Medicare, Medigap, and HMO Options

WHAT TO CONSIDER WHEN JOINING AN HMO

When looking for an HMO, there are a number of things to consider in order to make the best choice. What is best for you may not be right for your relative, friend or neighbor.

WHEN CHANGING YOUR HMO

If you are currently in an HMO and receiving care from a particular group of providers, you understand the basic way the HMO works, i.e. you have a primary care physician (PCP) who refers you to specialists and other providers when you need them. Basically, you should read the plan’s membership materials to understand the benefits you will receive. If you have questions, make sure you get the answers before you join!

If you plan to join a new HMO and wish to continue using your primary care physician (PCP), check to see which HMO’s he/she works with and if you would be able to use your PCP under the new plan. Find out how easy or difficult it is to change your primary physician. If you have specialists you wish to use, make sure that you will be able to be referred to them under your new HMO. You may find that all of your current providers are not in the same plan. You may have to pick the one with the best match for you. Check information on the providers and facilities (hospitals, home care agencies and other service providers) affiliated with the plan.

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ADDITIONAL BENEFITS

All HMO’s must provide the same services to you that you are entitled to receive under regular Medicare. Many offer additional benefits, eye exams and eyeglasses, preventive tests, dental benefits and prescription coverage. Ask about these extras. Some may cover acupuncture, etc. Ask, ask, ask.

COVERAGE AWAY FROM HOME

If you travel outside the area, ask the HMO what you have to do if you need emergency or urgent care. Are there limits on the services you may receive. Also, some HMO’s have agreements in areas such as Florida which enable individuals to receive non-urgent care in those states.

ACCESSIBILITY

If the plan is a staff model, is it at a convenient location for you. If the providers are at different locations, and you need public transportation, is it available.

AFFORDABILITY

Check the premiums, co-payments and benefits provided by each plan to find the one which best suits your needs at a price you can afford. (See chart prepared by the Westchester County Department of Senior Programs and Services).

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Important Protections For New York State Residents

You have recently been notified that your Medicare HMO will no longer provide your health care benefits.  You must now decide to either enroll in another Medicare HMO, if one is available in your county, or to return to the Original Medicare Plan.

If you are considering returning to Original Medicare, you are probably also contemplating the purchase of a Medicare Supplemental Policy (Medigap) to help defray some of the costs not covered by Medicare, including the Medicare deductibles and coinsurance.

As a New York resident, you are protected in the following ways:

OPEN ENROLLMENT
New York State law requires that any insurer writing Medicare Supplement (Medigap) policies must accept new applicants at any time throughout the year. Insurers may not deny the issuance of a policy or make any premium rate distinctions because of the health status, claims experiences, receipt of health care, or medical condition of an applicant.

Federal law only guarantees your right to buy Medigap policies designated "A", "B", "C", or "F". In New York State this guaranteed right to buy is for all Medigap policies "A" through "I".

PORTABILITY
Although Medigap policies may contain up to a 6 month pre-existing condition waiting period, New York State law provides that as long as there is no more than a 60 day break in coverage, the Medigap carrier must credit the time you were covered under the prior coverage towards the new waiting period. In other words, if you had your Medicare HMO for at least 6 months and you replace it with a Medigap policy within 60 days, you will have no new pre-existing condition waiting period. If you had your Medicare HMO for 4 months, you will have a waiting period of only 2 months.

NOTE: New York State’s Open Enrollment and Portability provisions protect you whether you are Medicare eligible by reason of age or disability.

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MEDIGAP INSURANCE COVERAGE

Medicare Supplemental Insurance, also known as Medigap Insurance, is a special kind of health insurance coverage available only to people who are enrolled in Medicare Parts A and B. Even with Medicare protection, there are still gaps in coverage. These gaps include: Medicare deductibles, co-payments, excess charges by doctors who do not accept Medicare assignments, and medical services and supplies that Medicare does not cover at all. Medicare Supplement, or Medigap, was developed to provide extra protection beyond Medicare by filling some of the gaps in Medicare coverage.

Medigap offers ten (10) standard policies designated "A" through "J". Plan A is the most basic, Plan I the most comprehensive.

Every Plan A , no matter which company sells it, offers the same coverage as every other Plan A. The same is true for all the Medigap policies.

In New York State, Medigap insurers must sell Plan A and Plan B, but they may choose which additional Plans to offer.

You have many possible Medigap choices, from different benefit plans to different insurers to monthly premiums where you live. As you compare policies, stop and consider prices, services and the reputation of insurers, and take your time in making your Medigap insurance decision.

Information regarding the availability of Medigap insurance throughout New York and the cost of such insurance can be obtained at http://www.hiicap.state.ny.us/mgap/index.htm.  Additionally, the Department will assist seniors through its toll free telephone number at 1-800-342-3736.

