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Welfare Fund Medicare Advantage Plus Plan FAQs

New information and updates regarding the NYC Medicare Advantage Plus Plan

  • The NYC Medicare Advantage Plus Plan is not being implemented on April 1, 2022. 
  • Retirees do not need to opt out of the Medicare Advantage Plus Program in order to remain in Senior Care or their current plan on April 1.
  • All retirees will remain in their current plans until further notice.   
  • For additional information, you can call the NYC Medicare Advantage Plus Plan call center at 1-833-325-1190, Monday to Friday, 8 a.m. to 9 p.m.

The Welfare Fund is waiting for more information at this time. As soon as we have it, we will post it on this page. The information below reflects guidance as of March 2, prior to the recent judicial ruling.

Q: I got a letter from the Office of Labor Relations saying I need to pick a new drug plan. Is this true? It also said I need to find out if my plan has a maximum benefit limit.

A: The drug coverage of retirees enrolled in the PSC-CUNY Welfare Fund SilverScript Medicare Part D Prescription Drug Plan is not affected by the changes to the NYC Health Benfits Program. And the plan has no maximum benefit limit.

Q: I have opted out of the NYC Medicare Advantage Plus Plan. I am keeping GHI Senior Care. How will I pay for the new monthly premium of $191.57 and the charge for the hospital rider, $2.83?

A: Members in TRS will have the charges deducted from their pensions. Members with TIAA will have the charges deducted from their healthcare annuity. If/when the healthcare annuity runs out, members will be billed directly.

Q: If I take the Medicare Advantage Plus program, can I use the doctors and hospitals I have always gone to? What if I don't live in New York?

A: Retirees can go to any doctor or hospital in the country that accepts Medicare. If your doctor or hospital was covered under your current plan, you can keep seeing them. 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 and you will not be billed for any balances. This includes all the hospitals in the NYC area including Memorial Sloan-Kettering (MSK) and The Hospital for Special Surgery (HSS).

Q: What if the provider I am seeing does not agree to accept payment from the NYCMedicare Advantage Plus Plan?

A: 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. 

Q: I do not have GHI Senior Care. I pay separately for Empire BC/BS. Will I be forced into this new Medicare Advantage program? If the answer is no and I will not be forced to join, will my monthly premium increase?

A: If you are currently enrolled in an NYC Health Benefits Program retiree plan and you want to keep it you will be charged the full cost of that plan via a premium that will be higher than the current rate. See the rates effective April 1.

Q: Will GHI Senior Care still be available as an option?

A: GHI Senior Care is still available but you will be charged the full cost of that plan, $191.57 per month.

Q: My husband is on my health plan but has his own Medicare & supplemental coverage through his job. I am not covered on his supplemental insurance. He does not want to switch to Medicare Advantage and will maintain his own coverage. Will I be able to drop him off the coverage if I decide to opt-in?

A: Yes, you will be able to drop your husband and opt into the MA plan. But if your husband is not enrolled in the NYC Health Benefits Program he will no longer be reimbursed for Medicare Part B or IRMAA.

Q: If I decide to stay with GHI Senior Care, will my costs be different, aside from copays? 

A: You will have to pay a premium of $191.57 per person per month. GHI Senior Care will continue to pay 20% of the Medicare-allowable charges.

Q: How do I opt out of the NYC Medicare Advantage Plus Plan?

A: All of the information & forms are available on the NYC Health Benefits Program website.

Q: I’ve already been told that my doctors will not be participating in this Medicare Advantage plan. These are specialists. I also get treatments done at home. Medicare pays and GHI Senior Care covers the rest (not a penny comes out of pocket). Will I be able to continue these treatments? At the same rate? Will there be a gatekeeper for this? 

A: According to the Alliance, "the Senior Care plan design is changing effective 1/1/2022, so these services would be subject to the $15 copayment under the Senior Care plan and the Medicare Advantage plan. Depending upon what treatments are being received there could be a prior authorization that the doctors will need to obtain from the plan. The Medicare Advantage plan is required to cover all Medicare-covered services."

