Medicare Advantage Resources

Below are resources to the Medicare Advantage Plan: presentation, deck slides, guidebooks, opt-out form, survey, and FAQs.

Survey can be completed via this link. Kindly complete this 5 question survey.

Medicare Presentation can be viewed via this link with until October 31. Slide deck of the presentation can be downloaded below.

Dear MEA Retiree:      

Thank you to all of you who submitted questions and participated in our September 22 program on the NYC Medicare Advantage Plus plan.

The presentation and following Q&A were a joint presentation by Kim Parker of Empire Blue Cross, Claire Levitt, OLR Deputy Commissioner, and Sang Hong, Deputy Director of Operations Employee Benefits Program.

Enclosed below is another Q&A we put together based on questions you submitted with answers provided by Kim, Claire and Sang, OLR’s responses to our previous written questions, or the NYC Medicare Advantage Plan Enrollment Guide recently mailed to those members who are currently enrolled in GHI Senior Care. I hope this proves helpful to you in making your decision on whether to participate in the NYC Medicare Advantage Plus plan or opt out, remain with your current plan or choose a different plan, and pay the premiums the City will no longer pay. Remaining guides for all other City plans should be sent out the first week in October.

A huge debt of gratitude goes to the many City retirees from other organizations we consulted and worked with, most of whom are members of COMRO, The Committee of Municipal Retiree Organizations and our own MEA members: first and foremost Stu Eber who led both the COMRO group and the MEA group; Stephen Fisher who drafted and edited numerous documents provided to members and letters sent to OLR with questions and concerns; Jane Roeder whose knowledge of OLR was invaluable in formulating strategy, Bob Pfefferman who sat in on some MLC meetings and reported back to us on what occurred; Ed Hysyk and Neal Frumkin, who likewise reported back to us on MLC meetings and discussions; Joseph Gioe who provided invaluable information on the city’s contracting process; Allan Pinchoff and Larry Konstan whose knowledge of medical insurance and the Medicare and Medicaid programs was invaluable; and our Retirees Chapter team – Sam Borkow, Candi Carcana and Lisa Yee – who all pitched in whenever we needed extra hands or eyes. A special thank you to MEA Executive Director Alice Wong for her technical support throughout these past six months. And to the numerous MEA members who emailed us with suggestions and information. Their assistance was invaluable.

The recording of the Alliance/OLR presentation to MEA members on September 22is available on the website for those who were unable to attend.  I urge all of you to view the OLR online presentations too. In addition, I will be working on responding to additional questions submitted by MEA members in the days following the program on September 22.

We will continue to keep members informed via email, the MEA website and social media platforms on new developments on this critical issue for retirees. Latest developments this week are two lawsuits, one by Aetna who lost the contract to the Alliance and the other by a group of retirees. We have not seen the retiree organization lawsuit as of this writing or the City’s response to either of these lawsuits.

As a reminder the deadline to “opt out” of the Medicare Advantage Plan is October 31. And you need to do it in writing. The “opt out” form can be found in the Enrollment Guide booklet and the OLR website. You can mail the form, FAX it, email it, or complete it online. All information is on the form itself.

Reminder: although we had a number of MEA members attend the program who are not yet retired, this form is only for members who are already retired and on Medicare.

Adrienne Leaf
MEA Retirees Chapter Director

Medicare resources for Senior Care Members:

Medicare resources for Non Senior Care Members:

NYC MEA Frequently Asked Questions

Medicare Advantage Plus
As of September 21, 2021

1. How will we know if our opt-out form has been processed?  

If you submit the form online, you will receive an acknowledgement via email. All acknowledgements will be mailed by the end of November.

2. When and where should we call if we do not receive the new NYC Medicare Advantage Plus plan (MAP) card by December 15, 2021?  What are the ongoing procedures for undelivered, lost, or stolen cards? If we choose to opt-out, will we be receiving new cards for the plan we are remaining in?