Chart of the Ten Standard Medigap Insurance Coverage Plans

Medicare supplement insurance can be sold only in 9 standard plans. This chart shows the benefits included in each plan. Every company must make available Plan A, Basic Benefits. New York State Law requires all companies to sell both Plan A and Plan B.  Select here for chart

When describing the benefits of their Medigap plans, all insurance companies are required to use the same format, language and definitions. They are also required to use a uniform chart and outline of coverage which summarizes the benefits of each plan they offer. These requirements make it easier for you to compare policies from different insurers.

As you shop for a Medigap policy, keep in mind that each company's products are alike, so they are competing based on their price, service and reputation.

You can learn almost everything you need to know to make your Medigap decision from the five steps given on these Medigap pages without talking with an insurance agent or company. BUT, after you have selected the plan you feel is  best suited to your needs, you will need to talk with representatives of the insurance companies selling the plan you are interested in. When you do, confirm policy prices and compare the services and reputations of the different companies offering the policy of your choice.

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• Prices

While the benefits are identical for all Medigap plans of the same type, the premiums (see Monthly Premiums for Plans) vary from one company to another and from area to area. The plan with the lowest price is not necessarily the best plan for you. The price should not be your only concern.

You may have a preference for a particular schedule of payments. Some companies bill the premium each month, while others bill each quarter or once a year.

In addition, prices are based in part on the services a company provides and on
their reputation. These are important factors in your Medigap decision.

• Customer Services

When you contact Medigap insurers, ask about the insurance company's customer services. For example, some companies link their computers to the computers at the federal Medicare office to process your health insurance claims without additional paperwork for you. This and other available customer services may be important considerations in your Medigap decision.

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• Reputation

Satisfy yourself that the insurance company you are considering is reputable before buying from them. Research the company by asking for referrals and by talking to others about their experiences.

In addition, determine the financial stability of any insurer you are considering by checking their "rating." Call the following "raters" and telephone numbers for reports on specific insurance company or you link to their Web sites from our Help Links page.

• M. Best Company (900-555-best).
• A very high rating is A++ or A+.
• Duff & Phelps Credit Rating Company (DCR) (312-368-3157).
• A very high rating is AAA or AA+.
• Moody's Investors Service (212-553-1653).
• A very high rating is Aaa, Aal, Aa2, or Aa3.
• Standard & Poor's (212 -208 - 1527).
• A very high rating is AAA, AA+. or AA.
• Weiss Research, Inc. (800-289-9222).
• A very high rating is A+, A-, B+, or B-.

• Take Your Time

Take your time in making your choice. Choosing a Medigap plan and insurer is a major decision. Make sure you understand your choices, your responsibilities
and the consequences of your decisions. Don't hesitate to call an insurance representative more than once. Obtain the additional information, any needed clarifications and the answers to new questions you need to make an informed Medigap decision.

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Standard Medigap Plans

PLAN A (the basic policy) consists of these basic benefits:

Coverage for the Part A coinsurance amount ($210 per day in 2003) for the 61st through the 90th day of hospitalization in each Medicare benefit period.

Coverage for the Part A coinsurance amount ($420 per day in 2003) for each of Medicare’s 60 non-renewable lifetime hospital inpatient reserve days used.

After all Medicare hospital benefits are exhausted, coverage for 100% of the Medicare Part A eligible hospital expenses. Coverage is limited to a maximum of 365 days of additional inpatient hospital care during the policyholder's lifetime. This benefit is paid either at the rate Medicare pays hospitals under its Prospective Payment System (PPS) or under another appropriate standard of payment for hospitals not subject to the PPS.

Coverage under Medicare Parts A and B for the reasonable cost of the first 3 pints of blood or equivalent quantities of packed red blood cells per calendar year unless replaced in accordance with federal regulations.

• Coverage for the coinsurance amount for Part B services (generally 20% of approved amount; 50% of approved charges for outpatient mental health services) after $100 annual deductible is met.

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PLAN B includes basic benefit plus:

• Coverage for the Medicare Part A inpatient hospital deductible ($840 per benefit period in 2003).

PLAN C includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care coinsurance amount ($105 per day for days 21 through 100 per benefit period in 2003).

• Coverage for the Medicare Part B deductible ($105 per calendar year in 2003).

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

PLAN D includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care daily coinsurance amount.

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

• Coverage for at home recovery. The at home recovery benefit pays up to $1,600 per year for short-term, at home assistance with activities of daily living (bathing, dressing, personal hygiene, etc.) for those recovering from an illness, injury or surgery. There are various benefit requirements and limitations.

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PLAN E includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care daily coinsurance amount.