Q: Under ther MA Plus, will I still pay Medicare B & IRMAA premiums, and if so, will these premiums be reimbursable as they are now?

A: Yes.

Q: I have the Aetna Medicare plan and I annuitized $50,000 for this when I retired. Why does this plan change apply to me?

A: All retirees in the NYC Health Benefits Program (Aetna, GHI, Empire, etc.) are being enrolled in the NYC Medicare Advantage Plus plan, regardless of their current coverage. You have been paying for your Aetna Plan while NYC has been paying for GHI Senior Care coverage for retirees. You can continue to pay for your plan but you may want to compare both plans to see if the new plan may actually offer you better benefits at no cost to you.  

Q: If I choose to stay with original Medicare, will I still receive Medicare Part B and IRMAA differential reimbursements?

A: If you choose traditional Medicare AND a NYC Health Benefits Program plan like GHI Senior Care (which will cost you an additional unreimbursed premium) you will be eligible for Medicare B and IRMAA reimbursements. If you do not enroll in an NYC Health Benefits Program Medicare supplemental plan, you will not be eligible for the Medicare reimbursements.

Q: If I choose the NYC Medicare Advantage Plus, will I be able at a later date to switch back to original Medicare? And vice versa?

A: There will be an annual open enrollment period when retirees can change back to traditional Medicare, although they will have to pay a premium of $191.57 for GHI Senior Care coverage.

Q: I have Medicare and GHI Senior Care. If I stay with regular Medicare can I remain on GHI Senior Care? If I go with the Advantage Plus program will I still need a plan to cover the 20%? How do doctor’s receive payment and what covers the 20% Medicare doesn't cover?

A: The Medicare Advantage Plan covers Medicare's 80% portion of physician & hospital charges as well as the 20% that GHI Senior Care currently pays for.

Q: What about the the GHI Senior Care Optional Rider that covers 365 days of hospital care?Will that be covered by the MA plan?

A: 365-day hospital care is included without charge in the Medicare Advantage Plan.

Q: I want to opt out, period. What are the costs to the individual of doing so? 

A: If a member opts out of the MA plan and does not elect an NYC Health Benefits Program retiree health coverage plan (which will require an additional member premium) the member will lose Medicare Part B and IRMAA reimbursement. 

Q: What is the telephone number to call to find out if your medical providers are in the network?

A: The number is 833-237-2612.

Q: I'm confused as to what Senior Care is. Is it traditional Medicare? If I stay in traditional Medicare, will I be billed or will it come out of my Social Security check? Will Catholic Health hospitals and Northwell Health system be part of the Medicare Advantage plan?

A: Traditional Medicare is Medicare A (Hospital) and Medicare B (Doctors). Medicare sets the rates and Medicare B pays 80% of physicians' charges. GHI Senior Care pays the remaining  20% and is considered a Medigap plan. Right now the Medicare B premium comes out our your Social Security check and NY City pays for your GHI Senior Care Policy. NYC also pays for your Medicare B reimbursement. Call 833-237-2612 to if those hospitals are in the network.

Q: If we opt out and stay with standard Medicare, will Emblem GHI Senior Care still automatically be available as the secondary coverage, under the 2022 rules, and will the city continue to reimburse Part B premiums and IRMAA premiums? And are there other NYC Health Benefit Program plans that we could choose instead of GHI Senior Care?

A: If a member opts out and does not elect an NYC plan like GHI Senior Care (which will require additional member premium) the member will lose Medicare Part B and IRMAA reimbursement. There are other Medicare Supplemental plans (please go to the NYC HBP website) but, again they will require additional premiums.

Q: Will Members’ spouses and other dependents who have their own Medicare coverage be enrolled in the new Medicare Advantage Plus plan, or will only the Member join the plan? If only the Member is enrolled in the new plan, will the spouse or dependent keep the current CUNY supplementary insurance?

A: Members’ spouses and dependents over 65 and/or disabled dependents will automatically be enrolled in the new Medicare Advantage plan unless they opt out, in which case they will be completely disenrolling under the member's health coverage and will remain ineligibile until the next open enrollment period. 

