New information and updates regarding the NYC Medicare Advantage Plus Plan from OLR.
Download the letter here.
Dear Retiree:
We have new information and updates to share with you about the new NYC Medicare Advantage Plus Plan. These updates include the start date for the new plan, the timeline to opt in or out, and a new summary of key information about the plan itself.
There are three notable updates about the timeline for opting in or out:
- The new start date for the NYC Medicare Advantage Plus Plan is April 1, 2022. The plan was previously set to begin on January 1, 2022. You will remain on your current health plan until March 31, 2022. Also, you will be responsible only for one health plan’s deductible in the 2022 calendar year.
- The new opt-out deadline has been extended to March 31, 2022. The deadline for retirees to opt out of automatic enrollment into the NYC Medicare Advantage Plus Plan was previously October 31,2021.
If you opted out of this plan already, you do not need to submit another opt-out form. You will be receiving an opt-out confirmation letter shortly.
If you do not opt out of the NYC Medicare Advantage Plus Plan, you will automatically be enrolled in the plan effective April 1, 2022. - You have a new opportunity to choose between the NYC Medicare Advantage Plus Plan and your current plan from April 1, 2022 until June 30, 2022. You can give the NYC Medicare Advantage Plus Plan a try for up to three months. If you want to return to your old plan, you will be able to do so during that time period. If you previously chose to opt-out of the NYC Medicare Advantage Plus Plan on or before March 31, 2022 and chosen to stay in your current plan and subsequently would like to enroll in the NYC Medicare Advantage Plus plan, you may do so from April 1, 2022 until June 30, 2022.
More details about these new deadlines are provided in the “Opt-Out and Plan Switch” section below.
You may have more questions about the new plan. We want to make sure you have all the information and answers you need. Key points all retirees should know:
• What it is: The NYC Medicare Advantage Plus Plan is a premium-free, Medicare Advantage program for all Medicare-eligible City retirees and their Medicare-eligible dependents.
• Who is providing it: The NYC Medicare Advantage Plus Plan will be provided by an alliance between Empire BlueCross BlueShield and EmblemHealth.
• You should have already received an enrollment guide and opt-out form, among other materials. Some of these materials, including the Enrollment Guide, have been updated and you can request an updated copy. See details in the “Enrollment Materials” section.
• The plan is flexible. You may see any provider that accepts Medicare at no extra cost to you other than your deductible or co-pay/co-insurance for covered services under the new plan. See details in the “Flexibility” section.
• The plan’s network is broad. While you do not have to see an in-network provider under this plan, you can. The plan’s network, via the combined Medicare Advantage networks of EmblemHealth and Empire and their partners, includes more than a million healthcare providers nationwide. In-network providers are contractually obligated to see members of the plan. See details in the “Network” section.
• You can see out-of-network Medicare providers. See more information in the “Out-of-Network Providers” section.
• Prior authorization. Under the plan, most covered services do not require a prior authorization (pre-approval), but some do. Prior authorization is a feature of all Medicare Advantage plans and an existing requirement for many active City employees and pre-Medicare retirees. A new flyer about prior authorization has been posted on the OLR website and will be mailed by the NYC Medicare Advantage Plus plan upon request. See details in the “Prior Authorization” section.
• Prescription drug benefits. Many retirees get prescription drug coverage directly from their welfare fund, and that remains unchanged. For those who do not, the current EmblemHealth prescription drug rider will be offered at a lower price. Some retirees currently purchase individual Medicare Part D coverage via a subsidy from their welfare fund; those retirees will not be able to do so and will need to obtain coverage through the EmblemHealth rider. See details in the “Prescription Drug Benefits”
section.
• More information is available online. See details in the “More Information” section of this letter.
