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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.

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.

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. 

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.

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 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. There is no change with 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 all the hospitals in the NYC area, including Memorial Sloan-Kettering (MSK) and The Hospital for Special Surgery (HSS), almost all hospitals nationally, and 99.5% of all doctors.

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. 

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. All other plans will still be available as a pay-up option. Retirees that choose to stay on their current plan will now pay the additional premium difference.

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.

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 EmblemHealth.

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. 

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 those programs. Note: Based on the robust design of the new plan, EmblemHealth 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?
If your spouse or dependents are not yet eligible for Medicare, they will stay in the GHI CBP program (the same plan that in-service and pre-Medicare retirees presently have).

Will I be able to use services at Memorial Sloan Kettering (MSK) and the Hospital for Special Surgery (HSS)?
The new plan guarantees that members will be able to use both hospitals.

Are the annual NYC Medicare Part B and IRMAA reimbursements continuing?
Yes.

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 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.15. 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. You will receive information about the NYC Medicare Advantage Plus plan and optout process in mid-August.

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, your choice of New York City health plan can always be changed during an open enrollment period or by invoking your once-in-a-lifetime change (under the rules that govern the NYC Health Benefits Program). In the past, transfers between plans were only permitted every other year. Beginning in 2022, transfers between plans will be permitted every year in the Fall.

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.

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.