Q: I am paying for the PSC-CUNY Welfare Fund Catastrophe Major Medical Plan. How will this plan be affected by the proposed Medicare Adv. plan? Should I cancel this plan?

A: You will be able to make the same claims on the CMM plan as you are making now. The MA plan does not change the CMM coverage.

Q: As a CUNY retiree, will my spouse (when she retires in a couple of years) be able to be part of my MA Plus plan? Then, when I die, will she have the option of continuing that MA Plus plan?

A: Yes, your spouse is eligible when she turns 65. Unfortunately, when you die all of your CUNY benefits cease. Your spouse will be eligible to COBRA her benefits.

Q: My husband and I are both retirees. Upon retirement we opted for a Senior Care FAMILY plan because our disabled son (now age 45) is our dependent and also enrolled in our Senior Care FAMILY plan. (Our son's Primary health coverage is Medicare, as is ours.)

1. Will our son remain a dependent on the new Medicare Advantage Plus Plan with my husband in a FAMILY Plan? (I heard one of the speakers mention something about under age 55 but, unfortunately, did not get what was said.)

2. May I opt to enroll on my own in the new Medicare Advantage Plus Plan rather than join my husband and my son on the Medicare Advantage Plus Plan FAMILY Plan? If I do so, and my husband is first to die, will my son be able to enroll as my dependent in the plan?

3. After my and my husband's death will our son be able to remain in the Medicare Advantage Plus Plan if he pays COBRA premiums? 

If so, what are the monthly premiums (at today's rate) since we are told that we will have NO premium?

A: 1) Yes, the Medicare-eligilbe son will be covered under NYC Medicare Advantage Plus plan as a dependent under  the family plan.  2) Yes, you can enroll in your own plan and keep your son on the family plan with your husband. And if he were to predecease you, you can transfer your son to your coverage. 3) Yes, if your son outlives both you and your spouse he can COBRA his coverage. The Family rates will be posted on the OLR website by the end of the month.

Q: What is the monthly charge for my spouse? If I stay with my plan what is the additional cost? Chemotherapy covered at all? If the doctor takes Medicare does he have to accept this plan? I’m planning on moving to Florida will it be difficult finding doctors?

A: The MA Plan has a $0 Monthly Charge. The additional cost of staying with GHI Senior Care is $191.57 per member per month. Chemotherapy is covered under the PSC-CUNY Welfare Fund's Silverscript Plan. Most doctors who accept Medicare, including those in Florida, should accept this plan. NYC Medicare Advantage Plus Plan is named NYC because it covers NYC employees but it uses Medicare's national network of available physicians.

Q: GHI/Emblem Health is my tertiary insurance that picks up what Medicare and my NJ BC/BS doesn't cover (mostly co-pays). What will my tertiary carrier be under this new plan?

A: Medicare Advantage is a primary carrier and is not allowed to be a tertiary carrier. Enrolling in Medicare Advantage will force you out of NJ BC/BS. Please see Medicare Advantage's list of which copays you would be responsible for.

Q: GHI Senior Care 2022 includes a $15 co-pay. Does that mean that it isn't traditional Medicare? If it is traditional Medicare who is the medigap provider and why are there copayments?

A: Traditional Medicare is Medicare A (Hospital) and Medicare B (Doctors). Medicare sets the rates. Medicare B pays 80% of the charges, and the suppemental plan, such as GHI Senior Care, covers the remaining 20%. GHI Senior Care was set to start a $15 copay effective 7/1/2021 but NYC postponed it because of all the confusion related to the MA program. It will take place effective January 1st, 2022. The $15 copay is not charged for PCP doctor's visits.

Q: Will my spouse be automatically transferred to the Medicare Advantage plan along with me or will she continue to have coverage through traditional Medicare?

A: Members' spouses will automatically follow the member's election.

Q: My wife, over age 65, presently has Medicare and Empire BCBS as her secondary coverage. She also uses GHI Senior Care (my plan) as her third provider and is able to collect whatever BCBS does not pay. Will the new Medicare Advantage Plan still cover her as a tertiary provider?

