NYC Medicare Advantage Plus Plan FAQs

The following information was provided by the NYC Office of Labor Relations and the BlueCross
BlueShield/Emblem Alliance, and is subject to change.

• What is the deadline to decide whether to enroll in the NYC Medicare Advantage Plus Program?

City retirees have until October 31, 2021 to make a decision whether to enroll in the NYC Medicare
Advantage Plus Plan, or to keep their current plan, whether it is Senior Care or another plan, and pay the
buy up premium to keep their current plan.

The cost for the Senior Care plan will be $191.57 per month. In the open enrollment for 2023, City retirees
who chose the NYC Medicare Advantage Plus Program will have an opportunity to return to their prior
coverage. After that, the only options will be between the Senior Care plan and the NYC Medicare
Advantage Plus Plan.

Once enrollment is processed, members will receive their ID cards and the welcome guide in December.
Monthly Newsletters will be sent starting in January. Members will have access to obtain the evidence of
coverage document online, or can request it through the call center.

• How do City retirees enroll in the NYC Medicare Advantage Plus Program or opt out?

The NYC Medicare Advantage Plus Program is the new default plan for City retirees. All members will be
automatically enrolled unless they opt out by October 31, 2021.

If a member opts out of the NYC Medicare Advantage Plus Program, they will be responsible to pay the
difference between the cost of their current plan and the Medicare Advantage Plus Program premium cost.
For example, if a member decides to stay with their Senior Care Plan, the opt-out buy-up premium will be
$191.57 per month for the base plan. If they sign up for the hospital rider, the cost is $2.83 per month, for a
total monthly cost of approximately $194 per member per month.

There are five ways to opt out of the NYC Medicare Advantage Plus Plan:

1. Complete enrollment electronically at: https://nyc-ma-plus.empireblue.com/ (if you are opting to keep
your Senior Care Plan, select the option to remain on Senior Care)
2. Mail the completed opt-out form provided in your NYC Medicare Advantage Plus Plan Enrollment Guide
to: NYC Medicare Advantage Plus Plan, PO Box 173605, Denver, CO 80217
3. Fax the completed opt-out form to: 877-494-7195
4. Phone: 833-325-1190
5. Email the completed opt-out form to: [email protected]

• When opt out forms are submitted, will City retirees receive confirmation?

Once the opt out is registered with the plan, a confirmation letter will be sent to the member.
• How does the NYC Medicare Advantage Plus Plan work?

Under the current plan, most City retirees have traditional Medicare plus a supplemental plan (Medigap
plan/GHI) free from the City known as Senior Care. The NYC Medicare Advantage Plus Plan will replace both
the traditional Medicare plan and the Medigap plan. Dental, vision, and prescription drug benefits are not
impacted. The City will continue to reimburse Medicare Part B premiums as long as City retirees remain in
one of the plans offered by the City.

The following are other characteristics of the NYC Medicare Advantage Plus Plan (referred to below as “the
plan”):

o The plan must cover all services that are covered under traditional Medicare. The plan also follows the
same Medicare coverage and medical necessity guidelines.
o Members will be able to access any Medicare participating provider nationally and in U.S. territories (as
long as the Medicare participating provider will accept payment from the plan)
o The plan will pay out-of-network Medicare providers 100% reimbursement based on the Medicare
allowable rate. Cost sharing for members will be the same whether they see in-network or out-of-
network Medicare providers.
o Members will not be required to get a referral to see a specialist
o Members are responsible to pay copayments and deductibles for medical services out-of-pocket. Out—
of-pocket expenses are capped at $1,470 per year.
o Some services will require preauthorization on the front end vs. a retrospective review that Original
Medicare does on the back end. In-network Medicare providers are responsible for taking care of the
preauthorization process for members; out-of-network Medicare providers are not, however, members
may ask out-of-network providers to request preauthorization, and are encouraged to do so).