The ID Cards for the new NYC Medicare Advantage Plus Plan will be mailed toward the end of December. Beginning in December, retirees can call the Alliance Hot line at 833-325-1190 for their new MAP ID number. Retirees can then go to the portal and set up an account.  This will allow the retiree to print temporary ID cards. The same number is called for lost, stolen or replacement ID cards.

The Welcome Guide to Alliance will be mailed toward end of December. Periodic newsletters will be mailed.

There will be no new cards for people opting out to remain in their existing plan.

3. Can we keep our current City GHI Senior Care Part D drug plan regardless of whether we opt-in or opt-out?

Yes. The Retiree Drug Rider for both GHI Senior Care and MAP is the same. It is available from Emblem Health and will cost $125 per month. Per CMS guidelines for Medicare Advantage Plans, the Part D drug coverage must be included in the plan. The retiree must take the Emblem Health Part D Pharmacy Coverage for $125 per month. Retirees can keep all City authorized plans, including Express Scripts and Humana, regardless of whether you opt-out or convert to MAP. See pages 14 and 29 of the Enrollment Guide.

If you have Part D coverage with a private plan, enrollment in MAP will cause the cancellation of the private plan drug coverage. If a retiree wants to retain this private coverage, retirees will have to make a choice as they would have to opt out to GHI Senior Care and pay the monthly premium in addition to their private drug coverage plan. The decision is a financial one for the retiree.

4. What are the transition procedures for people with ongoing treatments such as dialysis or chemotherapy?  How and when will members be advised of these procedures?  How far in advance can a member’s doctor submit to MAP their plan for the patient ensuring that there is a high level of continuity of care being provided for the employee? 

Beginning in December, retirees can call the Alliance Hotline at 833-325-1190 to obtain their new MAP ID number.  Members should also contact their providers in December with their new MAP ID.  Retirees should also have their providers inform the Alliance Hotline of ongoing cancer treatments, scheduled surgeries, and other treatments such as dialysis and chemotherapy.  The MAP Clinical Review Team will work with the provider to obtain all information to ensure a seamless continuity of care.

5. Why does the guide show an asterisk in front of in-patient and out-patient hospital-based services?  This indicates pre-certification is required.  Does that mean that members of the MAP cannot go for a colonoscopy in a hospital? Will we be discouraged from seeing a doctor at an office in a hospital building like Cornell, NYU Langone, or Mayo Clinic?

The asterisk is explained on page 28 of the Enrollment Guide. 

The NYC Medicare Advantage Plus Plan is a Group Medicare PPO, which does not restrict access to providers. Retirees can go to any doctor or hospital that accepts Medicare.

It is important to note that any provider currently in the Empire/Emblem Health Alliance network including any Blue Cross/Blue Shield plan in the Unites States is considered “in network” and contractually bound to see MAP 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 does not make a difference if that provider is in the insurer’s network or not. If the provider accepts payment from Medicare, they can bill the NYC Medicare Advantage Plus Plan and be paid the same amount as traditional Medicare pays.

6. How are out of network providers paid?

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. If the provider accepts payment from Medicare, they can bill the NYC Medicare Advantage Plus Plan and be paid the same amount as traditional Medicare pays.

This has been an area of confusion to some retirees. For a summary of how Medicare pays providers, the following website offers an explanation:

  • Opt-out physicians: These providers have opted out participation in the Medicare program. Neither the physician nor the patient can obtain reimbursement from Medicare. This represents a very small percentage (<1%) of physicians. This tends to be isolated to certain geographic areas and specialties).  In any event, it doesn’t matter whether you convert to MAP or opt out for another plan as you will pay out-of-pocket for any care provided by these doctors.
  • Accept Medicare Assignment: These providers receive from Medicare (and secondary insurers) the approved Medicare amount minus whatever co-payment is owed by the patient.
  • Non-Participating Medicare Providers: These providers can require the patient to pay upfront and bill Medicare for reimbursement. In total they are subject to a limiting charge of 115% of the Medicare approved amount.

