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Q&A on the Issues

FAQ about the NYC Medicare Advantage Plus Plan

You Should Know

Over the past few months, the UFT has worked tirelessly with fellow municipal union leaders on the Municipal Labor Committee (MLC) to address the rising cost of health care while maintaining members’ current benefits and quality of care. On July 14, the MLC voted on and approved the NYC Medicare Advantage Plus Plan, which means retirees will continue to benefit from premium-free coverage while maintaining access to all of the same providers and hospitals they currently use. Unlike any other Medicare Advantage program in existence, this new plan not only mirrors and improves on the GHI Senior Care Plan, but also includes aggressive oversight to protect member benefits.

NEW - Read the updated FAQs on the NYC Medicare Advantage Plus Plan from the MLC

What is the new NYC Medicare Advantage Plus Plan?
The Municipal Labor Committee (MLC) and the city have been working to negotiate a unique custom-made large group Medicare Advantage plan that would provide the same — or ideally increase — member benefits currently covered by the GHI Senior Care plan. The NYC Medicare Advantage Plus Plan is a result of the work done by the MLC. The MLC met all its goals by maintaining all of retirees' current, premium-free benefits while adding additional enhancements. See the MLC's FAQ on this new plan »

When was this decision made?
The MLC voted to adopt the new NYC Medicare Advantage Plus Plan on July 14.

What is the start date for the NYC Medicare Advantage Plus Plan to take effect?
The start date is Jan. 1, 2022. 

Who will provide the NYC Medicare Advantage Plus Plan?
After careful consideration, the City and the Municipal Labor Committee selected an alliance between Empire BlueCross BlueShield and EmblemHealth to provide the program. This provides continuity and familiarity for the majority of employees and retirees who are currently enrolled in the City’s CBP and Senior Care programs that are offered by the same insurers. EmblemHealth will continue to administer the Part D rider. See the plan enrollment guide for current Senior Care members and for members in all other city health plans.  »

How does the new plan work?
The NYC Medicare Advantage Plus Plan replaces both traditional Medicare and a Medicare Supplement plan with a single integrated program administered by an insurer approved by Medicare. Through a contract with Medicare, the NYC Medicare Advantage Plus Plan provides all health care services previously covered by original Medicare and supplemented by the Senior Care program. The Plan must follow Medicare rules and provide all benefits provided by Medicare.

How will I be enrolled in the new plan? What do I have to do?
If you are a retiree covered by a city Medicare health plan, you will be automatically enrolled in the new plan for 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. See the plan enrollment guide for current Senior Care members and for members in all other city health plans.  »

What new enhancements does this plan have?
This program 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). 

The new plan will also add some important new benefits not covered by the current Senior Care plan, including:
• transportation costs for 24 one-way trips per year to doctors’ offices 
• home meals delivery for patients after they are discharged from the hospital
• a fitness program
• a wellness rewards program
• $0 copay telemedicine with the LiveHealth platform.

How do I enroll in the Medicare Part D prescription drug rider through the NYC Medicare Advantage Plus Program?

If you already have the prescription drug rider with the Senior Care program, you do not have to do anything. If you want to purchase the prescription drug rider, you may purchase it during the upcoming annual Fall Transfer Period in November, effective for January 1, 2022. You may purchase the prescription drug rider for the NYC Medicare Advantage Plus Plan. The cost of the prescription drug rider is $125.00 per member, per month. This Part D group prescription drug plan rider will be the same as the one offered through Emblem Health for the Senior Care program. If you choose not to take any Part D coverage, you may be subject to a permanent penalty in the future, if you decide to purchase a prescription drug rider at a later date. If you have purchased individual Part D coverage, enrolling in the NYC Medicare Advantage Plus Plan will result in disenrollment from your individual Part D plan and you will need to obtain prescription drug coverage through the city's Part D prescription drug plan rider. 

How does the prescription drug benefit differ from GHI Senior Care?
In this new plan, prescription benefits offered through the optional drug rider are exactly the same but with a lower monthly cost of $125 per member, per month. There is no change to the drug formulary or copayment structure.

