO-POS) Plans
HMO Point-of-Service Plans generally follow the rules of a traditional HMO plan. Still, they may allow members to receive certain services out of network by paying out a higher copay or coinsurance amount.
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations also use a network of doctors and hospitals, but without the restrictions of an HMO. To get the best coverage rates, members are advised to see in-network providers but don’t need to select a primary care physician, and unlike HMOs, PPOs offer at least partial coverage for out-of-network services. PPOs may also offer more flexibility when it comes to specialist visits as well, often eliminating the need for a referral. PPOs typically cover prescription drugs. Higher premiums generally offset the versatility of a PPO.
Private Fee-For-Service (PFFS) Plans
PFFS plans are similar to PPOs since members can opt for in-network or out-of-network care, with lower costs for in-network visits; however, physicians who treat patients with a PFFS plan must accept the plan’s payment terms. Patients are only responsible for paying the appropriate copayment or coinsurance amount at the time of service. PFFS plans don’t require referrals from a primary care physician for specialist visits, and they may or may not cover prescription medications, depending on the carrier.
Special Needs Plans (SNPs)
Special Needs Plans are designed to serve people with specific chronic illnesses or disabilities and other special-needs populations. Generally, participants must get care and services from a network of Medicare SNP providers, which typically include physicians who specialize in the conditions affecting the recipient. SNPs also provide coverage for prescription medications. These specialty plans aren't available to all Medicare participants; an individual must have a physical or mental disorder or be in a situation (such as living in a nursing home or having dual-eligibility for Medicare and Medicaid) for which the SNP is intended. Groups eligible for membership in Special Needs Plans include residents of specific institutions, individuals with dual Medicare/Medicaid eligibility and people living with disabling conditions, such as HIV, diabetes and end-stage renal disease.
Medical Savings Account (MSA) Plans
MSA Plans combine high-deductible health coverage with a plan-selected bank account. To pay for medical services, members can use the money deposited into the account by the program. Since MSA plans don’t include prescription drug coverage, members who want this benefit must sign up for a Medicare Prescription Drug Plan.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
New York seniors who seek prescription drug coverage should apply for a Medicare Advantage plan that includes this benefit. Although the majority of Medicare Advantage plans provide this coverage, MSA plans and certain PFFS plans can’t, or won’t, offer prescription drug coverage. Seniors who opt for Medicare Advantage HMO, HMO-POS or PPO plans and subsequently join a standalone Medicare prescription drug plan are automatically removed from their Medicare Advantage plan and returned to Original Medicare.
Medicare provides essential health care services to New York seniors, but navigating coverage options and getting enrolled can be challenging. For seniors who need help choosing a plan and understanding their coverage, it may be helpful to speak with a counselor who's had training in Medicare and Medicare Advantage plans. Below, we’ve listed several state and local Medicare resources that can help seniors enroll in the program that's best suited to their needs as well as get the most from their preferred plan.
The Health Insurance Information Counseling and Assistance Program (HIICAP) helps seniors navigate New York's many medical insurance options. The program employs more than 500 counselors in offices throughout the state, who work directly with Medicare beneficiaries or individuals who are eligible to apply for state programs.
These trained representatives provide information and education about Medicare, Medicare Advantage, Medicaid, prescription drug plans and other health insurance options. Counselors can answer questions about coverage, give access to CMS and help seniors resolve complaints with insurers. Counseling is available in person at county offices or via telephone through a toll-free hotline. The program also offers helpful online resources, including the HIICAP Notebook, where seniors can access additional information about Medicare and Medicare Advantage.
To access HIICAP's toll-free benefits hotline, call 1-800-701-0501. At the prompt, callers must state their county of residence so their inquiry can be directed to the appropriate Area Agency on Aging office or a participating community organization.
Community Health Advocates (CHA) provides confidential one-on-one counseling free of charge to help New Yorkers understand their health insurance options and choose the plan that’s right for their unique medical needs. CHA gives community presentations designed to guide consumers through the complexity of the health care system. The presentations focus on a variety of health care topics and serve to educate individuals on insurance options and how changes in health care laws may affect individuals in the state. The program's outreach services help high-need communities and offer help in more than 170 languages.
New York State residents can connect with CHA through its centralized helpline by dialing 1-888-614-5400 during weekdays from 9 a.m to 4 p.m. Seniors can also schedule a call by filling out the online form. A list of CHA affiliated organizations with staff who are qualified to assist consumers with health insurance questions and enrollment issues can be found online at CHA’s website.
The New York State Attorney General’s Health Care Bureau provides information and assistance to help New Yorkers connect with public and private insurers so they can get affordable medical coverage regardless of age. The bureau educates consumers about their health care rights under the Managed Care Bill of Rights and has outreach programs that serve high-need communities.
Through the bureau’s toll-free helpline, consumers can connect with trained intake specialists and advocates who can help individuals understand available benefits and how to secure coverage. The hotline also helps consumers resolve complaints concerning health plan denials, wrongful practices and prescription drug coverage.
Consumers can speak with a trained advocate or intake specialist at the New York State Attorney General’s Health Care Bureau through its toll-free helpline by dialing 1-800-428-9071. Additional information, including tips and brochures, is available through the Health Care Bureau’s website.
NYC Health provides in-person assistance at no cost to seniors who need help navigating health care enrollment and coverage-related issues. Certified health insurance enrollment counselors are available at locations in all five boroughs to help consumers explore plan options that are available to them. The counselors can also assist with complex enrollment or the renewal process for public and private insurance, including Medicare Advantage. NYC Health can help local immigrants secure quality health care regardless of their immigration status, and the agency provides assistance in a multitude of languages. Telephone enrollment appointments are also available.
New Yorkers aged 65 and older who need help with health care enrollment can find a counselor in their borough of residence by searching the NYC Health Map. They can also set up an in-person or telephone appointment by calling 311 or texting “CoveredNYC” to 877-877. A list of locations broken down by borough is also available by visiting NYC Health’s website.
New York StateWide Senior Action Council is a group that provides health care advocacy and support to New York elders. The organization runs a confidential health and prescription medication coverage helpline, where certified counselors provide information on Medicare Advantage benefits and prescription drug coverage, answer consumer questions and assist with plan enrollment free of charge.
New York StateWide Senior Action Council also connects seniors with essential resources at the local, state and federal levels. The council has offices throughout the state and hosts regional chapter meetings, presentations focusing on senior-friendly topics and telephone teach-ins on various subjects. It also sponsors a Senior Medicare Patrol, which empowers seniors and their families to detect, prevent and report potential Medicare fraud.
New York StateWide Senior Action Council’s Medicare and prescription drug coverage hotline is available free of cost by calling 1-800-333-4374. Seniors can also connect with a certified counselor by emailing [email protected]. To find out more information on chapters and events, interested parties should visit the regional section of StateWide’s website.
The Jewish Association Serving the Aging is a nonprofit organization that provides a multitude of no-cost services for seniors of all races and religions residing in Long Island and New York City's five boroughs. JASA’s Sally and Henry Pearce Help Center employs bilingual social workers trained to conduct comprehensive assessments to determine an individual’s health care needs and eligibility. Representatives can also help seniors navigate the health care enrollment process and secure benefits under programs such as Medicare and Medicaid.
Regardless of religion, race or economic background, seniors can connect with trained social workers through JASA’s bilingual Sally and Henry Pearce Help Center by calling 212-273-5272 or filling out a brief online form. Seniors or their family members who are looking for more information on Medicare and other health care benefits can search for association locations throughout the Bronx, Brooklyn, Queens, Manhattan and Long Island by visiting JASA’s website.