Frequently Asked Questions
The best answers start with good questions.
The questions and answers below provide information that can help you better understand Medicare, learn if you’re eligible, and find out when you can enroll. If you have a question, make sure you check here first.
What is Medicare?
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)
What are the different parts of Medicare?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. If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty.
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 different 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 should 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. Some employer plans offer equivalent prescription drug coverage to the coverage offered under Medicare Part D. If you already have coverage through an employer, you should check with your employer to see if you can keep that coverage. 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.
What is an HMO Plan?
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.
For HMO plans, it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The care exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers. You may get services from out-of-area providers when providers of specialized services are not available in the service area.
HMO plans provide more benefits than Original Medicare — for low or no monthly premiums.
HMO plans give you all of the benefits of Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Our VIP Medicare Advantage plans also provide our members with Medicare Part D (Prescription Drug Coverage) — for no additional plan premiums.
Who is eligible?
To receive coverage under an EmblemHealth VIP 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; and
- You don't have End-Stage Renal Disease (permanent kidney disease requiring dialysis or a kidney transplant), except under certain limited circumstances.
View EmblemHealth's HMO Service Area maps which include the following counties in New York: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester.
EmblemHealth HMO Medicare Service Area Map
EmblemHealth HMO Medicare Service Area Map
EmblemHealth PPO Medicare Service Area Map
When are the enrollment periods?
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. 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 SNP's Plan, visit EmblemHealth Dual Page Plan Description.
When does SEP coverage become effective?
- 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.
Who can qualify for an SEP?
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
- 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.
Learn more about the circumstances that qualify you for an SEP
Who is eligible to receive assistance from the state?
To find 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/TDD 1-800-290-9138) from 8 am until 5 pm, Monday through Friday.
How can a person enroll?
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.
How can a person disenroll?
We are sure that you will be happy with all the benefits EmblemHealth has to offer. But should you wish to leave your plan, you may do so in one of two ways:
- If you wish to leave the plan during the Medicare Advantage Disenrollment or Special Election Periods (see above), please send your request in writing, signed and dated to us.
- You can also call 1-800-MEDICARE (1-800-633-4227). If you have a hearing or speech impairment and use a TTY/TDD, please call 1-877-486-2048.
After you submit the request, the plan will make a decision on whether to approve or deny the disenrollment request within 10 calendar days of receipt of the request to disenroll.
If you leave our plan, it may take time before your membership ends and your new Medicare coverage goes into effect. During this time you must continue to get your medical care and prescription drugs through us. You can continue to use your network pharmacies to get your prescriptions filled until your membership in your current plan ends. If you are hospitalized on the day your membership ends, your hospital stay will usually be covered by the plan until you’re discharged (even if you’re discharged after your new health coverage begins).
How can My Advocate help you save money?
My Advocate helps seniors and disabled individuals apply for Medicare Savings Programs, Extra Help and other community assistance programs.
You must continue to pay your Medicare Part B premium.
The provider network may change at any time. You will receive notice when necessary.