A: No. You will have to drop her as a dependent or she will be automatically enrolled in the MA plan and dropped from her plan. She will also lose her Medicare B reimbursement if she stays on her plan. Or she can move to the Medicare Advantage Plan and keep her Medicare B reimbursement.

Q: My PCP submits to Medicare. I pay him his fee and Medicare sends me a check for the Medicare allowance. Will he continue to be covered under the new plan? I checked with he 800 number and he is not in network. How will this affect my coverage?

A: As long as your doctor is in the Medicare network you can continue the same arrangement.

Q: If my doctor charges $270 a visit and Medicare now pays $90 plus $25 from Emblem, will this doctor get paid $115? Is there a secondary coverage with Medicare Advantage? 

A: If the doctor accepts Medicare the MA plan will pay according to Medicare rules and regulations as your plan does now.

Q: I'm currently enrolled in the Aetna Medicare Advantage PPO. When I opt out of the new MA Alliance plan can I stay on my current plan? What will the monthly cost be? My wife and I currently live in Maryland. Our doctors are not on the new plan.

A: You may stay if it is the Aetna plan in the NYC Health Benefits Program. 

Q: I am a patient of MSKCC and have from one to two out-patient procedures per year, as well as blood tests, doctor visits and Survivalship Nurse visits. I understand Sloan will take out-of- network patients, but with this new plan what will my out-of-pocket costs be? 

A: It is difficult to provide a definitive answer as some procedures will be covered for a $0 copayment and others would be subject to a $15 copayment.  The most you would be paying out of your pocket would be the $15 copayment for each specialist visit and $15 copayment for all lab work done for each visit. (Kim Parker) Be aware that the GHI Senior Care will also have the same copayment increases. You will need to compare the GHI Senior Care 2022 copay schedule to the MA Plus copay schedule. 

Q: 1. If any doctor/hospital that takes Medicare takes Medicare Advantage Plus then why is there a difference between in and out of network providers? 2. Currently I have Aetna Medicare. Can I stay with Aetna and forgo my Medicare B reimbursement while continuing to pay through my TIAA annuity? 3. Please provide a comparison between this plan and the Aetna supplemental. 

A: In-network doctors will be familiar with the NYC Medicare Advantage Plus Plan. Out of network doctors may need to be given information on where and how to submit their claims. If you have the NYC Aetna MA plan you can keep it and still maintain your eligibility for Medicare B reimbursement but you should do a comparison with the New Medicare Advantage Plan because it might offer better services than the Aetna Plan. The new rates should be available at the end of August. The MA Plus plan will have no premium charge.

Q: You noted some procedures will require pre-authorization. I have 3 questions about this: 1. Is there a list of these procedures? 2. If one of my specialists has opted out of Medicare, can that doctor obtain the required preauthorization? 3. If the authorization is approved, can the doctor send me to the facility that he/she feels is best (even if they don't take Medicare)? If the facility accepts Medicare, I assume you will pay. If not, I assume this is my obligation.

A: Medicare mandates the procedures that require pre-authorization prior to payment by Medicare. Medicare will not pay a facility that does not do the required pre-authorizations, just as they will not pay a doctor or a facility that is not a Medicare-approved facility.

Q: Do we need prior authorization for preventative care exams, such as mammography, bone density, colonoscopy? If any of these providers have opted out of Medicare, I assume I receive no reimbursement and do not need preauthorization. If the provider is a Medicare provider, but will not accept  Medicare Advantage, please briefly explain the procedure for getting the bill paid again.

A: You will need to call the MA Plan number 833-325-1190 for the information on preventive care exams.  2) If the provider opted out of Medicare there will be no reimbursement.  3) If the provider is a Medicare provider but will not accept advantage the member can pay the provider submit the bill to NY Medicare Advantage Plus and receive a reimbursement at the approved Medicare rates.

Q: What type of out-of-network claim would be acceptable? If I see a provider who opts out of Medicare, that provider is likely not included. Please explain the in/out of network coverage.