Will I be able to continue seeing my doctors and visiting the same hospitals?
Yes. The NYC Medicare Advantage Plus Plan is a Group Medicare PPO, which does not restrict access to providers. This program will provide access to all doctors that take Medicare coverage, approximately 850,000 providers nationwide. About 640,000 of those Medicare providers are currently in the Empire/Emblem Alliance networks and are contractually bound to see NYC Medicare Advantage Plus members. Providers that are not contracted with the plan would bill the NYC Medicare Advantage Plus Plan to get reimbursed, like they do for traditional Medicare. It doesn't make a difference if that provider is in the insurer's network or not. As long as the provider takes payment from Medicare, they can bill the NYC Medicare Advantage Plus Plan and be paid the same amount as traditional Medicare pays. Only providers who opt out of the whole Medicare program would not be covered. This includes hospitals in the NYC area, almost all hospitals nationally, and 99.5% of all doctors. Specialized hospitals such as Memorial Sloan-Kettering (MSK) will accept this new plan and we anticipate that the Hospital for Special Surgery (HSS) will also accept this new plan. See how to search for a provider »

Is the NYC Medicare Advantage Plus plan still premium-free?
Yes. The NYC Medicare Advantage Plus Plan replaces the current GHI/EBCBS Senior Care program, which is a supplement to traditional Medicare, as the program that is premium-free to all Medicare-eligible retirees. Retirees that choose to stay on the Senior Care program will now pay the additional premium difference. The cost to continue with the Senior Care plan will be $191.57 per person, per month for the basic plan and $2.83 for the 365-day hospital rider. The HIP VIP Plan will also be available as a premium-free option, but it is only open to those retirees enrolled in the HIP VIP plan on Dec. 31, 2021. Costs for other current plans will be provided in the enrollment package sent to you in September.

Are copayments increasing under this plan?
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. Note: The GHI Senior Care program will be adopting a $15 primary care physician (PCP) copayment on Jan. 1, 2022; the new NYC Medicare Advantage Plus Plan will retain a $0 copayment to see a primary care physician.

Will this plan have a greater pension deduction than my current plan?
No, at its basic level this plan is free. The prescription drug rider will also cost less and will offer the exact same benefit.

Haven’t there been problems with Medicare Advantage plans in the past?
Yes. Many individual and small-group Medicare Advantage plans leave subscribers with fewer medical options and/or higher costs. The new NYC Medicare Advantage Plus Plan is customized for NYC retirees so they can get the same service and quality care they currently do and avoid the problems that typically plague other Medicare Advantage programs. There is no other plan like this in the country.

Will I be able to continue my coverage in GHI Senior Care or HIP VIP?
Yes, but there will be a cost to remain in GHI Senior Care. The cost to continue with the Senior Care plan will be $191.57 per person, per month for the basic plan and $2.83 for the 365-day hospital rider. The HIP VIP Plan will also be available as a premium-free option, but it is only open to those retirees enrolled in the HIP VIP plan on Dec. 31, 2021. Based on the robust design of the new plan, Emblem Health recommends that retirees do not stay in the older plans.

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?
The over-65 member will be automatically enrolled under the NYC Medicare Advantage Plus Plan and the under-65 member will stay in the Empire GHI CBP plan, both at no cost to the retiree. If the retiree chooses to pay up to remain in another pay up plan, the under 65 spouse will pay up to remain with the same insurer.

Are the annual NYC Medicare Part B and IRMAA reimbursements continuing?
Yes, as long as you remain in one of the plans offered through the city. 

How will the new NYC Medicare Advantage Plus Plan affect my UFT Welfare Fund benefits?
Your Welfare Fund benefits are administered by the UFT Welfare Fund. All retiree benefits will continue in their present form.

Is the annual UFT Welfare Fund Optional Rider reimbursement continuing?
Yes.

