Frequently Asked Questions (FAQs)

Medicare is a health insurance program for:

• People age 65 or older
• People under age 65 with certain disabilities
• People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Part A — Hospital Insurance

You may not have to pay a premium for Part A if you or your spouse have already paid for it through your payroll taxes while working. Medicare Part A helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions to get these benefits.

Part B — Medical Insurance

Most people pay a monthly premium for Medicare Part B. Part B helps cover doctors' services and outpatient care. It also covers some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Part C — Medicare Advantage Plans

These plans offer excellent benefits, often for low — or no — monthly plan premiums. They include Parts A and B, and some of them even include Part D (prescription drug coverage). The great thing about Medicare Advantage plans is they offer more benefits than Original Medicare, usually for the same cost. Different plans offer options to help you find the coverage that meets your unique needs.

Part D — Prescription Drug Coverage

On January 1, 2006, new Medicare prescription drug coverage became available to everyone with Medicare. Everyone with Medicare can get this coverage, which may help lower prescription drug costs and protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance and private companies provide the coverage. You choose the drug plan and pay a monthly premium. Like other insurance, if you decide not to enroll in a drug plan when you’re first eligible, you may pay a penalty if you decide to join later.

Some of the most common Medicare Advantage plans are Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans. EmblemHealth offers both. Which one you choose depends on two factors: cost and benefits.

HMOs offer the convenience and efficiency of coordinated care.

You must choose a primary care physician (PCP) from a network of providers who will coordinate all
of your care for you, such as giving you referrals to see specialists. Because HMOs are set up for in-network care, they can help minimize your out-of-pocket costs with low, predictable copayments
for most covered medical services.

PPO plans let you choose your own doctors.

PPO plans give you the opportunity to choose the doctors you want to see in or out of a plan network without a referral. The same goes for specialists and hospitals. You don’t even need to have a primary care doctor when you have one of these plans. Your out-of-pocket costs will be even lower for an in-network doctor than for one out-of-network. If having the freedom to see doctors outside of a plan network is important to you, a PPO is a great option to consider.

Both HMO and PPO plans provide more benefits than Original Medicare — for low or no monthly premiums.

Both types of plans give you all of the benefits of Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). And most of our Medicare Advantage plans also provide our members with Medicare Part D (Prescription Drug Coverage) — for no additional plan premiums.

To receive coverage under an EmblemHealth Medicare Advantage Plan, all you have to do is meet the following qualifications:

• You qualify for Medicare Part A (you are 65 or older, or under 65 with certain disabilities); and
• You are enrolled in and continue to pay for Medicare Part B; and
• You reside in EmblemHealth’s service area. (View service area maps:
  Medicare HMO Service Area H3330_123226 File and Use 08/04/2012
  Medicare PPO Service Area H5528_123227 File and Use 08/04/2012)
• You don’t have End-Stage Renal Disease (permanent kidney disease requiring dialysis or a kidney transplant), except under certain limited circumstances.

To receive coverage under an EmblemHealth Prescription Drug Plan, all you have to do is meet the following qualifications:

• You qualify for Medicare Part A (you are 65 or older, or under 65 with certain disabilities); or
• You are enrolled in and continue to pay for Medicare Part B; and
• You reside in New York state.

 

You can enroll in an EmblemHealth Medicare Advantage Plan during specific enrollment periods.

Initial Coverage Election Period (ICEP)

You can enroll when you first become eligible for Medicare (three months before the month you turn age 65 until three months after the month you turn age 65). If you get Medicare due to a disability, you can join from three months before to three months after your 25th month of cash disability payments.

October 15 - December 7 (Annual Enrollment Period)

If you are eligible for Medicare, you can enroll in or switch plans during the Annual Enrollment Period. For example, you can switch from Original Medicare to a Medicare Advantage Plan (like an EmblemHealth Medicare Advantage PPO Plan). Your coverage will be effective on January 1 of the upcoming year.

January 1 - February 14 (Medicare Advantage Disenrollment Period)

Beginning in 2011, Medicare beneficiaries have the opportunity to disenroll from their Medicare Advantage program during the period of January 1st through February 14th. If a beneficiary decides to disenroll, he or she must switch to Original Medicare and must select a Part D carrier if disenrolling from a Medicare Advantage Prescription Drug plan (MAPD). All changes are effective the first day of the next month.

Special Election Periods (SEPs)

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, such as a move or a loss of other insurance coverage. These chances to make changes are called Special Election Periods (SEPs). Rules about when you can make changes and the type of changes you can make are different for each SEP. Visit our Who can qualify for an SEP section to learn more.

If you qualify for a Special Needs Plan (SNP), you can enroll, change or drop Medicare Advantage or Medicare prescription drug coverage year-round. SNPs are available for those who are in a Medicare savings plan, or are receiving assistance from the state. For more information about EmblemHealth SNPs, please visit our Medicare Special Needs Plans (SNP) section.

• If you enroll in Medicare Part B while covered by a group health plan or during the first full month after coverage ends, your Medicare Part B coverage starts on the first day of the month you enroll. You also can delay the start date for Medicare Part B coverage until the first day of any of the following three months.
• If you enroll during any of the seven remaining months of the SEP, your Medicare Part B coverage begins the month after you enroll.

For a variety of reasons, you may qualify to enroll in Medicare coverage at any time of the year. Below are situations that might qualify you for an SEP:

• You move permanently outside your plan’s service area.
• You’re enrolled in another prescription drug plan or a Medicare Advantage Plan whose contract is terminated.
• You are eligible for both Medicare and Medicaid (a "dual eligible")
• You recently qualified or no longer qualify for extra help paying for prescription drugs
• You belong to a pharmacy assistance program provided by the state.
• You want to move from an employer sponsored Prescription Drug Plan to a Medicare Prescription Drug Plan.
• Your enrollment or non-enrollment is caused by an error by a federal employee or contractor hired by the federal government.
• You lose your previous creditable coverage through no action of your own.
• Your Medicare entitlement determination is made retroactively.
• You want to leave your current Medicare Prescription Drug Plan because it was reprimanded by the federal government or the federal government has determined the plan violated a material provision of its Medicare contract in relation to services provided to you.
• You wish to enroll in a stand-alone Prescription Drug Plan (PDP) between January 1 and
  February 14, and you recently ended your enrollment in a Medicare Advantage plan between
  these dates.
• You’re enrolled in a Cost Plan that isn’t renewing its contract with Medicare. This SEP begins 90 calendar days prior to the end of the contract year (i.e., October 1) and ends on December 31 of the same year.
• You want to move from a Program of All- Inclusive Care for the Elderly — PACE — to an MA-PD.
• You live in — or are moving in or out of — a skilled nursing facility, nursing facility, intermediate care facility for the mentally retarded, psychiatric hospital or unit, rehabilitation hospital or unit, long-term care hospital, or swing-bed hospital.
• You are not eligible for premium free Part A and enroll in Medicare Part B during the Part B General Enrollment Period.

To learn more about the circumstances that qualify you for an SEP, visit
http://www.medicare.gov/Publications/Pubs/pdf/11219.pdf

To fi nd out if you are eligible to receive assistance from the state, contact your local Department of Social Services or your local Medicaid Office. New York State also offers a program, called Elderly Pharmaceutical Insurance Coverage (EPIC), which helps seniors pay for their prescription drugs.
For more information, please call toll-free 1-800-332-3742 (TTY 1-800-290-9138) from 8:00 a.m. until 5:00 p.m., Monday through Friday.

At EmblemHealth, our goal is to make the enrollment process as easy as possible for you.
For enrollment options, visit our Enroll in a Plan section.