When medical services are provided by out-of-network Medicare providers, there will be a retrospective
review for medical necessity like with Original Medicare, unless the member asks the Medicare provider
to request a preauthorization (see further below in this document for more information about the
preauthorization process).

• What if a City retiree is admitted to the hospital, or is treated in the ER, and a treating physician does not
accept Medicare. Will the medical services provided by that physician be covered?

Members will be held harmless in emergency situations. It would be a rare situation for a provider rendering
services in an in-network facility to not accept Medicare.

• What is the copay if a City retiree needs to stay in a skilled nursing facility longer than 100 days?

Traditional Medicare, as well as Medicare Advantage plans, follow the Medicare benefit of 100 days per
benefit period for skilled nursing care. Skilled Nursing Facility (SNF) care follows Medicare coverage
guidelines and is covered for 100 days per benefit period. A “benefit period” begins on the first day you go
to a Medicare-covered inpatient hospital or a SNF. The benefit period ends when you have not been an
inpatient at any hospital or SNF for 60 days in a row. Coverage is always based on the benefit design and
medical necessity. The Alliance medical management department will perform continued stay reviews at
intervals until discharge to ensure medical appropriateness and determine discharge needs. If the Alliance
reviewer does not agree upon medical necessity, the next step would be a peer-to-peer review between the
provider and an Alliance provider. The member would be responsible for days beyond 100.
• What are some of the additional benefits of the NYC Medicare Advantage Plus Plan?

According to the plan administrators:

➢ Silver Sneakers: There are over 16,000 silver sneakers locations nationally; members can use locations
in different states
➢ Transportation for health care visits: Transportation is available for hospital, doctor, and pharmacy
visits; members should coordinate transportation at least 48 hours in advance of the trip.
➢ Telehealth: Telehealth services are included at $0 cost sharing
➢ Home meal delivery: Members can receive up to 56 healthy meals per year after being discharged from
the hospital. Meals are delivered to members’ homes.
➢ Healthy pantry benefit: There is a healthy pantry benefit for members with certain chronic health
conditions to help manage the condition through dietary changes (diabetic or cardiac patients, for
example). Eligible members may receive a shelf stable pantry box each month, and may also receive
monthly nutritional counseling with a dietician.
➢ Wellness rewards: Incentives are available for wellness screenings and preventive care; for example,
members may earn rewards gift cards after having a colonoscopy, mammography, or annual physical.
➢ Medicare community resource support: Members will be provided assistance with finding community
resources, such as assistance with shopping, wheelchair ramp installation, etc.
➢ Health and fitness tracker: Members are eligible for a fit bit every two years, as well as access to an
online health and fitness tracker that coordinates with the fit bit.
➢ 24/7 nurse line: Members may call this helpline 24/7 to help triage their medical condition and
determine if they need immediate emergency care, or if they can wait until the next day to seek medical
attention.

• Which health care providers are in-network vs. out-of-network providers?

Under the passive PPO plan, in and out of network care has the same cost share to the member. In-network
providers are those participating with Emblem, Empire or BCBS nationally. All providers in and out of
network must be Medicare participating providers.

All providers must be Medicare participating providers in order to be paid by Original Medicare or Medicare
Advantage Plans. Members that choose to see a non-Medicare participating provider that has Opted Out of
the Medicare program have signed a private pay agreement with the provider (i.e. in this situation, a
member is responsible to pay all medical expenses out-of-pocket).

• What is the best way for City retirees to verify whether a provider is in-network or out-of-network?
o In-network providers are Medicare providers who are contracted with Emblem, Empire, or Blue Cross
Blue Shield nationally.
o Out-of-network providers are Medicare providers who are not contracted with Emblem, Empire, or Blue
Cross Blue Shield. This includes Medicare providers nationwide.

To verify that a Medicare provider is in-network:

➢ Call the Alliance Call Center at 833-325-1190 to ask if a Medicare provider is in- or out-of-network.