Can I choose another plan or is the NYC Medicare Advantage Plus plan my only choice?
You can choose to remain on your current plan by opting out of the NYC Medicare Advantage Plus plan during the opt-out period between Sept.1 - Oct.31. By opting out of the NYC Medicare Advantage Plus plan, you will be responsible for the full premium difference between the NYC Medicare Advantage Plus plan and your plan’s cost. The cost to continue with the Senior Care plan will be $191.57 per person, per month for the basic plan and $2.83 for the 365-day hospital rider. The HIP VIP Plan will also be available as a premium-free option, but it is only open to those retirees enrolled in the HIP VIP plan on Dec. 31, 2021. Costs for other current plans will be provided in the enrollment package to be mailed in September. See the opt-out forms in the enrollment guides for current Senior Care members and for members in all other city health plans. »

If I enroll in the new NYC Medicare Advantage Plus plan initially and wish to opt out later, will I be able to do so?
Yes, the City will be offering an Annual Transfer Period. In the past, transfers between plans were only permitted every other year, but beginning in 2022, transfers between plans will be permitted every year in the fall. Members also maintain their right to a once-per-lifetime transfer between retiree plans under the rules that govern the NYC Health Benefits Program. See the opt-out forms in the enrollment guides for current Senior Care members and for members in all other city health plans. »

If I initially chose to opt-out of the NYC Medicare Advantage Plus plan is it possible to rescind that decision? 

Yes, but only until the end of the opt-out period, which is Oct. 31, 2021. Call the dedicated call center (1-833-325-1190) as soon as possible. 

Under the new plan, will I need a referral to see a specialist?
No.

Will certain procedures/diagnostics require prior authorization?
Yes. Just like the plans for active 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 prior authorizations are not required, we recommend you ask your provider to request a prior authorization to confirm that the services they are providing will be considered medically necessary and covered. Please keep in mind that the prior authorization process is regulated by the federal Centers for Medicare & Medicaid Services (CMS) and must adhere to an expedited time frame.

Isn’t this privatizing Medicare?
Medicare continues to be a federal program. The GHI Senior Care program is a Medicare supplement, designed to help cover the expenses that Medicare doesn’t cover. A new supplemental plan would not be any more privatized than the current plan run by Emblem Health.

Is this supposed to save money for the city?
Implementing a Medicare Advantage plan produces approximately $600 million in savings per year, starting as early as Jan. 1, 2022. The city has agreed to place all savings from this program into a fund to support the health care and benefits of New York City municipal workers and retirees. 

What if I live out of state? Will I be covered under this plan?
The program is a national one, so it covers retirees in any state in which they work or reside and when they travel. To be eligible for the NYC Medicare Advantage Plus Plan, members must live within the 50 states or in any U.S. territory, including Puerto Rico. 

What happens if I go into the hospital in December and I’m not discharged until January when the new plan is in effect?
The insurer that was in place at the time of the inpatient admission will be responsible for the entire inpatient stay. If that was traditional Medicare and GHI/Empire Senior Care, they would be responsible for the claim for the entire stay.

I have surgery scheduled for January 3rd with my current carrier. 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.

Are doctors going to get paid less under this new plan?
No, doctors will be reimbursed according to the payment structure guidelines provided by the Centers for Medicare & Medicaid Services (CMS).

What if the provider I am seeing does not agree to accept payment from the NYC Medicare Advantage Plus Plan?
In the very rare instance where a provider that accepts Medicare tells a retiree they will not accept payment from the NYC Medicare Advantage Plus Plan, the retiree should first contact the concierge service that will be provided so that the plan can work with 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. So long as the service is a Medicare covered benefit and Medicare fee schedule is followed, the member will only be responsible for their copays/coinsurance as defined by the plan.

Will this new plan create an administrative paperwork burden on doctors when they submit claims in order to get paid?
No, unlike the current GHI Senior Care program, doctors will submit claims to one organization. Members also have one ID card and receive one Explanation of Benefits.

Where can I call for more information about the NYC Medicare Advantage Plus Plan?
A special call center (1-833-325-1190) has been established for the NYC Medicare Advantage Plus Plan to answer all your questions. The call center hours of operations are Monday to Friday, 8 a.m. to 9 p.m. ET, except holidays. You will also be receiving extensive materials in mid-August that explain the details of the plan and the enrollment process. In addition, there will be retiree meetings available all over the NYC area in September, as well as webinars for those who prefer not to attend in person meetings. See the main page of the UFT's Retired Teachers Chapter for recorded Zoom presentations as well as upcoming events for more detailed information.