Here are answers to commonly asked questions about the new Aetna Medicare Advantage PPO plan, the new premium-free health plan for Medicare-eligible New York City retirees. Be sure to also check out the Aetna Plan Info Hub and the UFT's full set of FAQs on the Aetna Medicare Advantage PPO for additional information. 

When will the Aetna Medicare Advantage PPO plan go into effect?

The Aetna Medicare Advantage PPO plan for medical coverage will go into effect on Sept. 1, 2023. However, retirees currently in GHI Senior Care with the Emblem Health/ExpressScripts prescription drug rider will remain in the GHI Senior Care prescription drug plan until Jan. 1, 2024.

How does a Medicare Advantage plan work?

A Medicare Advantage plan combines Medicare Part A and Medicare Part B into one plan. You have one medical ID card and a separate pharmacy ID card and one Explanation of Benefits (EOB) for the prior month. Medicare Advantage plans must cover what traditional Medicare covers, but they can also cover more benefits and services than traditional Medicare.

How is the Aetna Medicare Advantage PPO plan different from a typical Medicare Advantage plan offered in the individual market?

Unlike with most Medicare Advantage plans offered in the individual market, you can access any Medicare provider who is willing to accept the Aetna Medicare Advantage PPO plan and you will always pay the in-network cost share. There are no penalties or higher cost shares if you see providers who are outside the Aetna Medicare network. The plan also travels with you, so it provides coverage wherever you live throughout the country and in U.S. territories.

Doctors

Are my doctors covered under the Aetna Medicare Advantage PPO plan?

If your doctor accepts Medicare, they will be paid under the Aetna Medicare Advantage PPO plan. Aetna’s nationwide network is robust, with more than 1.2 million providers. Approximately 96% of doctors who take GHI Senior Care are either in network or accept payment from Aetna, and the company is reaching out to the rest.

The Aetna Medicare Advantage PPO plan gives you the freedom to see any provider who participates in Medicare and accepts payment from Aetna, even if they are not part of the Aetna network. You will pay the same cost share both in or out of the network. Your copay, for instance, doesn’t change if you go to an out-of-network provider.

Do I need a referral to see a specialist?

No, referrals are not required. This plan is a Preferred Provider Organization (PPO), so you can go to any provider who participates in Medicare and accepts the Aetna Medicare Advantage PPO plan. A designated primary care doctor is not required but recommended.

What if I live outside the New York City area or out of state?

This PPO is a national plan. Aetna currently has more than 1.2 million participating providers across the country and in U.S. territories, and it is actively recruiting to make its network even bigger. You can use your benefits nationwide, whether you have different residences at different times of the year or you are traveling in the United States.

Enrollment

Do I need to enroll in the Aetna Medicare Advantage PPO plan?

If you are a retiree covered by a New York City Medicare health plan besides HIP VIP, you will be automatically enrolled in the Aetna Medicare Advantage PPO plan on Sept. 1, 2023. You don’t have to do anything. However, you must already be enrolled in Medicare Part A and Medicare Part B, and you must continue to pay your Medicare Part B premiums.

What if I am enrolled in HIP VIP?

The HIP VIP Premier Medicare Plan HMO will continue to exist after Sept. 1. If you are currently enrolled in the plan, you will have the option to remain in the HIP VIP Premier Plan. If you live in New York City or in Nassau, Suffolk, Rockland, Orange or Westchester counties, you also have the option to enroll in that plan. HIP VIP will remain premium-free, but there will continue to be a separate cost associated with the Emblem HIP VIP prescription drug rider (as with both GHI Senior Care and the new Aetna plan).

What other options do I have for coverage if I don’t want the new Aetna plan? Can I opt out?

You can opt out of the Aetna Medicare Advantage PPO plan during the opt-out period, which is between May 1, 2023, and June 30, 2023, and enroll in the HIP VIP plan if you live in New York City or in Nassau, Suffolk, Rockland, Orange or Westchester counties.

You can also choose to move to traditional Medicare coverage and pay directly for a private Medigap or Medicare Advantage plan on your own. If you go that route, you will lose city reimbursements for Medicare Part B and IRMAA, as you will no longer be enrolled in a city-sponsored health plan. You will also be subject to Medicare deductibles and coinsurance, and you will not have prescription drug coverage unless you purchase an individual Part D drug plan.

Out-of-pocket costs

Is there a limit to what I need to pay out of pocket each year?

The new Aetna Medicare Advantage PPO plan has an annual out-of-pocket maximum of $1,500 — the most you have to pay for covered services (including deductibles and copays but not prescription drugs) in a calendar year. GHI Senior Care has no such cap.

The Explanation of Benefits (EOB) for your medical claims will tell you how much you have spent toward the maximum.

What will my annual deductible be?

You will have an annual deductible of $150 with no Part B deductible starting in 2024. The annual deductible for 2023 will be waived for all New York City retirees since most will already have met the deductible by Sept. 1. (In GHI Senior Care, there is a $276 annual deductible — $50 for GHI and $226 for Medicare Part B.)

What are the copayments for doctor’s visits and other medical services?