OR

➢ Check online at: https://www.empireblue.com/find-care/ by following these steps:

• What if a Medicare provider does not agree to accept payment from the NYC Medicare Advantage Plus
Plan?

There are providers who accept Medicare but not Medicare Advantage. In the very rare instance that a
provider that accepts Medicare tells a City retiree that they will not accept payment from the NYC Medicare
Advantage Plus Plan, the City 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 that the payment schedule and billing
protocol is the same as Medicare and answer any provider questions. If despite that effort, the provider still
refuses the City retiree 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 the Medicare fee schedule is followed, the member
will only be responsible for their copays/coinsurance as defined by the Plan.

• Which local hospitals are in-network?

According to the plan administrators, most local hospitals are in-network, including NYP/Weill Cornell,
Columbia Presbyterian, Mount Sinai, and NYU. This is not a complete list of local in-network hospitals. You
can call the BCBS/Emblem call center or check online at: https://www.empireblue.com/find-care/ to verify
whether a hospital is in-network.

The NYC Medicare Advantage Plus Plan does not have a contract with Hospital for Special Surgery and
Memorial Sloan Kettering, and therefore, they are not in-network. There is a verbal acceptance from both
hospitals that they will continue to see members on an out-of-network basis. It is possible, however, that
individual doctors at these facilities may not accept payment from Medicare or the NYC Medicare Advantage
Plus Plan.

• Do any services require preauthorization?

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.

If an out-of-network doctor does not request a preauthorization, similar to how traditional Medicare works
today, a retrospective review of medical necessity will occur. If it is determined the Medicare medical
necessity guidelines have not been met, the claim could be denied as it would be denied under traditional
Medicare.
• Which medical procedures require preauthorization and where is that information located?

This information will be located in the members Evidence of Coverage, (EOC). The list of medical procedures
subject to preauthorization is similar to the list for active employees with some minor changes due to age
differences.

Some examples of medical services that require preauthorization include: planned inpatient hospital stays,
surgeries, complex diagnostics (MRIs, PET scans, CAT scans), physical therapy, infusion therapy, and
radiation therapy.

• When preauthorization is requested for surgery, what criteria are used to determine if surgery will be
approved? Is age a criterion? What if the surgery is not approved?

According to the plan administrators: The criteria used for preauthorization are the same used by Medicare
to determine medical necessity, and vary by surgery. Regarding whether age is a criterion, It depends on the
procedure. Medicare has age criteria for certain procedures that we will follow as well.

If preauthorization is denied, there is an opportunity for the provider and member to appeal and it will go to
a medical director for review and appeal. If it needs to go to an outside peer review with a third party, it can
do so as well. Both the provider and member have the ability to appeal the decision.

• How does preauthorization of physical therapy work?

According to the plan administrators: Medicare allows a certain number of physical therapy visits per year.
With documentation, Medicare will allow additional visits. It will be based on the need of the patient. There
will not be a cap on maximum number of physical therapy visits, but rather based on the number that the
patient needs and what the doctor is recommending.

• How long does it take for the preauthorization process to be completed?

The amount of time depends on the service and urgency. If urgent, within 24-48 hours. If planned, the
process could take a couple of days.

• If there are medical billing or coverage issues, who can City retirees call?

Members can call BCBS and Emblem’s call center at 833-325-1190 for assistance with medical billing or
coverage issues.

• Is there an independent consumer assistance entity that City retirees can contact for assistance with
denials of coverage?

Medicare Advantage plans are held to robust appeals and grievance processes, including multiple levels of
independent review, as required by CMS. Details on how to file an appeal or grievance are outlined in the
Evidence of Coverage document City retirees will receive when enrolled in the NYC Medicare Advantage Plus
plan. When a claim is denied, the member is also sent a CMS required IDN (Integrated Denial Notice). The
following assistance phone numbers are listed on the IDN – Member Services, 1-800-MEDICARE, Medicare
Rights Center, Elder Care Locator.