Enrollment Materials
In September or October 2021, you should have received an enrollment guide for the new plan. This included a detailed benefits summary and the Medicare Part D prescription drug rider information. We also informed retirees of their option to opt out of the NYC Medicare Advantage Plus Plan and stay in their current health plan. Retirees who choose to opt out will be responsible for the full cost of the premium difference between the NYC Medicare Advantage Plus plan and their current plan’s cost, if any.
Since then, we have updated the enrollment guide to reflect the new start date for the plan (April 1, 2022) and new opt-out deadline (March 31, 2022), and replaced or removed all references to the prior January 1, 2022 start date and October 31, 2021 opt-out deadline. We have also updated the “Retiree Health Plan Rates” section. We have also made additions to the “Prior Authorization” section of the enrollment guide, described below.
Pre-Enrollment Guide
Cover, pages 18, 29, Appendix: References to prior January 1, 2022 start date replaced with new April 1, 2022 start date
Page 31, 32: We have also updated the “Retiree Health Plan Rates” section
Appendix, Opt-Out Form: References to prior October 31, 2021 opt-out deadline replaced with new March 31, 2022 opt-out deadline.
Pages 20-25: In “Summary of Benefits” section the prior authorization asterisks were added to the benefit categories Diagnostic services/labs/imaging, Mental health services, Physical therapy, Acupuncture services, and Home health agency care.
An updated version of the enrollment guide is available on the website of the City’s Office of Labor Relations, and click on “View the NYC Medicare Advantage Plus Plan Enrollment Guide.”
We are also making hard copies of the revised enrollment guide available upon request. If you would like a copy, did not receive one initially, and/or have misplaced the materials, please call the NYC Medicare Advantage Plus Plan’s dedicated call center at 1-833-325-1190, Monday to Friday, 8 a.m. to 9 p.m. ET, except holidays.
Outreach Efforts
Since the new plan was announced, the NYC Medicare Advantage Plus plan and the City have conducted an extensive education program for those retirees with further questions. We have performed 81 informational sessions, reaching at least 38,000 retirees, and will reach even more throughout December 2021 and January 2022. Retirees can access these programs and obtain more information about the NYC Medicare Advantage Plus Plan on the plan website at www.empireblue.com/nyc-ma-plus. This website includes the latest updates, forms, and links to webinars regarding the new plan. Because we understand many retirees still have questions about the new plan, we wanted to address key matters
now.
Flexibility
As a NYC Medicare Advantage Plus Plan member, you may go to any provider for care that accepts Medicare at no extra cost to you, besides your deductible or co-pay/co-insurance, for covered services.
• If you go to an in-network provider, you’ll only need to pay your deductible or co-pay/co-insurance for covered services.
• If you go to an out-of-network Medicare provider, you’ll only need to pay your deductible or co-pay, and the provider can bill the plan directly for covered services.
This means if you go to any healthcare provider for covered services who takes Medicare, in or out of the network, you’ll have no expense other than your deductible or co-pay/coinsurance.
Network
It is not uncommon for Medicare Advantage plans to require using in-network providers only. The NYC Medicare Advantage Plus Plan is not one of them. You can choose the providers you want who takes Medicare. Almost all of them do. That said, there is a network that covers the NYC Medicare Advantage Plus Plan, which is the combined Medicare Advantage networks of EmblemHealth and Empire, including Empire’s “Blue” partners across the county.
This includes providers in:
• EmblemHealth’s Medicare Choice PPO
• Empire MediBlue PPO
• BlueCross BlueShield (BCBS) Medicare Advantage PPO Network
The NYC Medicare Advantage Plus Plan’s wide network encompasses more than one million healthcare providers across the county, including more than 91 percent of providers recently used by City retirees in the GHI/EBCBS Senior Care program. Approximately 89 percent of retirees live in three states, New York (69 percent), Florida (13 percent, concentrated in Palm Beach and Broward counties), and New Jersey (7 percent). Hospitals in those states are overwhelmingly in-network. With one exception, all New York hospitals (including Cornell, Hospital for Special Services, Montefiore, Memorial Sloan Kettering, Mount Sinai, Northwell, and NYU) are in-network, and the last hospital (Maimonides) has verbally agreed to join the network and is expected to be in contract soon. All New Jersey hospitals are in-network. And more than 90 percent (190 of 211) Florida hospitals are in-network, including the three main Palm Beach/Broward hospitals (Oak Hill, Del Ray Medical Center, Boca Raton Community Hospital).