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

• Coverage for preventive medical care. The preventive medical care benefit pays up to $120 per year for such things as a physical examination, serum cholesterol screening, hearing test, diabetes screenings, and thyroid function test.

PLAN F includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care daily coinsurance amount.

• Coverage for the Medicare Part B deductible.

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

• Coverage for 100% of Medicare Part B excess charges.*

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PLAN G includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care daily coinsurance amount.

• Coverage for 100% of Medicare Part B excess charges.*

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

• Coverage for at home recovery (see Plan D).

PLAN H includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care daily coinsurance amount.

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

• Coverage for 50% of the cost of prescription drugs up to a maximum annual benefit of $1,250 after the policyholder meets a $250 per year deductible (this is called the "basic" prescription drug benefit).

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PLAN I includes basic benefit plus:

• Coverage for the Medicare Part A deductible.

• Coverage for the skilled nursing facility care daily coinsurance amount.

• Coverage for 100% of Medicare Part B excess charges.*

• Basic prescription drug coverage (see Plan H for description).

• 80% coverage for medically necessary emergency care in a foreign country, after a $250 deductible.

• Coverage for at home recovery (see Plan D).

PLAN J includes basic benefit plus:

• Coverage for the Medicare Part A inpatient hospital deductible ($840 per benefit period, in 2003). 
• Coverage for the skilled nursing facility coinsurance amount ($105 per day, for days 21 through 100 per benefit period, in 2003).
• Coverage for the Medicare Part B deductible ($100 per calendar year, in 2003).
• 80 percent coverage for medically necessary emergency care in a foreign country, after a $250 deduction.
• Coverage for 100 percent of Medicare Part B excess charges. _*_
• Coverage for at-home recovery. The at-home recovery benefit pays up to $40 each visit and $1,600 per year for short-term, at home assistance with activities of daily living (like bathing, dressing, personal hygiene, etc.) for those recovering from an illness, injury, or surgery.
• Coverage for preventive medical care. The preventive medical care benefit pays up to $120 per year for things like a physical examination, serum cholesterol screening, hearing test, diabetes screening, and thyroid function test.
• Coverage for 50 percent of the cost of prescription drugs up to a maximum of $3,000 per year after the policyholder meets a $250 per year deductible ("extended" prescription drug benefit).

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2005 Medicare Supplement (MEDIGAP) Monthly Premiums

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Medigap Provider Company Phone List

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2005 MEDICARE  PREMIUM AMOUNTS

Part A - Hospital Insurance Premium

• Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare covered employment.

Part B- Medical Insurance

Monthly Premium- $78.20

2005 MEDICARE DEDUCTIBLES
CO-PAYMENTS AND PART B MONTHLY PREMIUM

Part A - Hospital Insurance

Note: For those with 40 or more quarters of covered employment there is no premium for Medicare Part A.

Part B- Medical Insurance

Deductible: $110 per year (Note: You pay 20% of the Medicare approved amount for services after you meet the $110 deductible)

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Medicare Patients' Rights

• The right to protection from discrimination in marketing and enrollment practices.

• The right to information about what is covered and how much you have to pay.

• The right to information about all treatment options available to you.

• The right to receive emergency care.

• The right to appeal decisions to deny or limit payment for medical care.

• The right to know how your Medicare health plan pays its doctors.

• The right to choose a women's health specialist.

• The right, if you have a complex or serious medical condition, to receive a treatment plan that includes direct access to a specialist.

If you believe that any of your rights has been violated, please call the State Health Insurance Assistance Program at 1-800-442-8430

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For additional information on Medicare, Medicare Supplement Insurance (Medigap), and Medicare HMOs, contact the Westchester County Department of Senior Programs and Services at (914) 813-6300

Contact List of  Community Based Senior Centers
For more information on Medicare/HMO Benefits:

CORTLANDT
Muriel H. Morabito Community Center 528-1464

EASTCHESTER
Eastchester Office for the Aging 771-3340

GREENBURGH
Greenburgh Office for the Aging 693-8997

MAMARONECK
Human Resources Office 777-7718

MOUNT KISCO
Mount Kisco - Fox Center 666-8931

MOUNT PLEASANT
Office of Elder Americans 592-6441

MOUNT VERNON
Mount Vernon Office for the Aging 665-2315/2316

NEW ROCHELLE
New Rochelle Office for the Aging 235-2363

OSSINING
Ossining Community Center 762-8953

PEEKSKILL
Neighborhood Facility 734-4227

PORT CHESTER
Don Bosco Community Center 939-4975

WHITE PLAINS
White Plains Senior Center 422-1424

YONKERS
Yonkers Office for the Aging 377-6822

YORKTOWN
Yorktown Community Center - 6th Grade School 962-7447

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