For both the Medicare Assignment and Non-Participating categories, providers cannot balance bill up to their charge level as can happen with out-of-network doctors in commercial insurance programs, even if they do not participate in the Blue Cross MAP network. 

Please also view the FAQ on the OLR website.

7. What is the status of the agreements with the Hospital for Special Surgery and Memorial Sloan Kettering? All other specialized hospitals in New York City? All hospitals outside the New York City metropolitan area? Will a decision be reached before the open enrollment period is closes on October 31, 2021?

The Alliance has been in negotiations with the Hospital for Special Surgery and Memorial Sloan Kettering. It is anticipated that contracts will be signed within a few weeks. The CEO/CFOs of both hospitals have been advised to notify affiliated physicians that the hospital will be accepting the MAP plan. All hospitals within the Empire Blue Cross Blue Shield network will continue to participate in MAP including the Mayo Clinic and John Hopkins.

8. What procedures will require pre-authorization? What are the differences between current Medicare and MAP pre-authorization procedures? Are they more restrictive? Can we expect roadblocks with approvals moving forward if we join MAP? Please explain what levels of medical expertise will be used to review the requests. What are the time limits for responses to providers? What is the appeal process? 

Please see page 16 of the Enrollment Guide for a description of the types of services requiring prior authorization.

It is important to note that MAP follows all of the CMS guidelines for Medicare. For prior authorization, this includes reviewing each case for medical necessity based on the criteria established by CMS. The only difference is that CMS authorizes procedures on the back end after the services are provided. MAP screens at the front end before the services are provided.

Providers know the criteria and how to answer the relevant questions.

The time frames are:

  • expedited prior approval within 24 hours
    • ordinary approvals (if everything is completed in the request) within 72 hours (usually 3-7 days maximum)
    • surgery approvals within 7 days
    • on average, there are 4% denials per month

The appeals process has five levels of review and per CMS guidelines cannot exceed 30 days. The provider handles the first level of review with an Alliance medical director. Peer review is also available as well as outside specialists for unfamiliar issues. In all instances, the appeals process is not allowed to impede the health care of the member.

The Alliance is aware that retirees with chronic conditions need continuity of care and Alliance can identify retirees with chronic conditions. Providers can contact the Alliance

9. Can a couple split their coverage if both are Medicare eligible or must they choose the same plan? What if one is not Medicare eligible and the other is? Can they split? In both instances how are premiums paid? Through what mechanism? What type of costs would be associated with those decisions?

The following information is from the FAQ by the Office of Labor Relations:

“As they do today, the retiree and spouse have to choose a health insurance plan that offers both a Medicare option and a non-Medicare option (e.g.: GHI/EBCBS CBP and GHI/EBCBS Senior Care). Effective, January 1, 2022, the Medicare eligible member will automatically be enrolled into the NYC Medicare Advantage Plus Plan and the non-Medicare member will be in the GHI/EBCBS CBP plan, both at zero premium cost to the retiree. If the retiree chooses to pay the additional premium to remain in another Medicare plan, the non-Medicare spouse will also have to pay the additional premium to remain with the same health insurance plan, unless it is one of the following three non-Medicare plans for which there is currently no additional premium, namely the GHI/EBCBS CBP plan, the HIP HMO plan, and the DC-37 Med Team plan. As an example, if a Medicare retiree is enrolled in the GHI/EBCBS Senior Care plan and his or her non-Medicare spouse is enrolled in the GHI/EBCBS CBP plan, there would be an additional premium for the Medicare retiree, but zero premium for his or her non-Medicare spouse.”

10. How does MAP make its profit and how does City save $500,000,000 a year? Can you explain how this is beneficial to retirees?

The Alliance makes it profit from its contract with the Centers for Medicare and Medicaid Services. The City will save $500M a year by no longer paying the GHI Senior Care monthly premiums of about $191 a month for approximately 240,000 people.