While you do not need to go to an in-network provider in the NYC Medicare Advantage Plus Plan, you can. The odds your existing provider is already in-network are very high.
In-network providers are not only contractually obligated to see you as a patient (unless their practice is closed to new patients), but also required to obtain prior authorization for you as needed.
If you are interested in finding out whether a certain provider is part of the NYC Medicare Advantage Plus Plann etwork, you can contact them directly. You can also look up the status of providers online. Or, you can call 1-833-325-1190 and the NYC Medicare Advantage Plus Plan will help you. Given this is a new, custom-crafted plan for NYC retirees, the front-office staff may not be aware of the name yet. Please be sure to inform whom you speak with this is an Emblem/Empire/BlueCross BlueShield (BCBS) Medicare Advantage PPO program, and material on the plan has been furnished to the medical providers.
Out-of-Network Providers
If you go to an out-of-network provider, that provider should bill the NYC Medicare Advantage Plus Plan directly. You will be responsible only for your deductible or co-pay/coinsurance for covered services.
That said, in extremely rare circumstances, the provider may ask you to pay for the services directly. If this happens, your first call should be to the NYC Medicare Advantage Plus plan at 1-833-325-1190. Our concierge service will urge the provider to bill the plan directly and explain the benefits of doing so.
If the provider refuses to bill the plan directly, you can still see the provider, but you will have to pay the provider’s bill and get reimbursed from the NYC Medicare Advantage Plus Plan. Details on how to ask for reimbursement are provided in the enrollment guide. You can also call the plan’s dedicated help line at 1-833-325-1190. You’ll need to submit the related documentation, and the Plan will pay you within 30 days so long as all the needed information is included.
Prior Authorization
Some services in the NYC Medicare Advantage Plus Plan have a prior authorization requirement. Prior authorization (also called pre-approval) is not new; it has been part of the GHI CBP/Empire BlueCross BlueShield plan for active employees and pre-Medicare retirees, which contains a similar requirement. It will also be familiar to the tens of thousands of City retirees in existing Medicare Advantage programs.
Prior authorization is a common part of healthcare plans. The goal is to ensure members receive high quality, evidence-based care by working with your doctor to evaluate services. Prior authorization is handled by providers, not retirees.
In the NYC Medicare Advantage Plus Plan, most covered services do not require prior authorization. Some services do however, like non-emergency elective hospital admissions. For those services, requests are clinically reviewed by the plan’s team of doctors and nurses (and not clerical staff) for prior authorization. The plan follows Centers for Medicare & Medicaid Services guidelines for completing reviews. Prior authorizations are completed as soon as all information is available.
If you would like more information about prior authorization:
• The City and the NYC Medicare Advantage Plus plan have prepared a 2022 “Evidence of Coverage” document (EOC), which contains more information about prior authorization. To see the EOC online, please visit OLR’s website and choose “View the 2022 Evidence of Coverage.”
• The City and the NYC Medicare Advantage Plus plan have also prepared a flyer with more details about prior authorization. Please visit OLR’s website and click on “Prior Authorization FAQs” to view the flyer online. Or, if you would like to have a copy mailed to you, please call the dedicated help line at 1-833-325-1190.
• The “Prior Authorization” section of the enrollment guide for the NYC Medicare Advantage Plus Plan has been updated. Asterisks have been added to select benefit categories (Diagnostic services/labs/imaging; Mental health services; Physical therapy; Acupuncture services; and Home
health agency care) in the Summary of Benefits section.
• If you have more questions, please reach out to your medical providers.
