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Q&A on the Issues

NYC Medicare Advantage Plus Plan

New York Teacher

The Municipal Labor Committee on July 14 voted to approve the NYC Medicare Advantage Plus Plan for Medicare-eligible New York City retirees. The following Q&A answers some of the most common questions that retired UFT members have. Check the UFT website for the latest updates and information.

What is the new NYC Medicare Advantage Plus Plan?

The NYC Medicare Advantage Plus Plan was created to replicate traditional Medicare and the current GHI Senior Care program, which is a supplement to Medicare, with a single integrated program for city retirees. Through a contract with Medicare, the NYC Medicare Advantage Plus Plan provides all health care services previously covered by traditional Medicare and supplemented by the GHI Senior Care program. The plan must follow Medicare rules and provide all benefits provided by Medicare.

The NYC Medicare Advantage Plus Plan preserves or enhances New York City retirees’ current, premium-free benefits and quality of care while maintaining their access to the same providers and hospitals they currently use.

Do I need to enroll?

If you are a retiree covered by a city Medicare health plan, you will be automatically enrolled in the new plan starting Jan. 1, 2022. You don’t need to do anything. However, you must be enrolled in Medicare Part A and Medicare Part B and continue to pay your Medicare Part B premiums.

Can I choose another plan if I wish?

You can choose to remain in your current plan by opting out of the NYC Medicare Advantage Plus plan during the opt-out period between Sept. 1 and Oct. 31, 2021. But remember that the new plan is premium-free at its basic level. All other plans will be available as a pay-up option. Retirees who choose to stay with their current health care plan will pay the additional premium difference. The additional cost for the GHI Senior Care program will be $191.57 per person per month for the basic plan in addition to what they are currently paying for the optional rider for prescription drugs and 365-day hospitalization. Costs for other current plans will be provided in the enrollment package being sent to you in September. You will have the opportunity to transfer between plans every year in the fall.

Who is administering the NYC Medicare Advantage Plus Plan?

Empire BlueCross BlueShield and EmblemHealth are jointly administering the new plan. EmblemHealth will continue to administer the same Medicare Part D rider that is part of the GHI Senior Care program.

What enhancements does the new plan have to offer?

It has a new annual out-of-pocket maximum of $1,470 that will protect members from catastrophic claims. (Prescription drug and diagnostic copayments are not part of this maximum out-of-pocket amount.)

The new plan includes these new benefits not covered by the current GHI Senior Care program:

  • Transportation costs for 24 one-way trips per year to doctors’ offices.
  • Home meal delivery for retirees after they are discharged from the hospital.
  • A fitness program.
  • A wellness rewards program.
  • No copay for telemedicine with the LiveHealth platform.

How does the plan’s prescription drug benefit differ from GHI Senior Care?

In the new plan, prescription benefits are the exact same as in the GHI Senior Care program but with a lower monthly cost. There is no change in the drug formulary or copayment structure.

How do I find a doctor?

Go to empireblue.com and click on “Find Care” in the top right corner. Select guest and then select “medical” for type of care, select your state, select “Medicare” for type of plan and select “NYC Medicare Advantage Plus” for plan/network. You’ll be able to search by specialty or doctor’s name. You can also call the plan’s toll-free number at 833-325-1190.

Will I be able to continue to see my doctors and visit the same hospitals?

Yes, the NYC Medicare Advantage Plus Plan will provide access to all medical providers that take Medicare coverage, approximately 850,000 providers nationwide. About 640,000 of those Medicare providers are currently in the Empire/EmblemHealth Alliance networks and are contractually bound to see NYC Medicare Advantage Plus members. Providers who do not have a contract with the new plan would bill the NYC Medicare Advantage Plus Plan to get reimbursed, just as they do for traditional Medicare, and they will be paid the same amount that traditional Medicare pays. City retirees enrolled in the plan will have access to all hospitals in the New York City area, including Memorial Sloan Kettering and the Hospital for Special Surgery; almost all hospitals nationwide; and 99.5% of all doctors nationwide.

What if the provider I am seeing does not agree to accept payment from the NYC Medicare Advantage Plus Plan?

In the rare instance when a provider that accepts Medicare tells a retiree they will not accept payment from the NYC Medicare Advantage Plus Plan, the retiree should notify the plan. The plan will reach out to the provider to make sure they understand it is the same payment schedule and billing protocol and answer any questions the provider may have. If, despite that effort, the provider still refuses, the member can pay the provider and then submit the claims to the plan for reimbursement. As long as the service is a Medicare-covered benefit and the Medicare fee schedule is followed, the member will only be responsible for copays or coinsurance as defined by the plan.

Are copayments changing?

There will be new $15 copayments for seeing specialists, having diagnostic procedures and visiting urgent care facilities. The GHI Senior Care program will also be adopting these new copayments effective Jan. 1, 2022. The GHI Senior Care program will be adopting a $15 primary care physician copayment on Jan. 1, 2022; retirees in the new NYC Medicare Advantage Plus Plan will have no copayment when seeing a primary care physician.

I am Medicare-eligible but my spouse isn’t, and my spouse is currently listed under my health insurance. How would that work with the new plan?

If your spouse or dependents are not yet eligible for Medicare, they will stay in the GHI CBP program (the same plan that most in-service employees and pre-Medicare retirees presently have).

Under the new plan, will I need a referral to see a specialist?

No.

Will certain medical procedures require preauthorization?

Yes. The same as under the plans for in-service city employees, some medical procedures will require preauthorization under the NYC Medicare Advantage Plus Plan. When you see an in-network provider, the doctor and the insurer will handle the preauthorization. When seeing out-of-network doctors, while a preauthorization is not required, we recommend you ask your provider to request a preauthorization to confirm that the services they are providing will be considered medically necessary and therefore be covered.

What if I live out of state?

The NYC Medicare Advantage Plus Plan is a national program that covers New York City retirees who live in one of the 50 states or a U.S. territory, including Puerto Rico.

I have surgery scheduled for Jan. 3 with my current plan. What should I do?

The NYC Medicare Advantage Plus Plan clinical transition team will work with you and your doctor to ensure continuity of care.

Will the city still reimburse my Medicare Part B premiums?

Yes, as long as you remain in one of the plans offered by the city.

How will the new NYC Medicare Advantage Plus Plan affect my UFT Welfare Fund benefits?

Your UFT Welfare Fund benefits will continue in their present form.

Where can I get more information about the NYC Medicare Advantage Plus Plan?

Check the UFT website, or call the plan’s special phone line at 833-325-1190.

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New health plan for Medicare-eligible retirees

Following months of painstaking negotiations, the Municipal Labor Committee voted on July 14 to approve a new group health care plan for all Medicare-eligible New York City retirees that allows the municipal unions to address the rising cost of health care while maintaining their current benefits and quality of care.

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