11. What effect, if any, does this new plan have on our current Management Benefit Fund benefits such as vision, dental, etc.?

There is no effect on MBF benefits. They remain the same.

The MAP also includes a 24/7 nurse line; Fitbit and fitness tracker; Silver Sneakers.  Retirees who convert to MAP will collect a hearing benefit from Alliance and then the balance from the MBF, up to the MBF limit.

12. Can doctors opt-out of MAP? How are you reaching out to doctors who are not part of plan or opting out to encourage them to participate? How and when will members be advised if doctors have been added or deleted from the plan so that we can make an informed decision to join MAP or remain in current plan?

The Alliance announced the new plan to in-network providers in July. Many providers may not have noticed or read this notice and more intense outreach scheduled for October. Outreach starting this week to Med Part B providers not in the network.

Retirees can search now to see if their provider is in the Empire Network. Approximately 640K Medicare providers across the country are. To confirm if your doctors are participating in the program, you can call 833-325-1190 or go to the website. Retirees who are patients of Med Part B providers not in network should contact the concierge service of the Alliance at the above number to have them explain the plan to the provider. The concierge service is responsible for advocacy and guidance.

13. Can you clarify the copay differences for the current (2021) GHI Senior Care vs. the January 1, 2022, GHI Senior Care copays and MAP co-pays?

GHI Senior care had previously scheduled the co-pay increase for a primary care visit to be effective January 1, 2022. It is not part of the MAP conversion. MAP will not have a co-pay for a primary care physician visit. All visits to specialists in both plans require a co-pay.

Please review the Enrollment Guide pages 18-28 for details on co-pays. The Plan Benefit Comparison insert compares the GHI Senior Care Plan and the MAP plan.

In addition, comparison information for the other City plans is on the OLR website.

14. Can members switch annually from plan to plan after 2022? What are the parameters governing this? For example, can a person who is currently in GHI Senior Care and chooses to allow the City to enroll them in MAP for 2022 decides during the next open enrollment period that they want to opt-out of MAP and enroll in Medicare with AETNA or HIP as secondary, can they? Are they restricted to enrolling back into GHI Senior Care only? Can these choices continue moving forward to outer years? Will retirees still have the “once in a lifetime” change not within the open enrollment period?

Beginning in 2022, there will be a yearly open enrollment period for retirees to either switch to MAP or switch to their previous City plan. Switching to another current City plan (for example from GHI Senior Care to Aetna, HIP) is no longer available as enrollment in those plans has closed.

During the current opt-out period of September 15 – October 31, 2021, you cannot change to the any other City health plan. This period is only to opt-out of the MAP plan and remain in your current health plan. However, you may use the once in a lifetime option to choose any City health plan now and remain in that particular health plan if do not want to enroll in the MAP plan. You do not have to wait for the open enrollment period for your once in a lifetime change. If you switch to another city plan now, that plan will become the only city plan you can switch in or out of in the future

15. Most presentations are focusing on GHI Senior Care. Can you address other City plans retirees are currently enrolled in such as HIP, AETNA, etc? What are the cost comparisons for them? What can we expect if we opt-out of these plans? 

The detailed information is on the OLR website.

Booklets for the other City plans will be sent out the beginning of October 2021.

16. Will all future retirees continue to have the ability to choose a plan, or will they be “forced into” MAP as the City’s plan of choice? 

Future retirees who are Medicare eligible will have to choose between MAP and GHI/Senior Care.

17. Many retirees live outside New York City and will now be covered by MAP. What type of outreach is occurring to educate doctors outside of the metropolitan area who may not be familiar with this particular MAP? When people hear MAP, they think of Joe Namath and the plans he is pushing. How will you encourage doctors to participate?

The Alliance announced the new plan to in-network providers in July. Many providers may not have noticed or read this notice and more intense outreach scheduled for October. Outreach has started to Med Part B providers not in the network. 

The NYC Medicare Advantage Plus Plan is a Group Medicare PPO, which does not restrict access to providers. Retirees can go to any doctor or hospital that accepts Medicare.