A: An in-network provider is a provider in the NYC Medicare Advantage Plus network. A member would go to one of these providers, present their card and aside from any copay not have to pay or do anything.  If they went to an out-of-network provider who accepts Medicare but not in the NYC Medicare Advantage Plus network, they might or might not ask the member to pay the full amount of the Medicare rate.

Q: I want to remain in the traditional Medicare Part A & B program and purchase my own Medigap policy from AARP/United Healthcare, for example. To disenroll from the City's Health Benefits Program, do I have to wait until the opt-out period between September 1 – October 15, or can I do it now? And what is the procedure to waive my City retiree health benefits? I want to make sure that I am not "automatically enrolled" in any part of NYC's new Medicare Advantage Plan.

A: You can remain in the traditional Medicare A & B program and purchase your own supplemental policy. Please be aware that you will no longer be eligible for reimbursement of your Medicare Part B premium and IRMAA if you are not enrolled in one of the NYC HBP retiree programs.  Before you make your choice please be sure you do a comparison of both the AARP United Health care program you are considering and the MA program NYC is offering. 

Q: I am very concerned about the pre-approval process with this new plan. What procedures and tests will need pre-approval? For example, will I need pre-approval to get a mammogram or colonoscopy? My gyno does not accept any health insurance. How would the pre-approval process work in this case.

A: Medicare actually requires that certain procedures be reviewed before they will authorized for payment. MA plans require that these same procedures be pre-authorized prior to the procedure being performed so there are no surprises after the fact. You will have to call the 833-237-2612 number to see exactly which procedure these are. If your gyno is not a Medicare doctor you will not be reimbursed. If the doctor is a Medicare doctor you will be reimbursed at the Medicare rate.

The questions that follow were submitted by PSC Retirees in early July.

Q: Is the PSC-CUNY Welfare Fund considering terminating the current Medicare Part D coverage and folding this benefit into the proposed Medicare Advantage Plan, or will it remain an important part of the current Retiree Welfare Fund benefits package?

A: I can assure you the PSC-CUNY Welfare Fund is not considering terminating our Silverscript Medicare Part D Prescription Drug Plan. Unlike retiree basic health coverage, which is administered by and paid for directly by the City, retiree drug coverage is administered by individual NY City unions. The PSC-CUNY Welfare Fund provides for and pays for the Silverscript Medicare Part D Prescription Drug Plan for CUNY retirees.

Q: Will all doctors accept the new Medicare Advantage Plan?

A: Coverage will include all physicians who accept Medicare. Whether or not the physician is willing to bill the plan is entirely up to the physician.

Q: Will the coverage be equivalent to GHI SeniorCare? 

A: View the Plan Comparison Chart

Q: What is the cost to the City for the current health insurance program for retirees?

A: The approximate current medical and hospital spend for retired Medicare eligible participants and their spouses is $600 million. We assume a Medicare Advantage plan will reduce the Citys spend materially through efficiencies and moving to a single program.

Q: Will the new MA plan be accepted anywhere in the US?

A: Yes, you are covered anywhere in the US or US territories as long as the urgent care physician and/or hospital accepts Medicare.

Q: I have GHI Emblem health for myself and my husband. My monthly cost is $2.00 for me and $2.25 for my husband. What will the monthly cost for the new MA plan be for me and for my husband?

A: The monthly cost you are referring to is the cost of the optional 365-day Hospital rider. There is no cost for current GHI SeniorCare coverage, but that will change Jan. 1. There will be no cost for any Medicare Advantage (MA) plan currently being considered and all plans will include the 365-day hospital coverage at no additional charge.

Q: My primary care physician does not accept Medicare. I am currently reimbursed according to Medicare rates but pay extra to see him. Will this remain the same or will I not get reimbursed according to the Medicare schedule?

A: If your primary care provider accepts Medicare but does not accept Medicare Assignment of Benefits (in which Medicare pays physicians directly), you will still be able to see the physician under the MA plans.  

Q: Will the $50 deductible, NO copay feature still be available under the Medicare Advantage plan? 