• No copay for primary care physician office visits
• $15 copay for office visits to see a specialist or for mental health and substance use treatment
• No copay for Medicare-covered immunizations or preventative screenings
• No copay for outpatient surgery
• $15 copay for lab tests, X-rays, CT scans, PET scans and MRI scans
• No copay for radiation therapy, cardiac rehabilitation therapy or pulmonary rehabilitation therapy
• No copay or annual benefit maximum for durable medical equipment and ambulance
• 20% coinsurance and a $5,000 annual maximum benefit for private-duty nursing
• $0 for home health care services
• $15 for urgent care worldwide
• Other procedures have copays ranging from $0 to $15

Prior authorization

I’m concerned about the need to get prior authorizations. What do I need to know?

The Municipal Labor Committee negotiated aggressively with Aetna to build a customized Medicare Advantage plan that significantly limits the types of procedures and services that require prior authorization. Prior authorization will never be required for emergency or urgently needed services.

What procedures or services would not require prior authorization?

No prior authorization will be needed for the vast majority of services, including:

• Physical therapy
• MRIs
• CT scans
• PET scans
• Sleep studies
• Radiation therapy
• Pain management
• Diagnostic cardiology

These services typically require prior authorization in Medicare Advantage plans, but they don’t need it in this new customized Aetna Medicare Advantage PPO plan.

What will require prior authorization?

• Acute hospital inpatient care (not ER)
• Long-term acute care, acute physical rehabilitation, skilled nursing facility care and home care services
• Durable medical equipment
• Part D medications
• Specialty medications, some of which are Part B medications
• Placement on an organ transplant list
• Substance abuse treatment
• Services that are cosmetic in nature
• Services/items that are not covered by Medicare
• Services that could be considered experimental and investigational in nature
• New-to-market drugs, therapies, procedures, services and technologies covered by Medicare after Sept. 1, 2023

Prescription drugs

When will the prescription drug plan take effect?

If you currently have the prescription drug rider through GHI Senior Care, you will continue with your prescription drug plan through ExpressScripts until Dec. 31, 2023. You will make the transition to the Aetna Medicare Rx offered by SilverScript on Jan. 1, 2024.

If you are enrolled in any other plan through the City of New York and purchase the prescription drug rider through that plan, or you currently purchase and are enrolled in an individual prescription drug plan (Part D) in the open market, you will make the transition to the SilverScript prescription plan on Sept. 1, 2023, at the same time you are enrolled in the new Aetna Medicare Advantage PPO plan.

What is the cost for the optional prescription drug rider?

Beginning on Sept. 1, 2023, the cost of the Aetna Medicare Rx prescription drug rider will be $103.50 monthly. The cost of the rider increases to $135.50 in 2024.

Does this prescription drug plan have a deductible?

No, there is no annual deductible for this plan.

What are the copays for prescription drugs?

There is no copay for tier 1/preferred generic drugs at an Aetna preferred pharmacy.

The prescription drug rider cost share is 25% in all other tiers until you get to the catastrophic phase, which starts once $7,400 in true out-of-pocket costs have been incurred. Then, in 2023, you’ll pay the greater of 5% of the cost of the drug or $4.15 for a generic drug (or a drug that is treated like a generic) and $10.35 for all other drugs. In 2024, there will be zero cost share in the catastrophic phase.

Hospitals

How do I find out if my hospital is covered under the Aetna Medicare Advantage PPO plan?

There are more than 4,200 network hospitals nationwide with excellent coverage in areas where New York City retirees live. You can visit CONY.AetnaMedicare.com to check if a hospital is in network.

All hospitals in the downstate New York area are in network except Stony Brook University Hospital, but that facility does accept payment from Aetna. Memorial Sloan Kettering and the Hospital for Special Surgery are both in network. All other hospital facilities from the Hudson Valley to the D.C. Capital Region are also in network.

There are 193 hospitals in Florida — 95% statewide — that have contracts with Aetna. All of the hospitals are in network in the Florida counties where most UFT retirees live: Miami-Dade, Broward, Palm Beach, Hernando, Manatee, Pasco and Pinellas counties.

There are 109 hospitals in North Carolina — 96% statewide — that have contracts with Aetna. No large hospital systems in that state are out of network. In Charlotte and Wake counties, where most UFT retirees live, all of the hospitals, including Duke Health and the Carolina Center for Specialty Surgery, are in network.

The Cleveland Clinic is in network. The Mayo Clinic is not in network and sees patients only on a case-by-case basis. Aetna will work with members to try to get access to the Mayo Clinic, and if the Mayo Clinic refuses, Aetna will help the retiree find another provider.

What is the cost of a hospital admission?

The cost share is waived in 2023. Starting in 2024, you will pay $300 per admission with a $750 annual maximum and 0% coinsurance.

Do I need the 365-day hospital rider?

No, the Aetna Medicare Advantage PPO plan fully covers the cost of hospitalization outside the copay.

What is the coverage for emergency room visits?

• Emergency care worldwide: $50 (waived if admitted to the hospital)
• Ambulance: $0