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Medicare in New York

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Overview of Medicare in New York

In 2018, more than 3.5 million residents of New York received Medicare coverage in one form or another, according to the Centers for Medicare & Medicaid Services (CMS). As a Medicare beneficiary, you have a number of Medicare coverage options available to you in New York. You will want to consider the types of coverage described below.

Original Medicare is the government-run health insurance program for eligible American citizens and legal permanent residents of at least five continuous years. You’re generally eligible when you are age 65 and older, although some beneficiaries under 65 may also qualify by disability or through having certain health conditions, such as Lou Gehrig’s disease or end-stage renal disease.

In New York, as in the rest of the country, Original Medicare includes Part A and Part B.

  • Medicare Part A (hospital insurance): Covers inpatient hospital, skilled nursing facility, some home health visits, and hospice care.
  • Medicare Part B (medical insurance): Covers outpatient services, including doctor visits, some home health care, preventive services, and durable medical equipment.

If you’re a New York beneficiary enrolled in Original Medicare, you may have noticed that you’re not covered for all costs. For example, prescription drug coverage in Original Medicare is limited to medications you get during covered inpatient hospital or skilled nursing facility stays or medications you get in certain outpatient settings. However, for most other coverage, you’ll need to sign up for a stand-alone Medicare Prescription Drug Plan.

Original Medicare doesn’t cover costs like routine vision or dental care, hearing, long-term care, or health coverage outside of the country.

As mentioned, Medicare Part D Prescription Drug Plans (PDP) can provide stand-alone prescription drug coverage that works alongside your Original Medicare coverage. You’ll typically have a separate premium for this coverage, which you’ll pay directly to your Medicare Prescription Drug Plan; this is in addition to the Medicare Part B premium, which you’ll need to keep paying. These plans are offered through private insurance companies approved by Medicare and doing business in New York.

Medigap (Medicare Supplement) insurance plans are also offered by private insurance companies and can help you pay your out-of-pocket costs for services covered under Original Medicare.

You may opt to enroll in a Medicare Advantage plan in New York as an alternative way to get your Original Medicare benefits. Medicare Advantage plans are offered by private insurance companies that contract with CMS. Also known as Medicare Part C, these plans must provide at least the same level of Medicare coverage as Original Medicare, Part A and Part B, with the exception of hospice care.

One benefit of Medicare Advantage plans is that many plans also cover extra benefits such as routine dental and vision care, hearing, or wellness programs. Some plans, known as Medicare Advantage Prescription Drug plans, also include prescription drug coverage. In other words, these plans cover all of your Medicare medical and prescription drug benefits through a single plan.

Another important benefit that Medicare Advantage plans offer is that these plans are required to include a maximum out-of-pocket spending limit, which can vary from plan to plan. Once your out-of-pocket expenses have reached this amount (including the deductible), the Medicare Advantage plan pays 100% of covered health-care costs for the rest of the year. Notably, Original Medicare doesn’t include an annual spending limit, so there’s no cap on how much you could spend on health care in a given year. If you have chronic conditions that require a lot of ongoing care or if you have a medical emergency, your out-of-pocket costs could quickly skyrocket.

To be eligible for Medicare Part C, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in the Medicare Advantage plan’s service area. You also can’t have end-stage renal disease (with certain exceptions).You’ll need to keep paying your Medicare Part B premium, in addition to any premium required by your Medicare Advantage plan. Medicare Advantage members pay the equivalent of their Medicare premium and may also pay an additional premium directly to their plans.

Would you like to find and compare Medicare plan options from the convenience of your home? For information about the specific plan options available in your community, use the eHealth plan finder tool on this page and enter your zip code.

Medicare resources in New York

New York State Office for the Aging – The New York State Office for the Aging is one of the most comprehensive resources for information about Medicare. The office provides information and services to seniors to help them live independently well into their retirement years. The state office features a local branch in every county. The Medicare services provided by this office include the following three programs:

  • Health Insurance Information Counseling and Assistance Program – This program, also referred to as HIICAP, offers free counseling to New York Medicare beneficiaries. Since the office is not affiliated with any specific insurance companies, counseling services are unbiased.
  • NY Connects: Choices for Long-Term Care – When beneficiaries require long-term care, this program provides information about the options available. In addition, local offices in each county ensure that beneficiaries have easy access to personalized counseling services.
  • Senior Medicare Patrol (SMP) – These programs are created to help New York Medicare beneficiaries protect themselves from fraud through education, detection, and prevention. The program also educates beneficiaries about what to do in the event of an error on their billing claim.

New York State Department of Health – The Department of Health for the state helps Medicare beneficiaries, who also qualify for Medicaid benefits, get the information and assistance they need. The department also supplies information about Medicare Savings Programs available to beneficiaries who cannot afford their coverage premiums. This would include beneficiaries who are eligible for both Medicare and Medicaid benefits, known as dual-eligible beneficiaries.

Elder Care Resource Center – This website was formed as a partnership between the New York State Office for Aging and the New York Community Trust. The purpose of the website is to provide New York residents with a wealth of resources and news regarding health-care options, including information about Medicare plans.

Medicare statistical trends in New York

Listed below are some facts of interest regarding Medicare in New York:

  • 3,518,155 New Yorkers received Medicare coverage in 2018. More than 1.4 million people enrolled in Medicare Advantage plans and other Health plans. Slightly more than 2 million individuals enrolled in Original Medicare Part A and/or Part B.
  • In 2018, more than 2.7 million Medicare beneficiaries in New York elected to have Part D prescription drug coverage either from a Medicare Prescription Drug Plan or from a Medicare Advantage plan that included prescription drug coverage in its benefits (MA-PD). More than 1.27 million individuals chose to receive their Part D prescription coverage by selecting a Medicare Advantage plan that included Medicare prescription drug and medical benefits.

In 2018, some key features of New York’s Medicare landscape include:

  • Access to choice of coverage:
  • 100% of New York’s Medicare beneficiaries have access to a Medicare Advantage plan
  • 222 Medicare Advantage plans of various types (e.g., HMOs, PPOs, Special Needs Plans) are available in New York
  • 20 Medicare Prescription Drug Plans are available in New York
  • 89% of people with Medicare Part D coverage have access to a plan with a lower premium than what they paid in 2017
  • 36% of people with Medicare Part D coverage are eligible to receive Extra Help (also called the low-income subsidy, or LIS)
  • $12.60 is the lowest monthly premium for a Medicare Prescription Drug Plan (premiums may be lower for individuals who qualify for Extra Help or higher for individuals who select the lowest premium Prescription Drug Plan and who also pay a Late Enrollment Penalty)

Statistical data from the Centers for Medicare & Medicaid Services, Medicare Enrollment Dashboard ; and “2018 MA Part D Landscape State-by-State Fact Sheet”

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

The product and service descriptions, if any, provided on these eHealth Insurance Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

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