A: The new plan must meet the same coverage as the GHI Senior Care Plan now offered. GHI Senior Care currently has an annual deductible of $248 per participant, plus a $25 deductible for ambulance, durable medical equipment, and private duty nursing after the Medicare Part B deductible has been reached.

Q: My wife is under 65, is on the Affordable Care Act, and has supplemental coverage under my Empire Blue Cross plan. Will I know for sure whether she will be covered as well under the Medicare Advantage plan being proposed before I have to decide whether to join city's Medicare Advantage plan? 

A: Spouses over 65 are eligible for coverage under the proposed MA plans. Spouses and/or dependents under 65 will also be covered.

Q: How can continuing participation by Medicare doctors and other providers in the new Advantage plans be demonstrated and assured?

A: The only requirement is that a doctor must be a participating Medicare provider. Currently 97% of all doctors accept Medicare patients.

Q: If I remain with regular Medicare next year, can I join the Medicare Advantage plan the following year without penalty?

A: If you opt out of the proposed Medicare Advantage program you will have to wait until the next Medicare open enrollment period before changing again. The same goes if you take the MA plan and want to switch back.

Q: My spouse is not eligible for Medicare because he has fewer than 5 years legal residence in the US. He  is a dependent on my GHI plan for medical and Empire for hospital. How would this plan affect him?

A: Your spouse would be covered. 

Q: If my husband and I choose to stay with Traditional Medicare and purchase our own supplemental coverage, will NYC still reimburse us for our Medicare premiums?

A: Only if you choose an insurer offered by the NYC Health Benefits Program.

Q: Is there any way that they would grandfather those already in standard Medicare since that was what we were told we would get at the time of retirement?   

A: Since the new plan is offering the same or better coverage than GHI SeniorCare, I dont think NYC will be open to continue paying for the current plan.

Q: Will there be a way to pull out if they go through with this and it doesnt work well?

A: There are contractual guarantees and penalties that will come into play if the plan does not meet its obligations to provide the same or better coverage than the current plan.

Q: What kind of coverage does the MA plan provide for when we are out of the US?

A: You are covered in full from the 1st through 60th day, except for the Medicare deductible amount, and from the 61st through 90th day, except for the Medicare coinsurance amount.

Q: My husband is a dependent on my health coverage. If we are moved to an Advantage plan, what will happen to his coverage if I die before him?  

A: Whether you move to the MA plan or not, your spouse’s health care will cease on the last day of the month in which you die. Your death is a qualifying event and will trigger a special Medicare open enrollment period that will allow your spouse to select traditional Medicare A & B or another Medicare Advantage program.

Q: How do Medicare Advantage plans make money? 

A: Here is Donna’s overview: Medicare Advantage plans act as both Medicare A & B and Medicare Supplemental insurance. Medicare pays the vendor a monthly amount to manage the Medicare A & B claims and pays them an administrative fee to do so. CMS funding to MAs is based on Star” rating and risk” of membership.  Higher ratings equal more CMS funding. The star rating also has a direct impact on their Quality Bonus Payment (QBP). In 2018 Health plans with an Overall Star Rating of 4.0 and received up to a 5.0% QBP. Star ratings are also a tool to assist Medicare beneficiaries in selecting high quality plans.  See below for a description of the five main star categories:

  • Staying Healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical examinations, vaccinations like flu shots, and preventive screenings.
  • Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions.
  • Member experience: Plans are rated for overall satisfaction with the health plan.
  • Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and processing appeals and new enrollments in a timely manner

One benefit of the MA plan is that since it is responsible for Medicare A, B and supplemental care issues, our members and/or the welfare funds have a single go-to entity to reach  to for help on any issue related to Hospital, physician and/or other covered treatment. 

Another way the MA program is incentivized to help members is to help them better manage their conditions by identifying these members and offering them additional help.  This is in no way similar to a managed program which restricts members to certain providers. An example would be in identifying a diabetic and offering them better tools to help manage their condition (more current blood glucose monitor perhaps?).  The MA provider is betting that by identifying at risk members early they can help the members to remain healthier longer which means there will be less related hospitalizations thereby recognizing a savings in claims dollars spent and an additional savings in improving the members risk score. 


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