It is important to note that any provider currently in the Empire/Emblem Health Alliance network including any Blue Cross/Blue Shield plan in the Unites States is considered “in network” and contractually bound to see MAP 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 does not 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. 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.

18. Who will be monitoring this contract for the City? 

The City has hired consultants to design the list of required reports, the appeals process and customer satisfaction surveys.

19. For retirees who are not yet 65 and Medicare eligible, how will they be notified when they do become eligible that a decision needs to be made regarding their City health insurance? We know Medicare begins their notification at least six months in advance for you to sign up, just wondering what steps are in place for the City notification.

There will be no change to the current procedures. CMS will notify you before you turn 65 about what your next steps are. You should also notify your agency and the Office of Labor Relations that you are enrolling in Medicare and send copies of your Medicare card to OLR.

20. If I remain in Medicare/GHI Senior Care or HIP/VIP, will I remain eligible for both Medicare Part B Reimbursement and IRMAA? 

Yes. If you remain in a City retiree health benefits program, you will be eligible for Part B reimbursement and IRMAA payments. 

21. With the conversion from Medicare / GHI Senior Care or NHIP/VIP to the NYC Medicare Advantage Plus Plan, how will special approved Non-Formulary Prescription Drugs be treated for Part D? Will the co-payments be the same as the existing copayments or reduced? Will Emblem Health honor their current approvals for these medicines or will these prescriptions require new approvals by Emblem Health? 

The Drug Plan is not changing.

22. How often can I transfer from Medicare/GHI senior care to the NYC MAP plan? How often can I transfer back from the NYC MAP plan to Medicare/GHI Senior Care or HIP/VIP? 

Open enrollment will be annually in the Fall for a January 1 start date. Retirees can switch annually.

23. If the member pays the doctor the amount s/he is billing and the member submits it to the NYC MAP, the plan may only reimburse the Medicare rate, would I therefore have to pay the difference? If so, this is a prime example of balance billing which should not occur.

Any doctor who accepts Medicare patients is required to accept the Medicare payment as payment in full, so there should be no balance billing. The concierge call center at 833-325-1190 can assist if any payment issues arise.

24. I can use my Medicare/GHI Senior care outside of the United States; will I be able to use the NYC MAP plan outside of the US? 

The NYC MAP plan will cover emergency services outside the US. Retirees who live outside the US cannot enroll in the NYC MAP plan. See page 8 of the Plan Benefit Comparison booklet.

25. How will members without computers be able to navigate NYC MAP?

Navigating the NYC MAP is no different than any of the current plans. All requirements of the program can be handled by the call center as well as online. Computers are not required to navigate the plan. 

26. How will NYC MAP inform the providers outside the NYC area but within the 50 states, District of Columbia, or any US territory (including Puerto Rico) prior to January 1, 2022, of the new plan to ensure the doctors and hospitals will accept payment directly or indirectly and to encourage their participation?

Providers outside the NYC area will be included as part of the comprehensive provider campaign. The campaign will include articles in provider newsletters, posting on the provider portal page, telephonic outreach, and mailings. 

27. Are there other nationwide Group Medicare PPOs that exist so we can review their performance?

The City and the MLC went through a detailed RFP process and interviewed four national plans as finalists to compare their performance and ultimately selected this program. There are several states that already use an advantage model for retiree Medicare coverage. Member can do the research online about these plans.

28. Please provide more details on LiveHealth.

Members can see a board-certified doctor or licensed therapist through live video on their smartphone, tablet, or computer.

See page 8 of the Enrollment Guide for more details about this program. Medical – See a Doctor 24/7 – LiveHealth Online

29. What does the Annual Maximum Out of Pocket mean? GHI/Empire Senior Care Plan is unlimited & NYC Medicare Advantage Plus Plan is $1,470 combined in network & out of network. Please explain.

See pages 4-5 and page 18 of the Enrollment Guide.