Prescription Drug Benefits
Many retirees currently get prescription drug coverage from their unions or the related welfare funds. That will remain the same under the NYC Medicare Advantage Plus Plan. For retirees who do not receive drug coverage that way, the current EmblemHealth prescription drug rider will be offered as part of the new plan, but at a lower price. The cost has been reduced from $150.30 per month to $125 per month.
Some retirees currently purchase individual Medicare Part D benefit plans. Medicare rules do not allow individuals enrolled in a Medicare Advantage plan to obtain drug coverage in this way. For those retirees to obtain prescription drug coverage, they’ll have to enroll in the EmblemHealth prescription drug rider or their union drug plan.
If you have any questions about whether you fit into this category, contact your union or welfare fund plan administrator.
Opt-Out and Plan Switch
Opt-Out. As you may know, the original deadline for retirees to opt out of (or leave) the new NYC Medicare Advantage Plus Plan was October 31, 2021.
The opt-out period has been extended until March 31, 2022. The procedure for opting out remains the same as before. If you have any questions about how to opt out, you can call the NYC Medicare Advantage Plus Plan at 1-833-325-1190. Retirees who do not opt out by March 31, 2022, will be automatically enrolled in the NYC Medicare Advantage Plus Plan effective April 1, 2022. If you file an opt-out request in late February or March 2022, please be aware you may still receive materials from the plan indicating you are being enrolled in the NYC Medicare Advantage Plus Plan. You can disregard these materials; if you opt out, you will remain enrolled in your current health insurance plan.
If you previously opted out of the NYC Medicare Advantage Plus Plan, but have reconsidered that decision (for example, you may now have confirmed your current provider[s] are in the plan), you can withdraw your opt-out and remain in the NYC Medicare Advantage Plus Plan. To do so, please call the NYC Medicare Advantage Plus Plan at 1-833-325-1190. You can also submit a written statement with your name, address, date of birth, and Medicare Beneficiary Number by mail to NYC Medicare Advantage Plus Plan, PO Box 1620, New York, NY 10008-1620 or by fax to 877-494-7195. Telephone and mail are preferred, because they are more secure ways of transmitting sensitive personal information, but the plan will honor opt-out requests received by fax if that is how you send it.
Switch plans between the NYC Medicare Advantage Plus Plan and your current plan from April 1, 2022 through June 30, 2022. In addition to the opt-out procedure, retirees will also be able to make a one-time switch between the NYC Medicare Advantage Plus Plan and their current plan from April 1, 2022 through June 30, 2022.
This means:
• A retiree enrolled in the NYC Medicare Advantage Plus Plan as of April 1, 2022, can switch back to their current plan until June 30, 2022. (You will receive materials from the NYC Medicare Advantage Plus Plan indicating you are disenrolled from the plan)
To switch from the NYC Medicare Advantage Plus Plan back to your current plan, retirees should make the request through the NYC Medicare Advantage Plus plan call center or fill out the form located on the dedicate website.
• A retiree who has opted out as of April 1, 2022, can switch to the NYC Medicare Advantage Plus Plan until June 30, 2022.
To enroll in NYC Medicare Advantage Plus Plan retirees should use the City’s Health Benefits Application, which will be available on OLR’s website Plan switches will become effective on the first day of the month after they are made. For example, a plan switch submitted on April 15, 2022, would become effective May 1, 2022. Please note that this option will not count against the so-called “once-in-a-lifetime transfer”; it is a special switching option unique to this three-month period that allows you to return to your current plan.
More Information
More information about all these points, as well as others, are available to retirees from the following sources:
• OLR website
• NYC Medicare Advantage Plus plan website for the NYC Medicare Advantage Plus Plan
• NYC Medicare Advantage Plus Plan dedicated call center: 1-833-325-1190, Monday to Friday, 8 a.m. to 9 p.m.
Very Truly Yours,
Renee Campion
Commissioner