FAQ: Proposed Medicare Advantage Plan (pt2)

Frequently Asked Questions About the Proposed Medicare Advantage (MA) Plan (part 2) recap from the MLC May meeting (unofficial informal summary). This is a continuing negotiation; there is another round of bidding from the two entities that are still in the running for this contract. Details, including those below, are subject to change.

Q: Keep your current doctors?
Yes, but, your doctor can choose not to participate in the new plan. Although the plan will accept any doctor enrolled in Part B nationwide, the inverse is not true. Every medical provider who accepts Part B may not accept the new plan. It is up to your doctor whether or not to accept the plan.

Q: Nationwide coverage?
Again, doctors are free not to participate. See #1.

Q: International coverage?
There may be some limited international coverage for emergencies only. 

Q: Co-pays?
Effective July 1, 2021, there will be new $15 co-pays for most services and procedures including provider appointments and lab tests. The new plan is expected to have a $1500 annual cap on out of pocket, which would include the $15 co-pays, ambulance service and hospital admission co-pay.

Q: How does the vendor make a profit?
CMMS pays incentive bonuses to MAGP’s that save money through better health practices and outcomes from Evidence Based Care. This also includes quality of care and patient satisfaction surveys.

Q: Can you buy your own coverage?
Yes, you can purchase on the open market, but the City will not reimburse you for Part C. The City will no longer be contributing to a plan on your behalf.

Q: What about Medicare Part B Reimbursement and IRMAA?
If you stay in the MAGP you will continue to pay the equivalent of the Med Part B premium and the high-income surcharge (IRMAA). The City will continue to reimburse. You should receive the same reimbursements you do now and if you choose to take your own coverage you may not be eligible.

Q: What is the appeals process?
There will be two internal and one independent appeals process for rejected claims, etc.

Q: What about wellness benefits?
Some form of optical and hearing. Home-care meals when transitioning from the hospital to one’s home. Discounts on durable medical equipment. Rewards (gift cards) for meeting defined personal goals, such as weight loss, lowering your A1C, etc. Concierge service for medical appointments and limited transportation to health care providers. It is not clear if those benefits to be provided by the vendor will no longer be provided by the City.

Q: Prescription Drug Plan?
The prescription drug plan (Part D) remains separate, and coverage will continue as is but maybe there will be a reduction of deductibles for those prescription plans that have deductibles and a possible reduction in premium for those plans that have no deductible. However, it is expected that the formulary may be narrower than now exists

Q: What is the length of the contract?
The prices will remain the same for the first three years of the five-year contract. No guarantees about prices after that.

Q: Deductibles?
Retirees will continue to pay the Med Part B deductible ($203 for this year) and the equivalent of the GHI annual deductible of $50. This will be applied to the out-of-pocket cap. It is not clear if deductibles will count toward the annual cap.