Medicare Basics

Peace of mind starts with clear and simple information. We want you to feel comfortable and secure with your Medicare decisions. Whether you’re new to Medicare coverage or already have a plan, you’ve probably realized there are many Medicare plan options to choose from. With the right information, you can make the right Medicare choices. 

What is Medicare?

Medicare is the largest health insurance program in the United States. It is run by the Centers for Medicare and Medicaid (CMS), a government agency.


You can join Medicare if you’re 65 or older and:

  • You are either a citizen or a permanent resident of the United States, and
  • You or your spouse worked at least 10 years in the Medicare-covered employment
  • You are under 65 with certain disabilities and
  • People of all ages with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.

Types of Medicare

Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). It is a “fee-for-service” health plan. This means you pay for each service you receive. To better understand Original Medicare, let’s take a look at what each part covers.

 

Medicare Part A | Hospital Insurance
Medicare Part A covers care you receive when you stay in a hospital (this is called “inpatient” care). It also covers care you get at skilled nursing facilities, home health care and hospice care.

Most people get Part A from the Federal government when they turn 65 if they:

  • Have worked for a combined 10 years, or
  • Worked 40 quarters (three-month periods) paying into Medicare. They do not need to be quarters that come one after the other.

Most people do not pay any monthly fee, or a “premium,” for Part A. You do pay part of the costs for services you get under Part A. You pay a deductible plus your share of the Medicare-approved cost for services.

 

Medicare Part B | Medical Insurance
Medicare Part B helps you pay for medical services. These are services like doctor visits, tests, outpatient hospital services and other like services. Part B is voluntary, which means you can choose to join it. If you choose Part B, you pay a monthly fee, or “premium,” of $135.50 per month. (This fee might be higher, based on your income.)

If you do not sign up for Part B when you are first able to join Medicare, you will pay a higher monthly fee if you choose to join later.

 

How much do I pay for care I receive under Part B?

  • You must first pay a deductible, or a yearly fee for services, before your plan pays for any costs under Part B.
  • After you pay your deductible, Medicare pays up to 80 percent of Medicare-approved charges for most covered services. You pay the remaining costs — typically 20 percent of the total.
  • Medicare Part B covers many preventive health care services at no cost to you, like annual exams, screenings and certain vaccines.
  • Sometimes you may pay more than 20 percent. This can happen if your doctor does not accept “assignment”—the Medicare-approved rate for services. If a doctor does not accept assignment, you must pay your doctor what Medicare does not cover.

Medicare Part A and Part B do not cover everything. There are many services that you will need to pay for in full.

To learn more about what Medicare covers and does not cover, please call Medicare at 800-633-4227, or see the “Medicare & You” handbook at Medicare.gov.

Although Original Medicare, which includes Parts A and B, covers many health services, a Medigap policy can assist in covering such costs as deductibles, coinsurance and copayments. This plan supplements the Original Medicare (Medicare Parts A and B). It makes the coverage provided by Original Medicare more complete.

View Medicare Supplement Plans    

Original Medicare coverage is good, but it can be hard to manage multiple plans, ID cards, bills and networks. With a Medicare Advantage plan from a private company like EmblemHealth, you can get what you need from a single plan.

Having a Medicare Advantage plan means that you will still get all the benefits of Medicare Parts A and B; plus, you’ll get extra benefits—often for no more than what you already pay each month for Part B.

Extra benefits may include:

  • Dental care
  • Eye exams and prescription lenses
  • Fitness programs
  •  Hearing aids and exams for fittings
  •  Prescription drug coverage

You can join an EmblemHealth Medicare Advantage plan if:

  •  You are eligible for Medicare Part A and are enrolled in Medicare Part B (continue to pay your part B premium). And
  •  You live in EmblemHealth’s service area. EmblemHealth's 2020 Service Area includes the following counties in New York: Albany, Broome, Bronx, Columbia, Delaware, Dutchess, Greene, Kings, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Suffolk, Sullivan, Warren, Washington, Westchester and Ulster.You live in EmblemHealth’s service area. EmblemHealth's 2019 Service Area includes the following counties in New York: Bronx, Dutchess,Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland Suffolk, Sullivan, Westchester and Ulster.

Check out our service area map for more information.

2020 EmblemHealth HMO Medicare Service Area Map

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2019 EmblemHealth HMO Medicare Service Area Map

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Types of Medicare Advantage plans:

  •  Health Maintenance Organization (HMO) plans give you all the benefits of Original Medicare plus extra benefits. With an HMO plan:
    • You choose a doctor who will provide your everyday care called a primary care doctor (PCP).
    • Your PCP will arrange for any referrals that you need to see specialists.
    • You are usually only covered for care and services you get from your HMO network of doctors.
    • In an emergency, you can go to any doctor or hospital.
  •  Health Maintenance Organization Point of Service (HMO-POS) plans give you all the benefits of Original Medicare plus extra benefits. They are just like HMO plans, but with added flexibility. With an HMO-POS plan:
    • You can get covered services from doctors and other health care professionals in your plan’s network.
    • You can also get care outside of the network. When you get care outside of the network, the services you can get may vary by plan.
    • You often pay less when you use your plan’s provider network.
    • Some HMO-POS plans ask you to choose a PCP. This is the doctor who will provide your everyday care. This doctor can be in or out of your plan’s network.
    • In an emergency, you can go to any doctor or hospital; but you may pay more if the doctor or hospital is not in the network.
  • Preferred Provider Organization (PPO) plans give you all the benefits of Original Medicare plus extra benefits, just like HMOs. In most cases, PPOs will:
    • Have a network of doctors, other health care professionals and facilities.
    • Let you also get covered services outside the network, often at a higher cost
  • Special Needs Plan (SNP) can be an HMO or a PPO plan. You can join an SNP plan at any time if you qualify for one. SNP is only available to people who:
    •  Are eligible for both Medicare and Medicaid,
    • Live in certain institutions (like a nursing home) or require nursing care at home, or
    • Have specific chronic or disabling conditions (like diabetes or chronic heart failure)

View Medicare Advantage Plans

What is Medicare Part D and how do I enroll?
Medicare Part D is a prescription drug coverage plan for people who have either Medicare Part A or Part B. To sign up, all you need to do is join a plan that offers Part D.

Medicare Part D is a voluntary program. This means you don’t have to buy it when you join Medicare. Many people buy it, and some people choose not to. But if you decide to buy a Part D plan after you first sign up for Medicare, you may pay more for it each month. This is called a “late enrollment penalty.”

What drugs are covered under Medicare Part D?
All Medicare Part D plans have a list of covered drugs. This is called a “formulary.” Plan drug lists will include both generic and brand name drugs, and will list them in levels, or “tiers,” based on cost. The lower the level or tier, the lower your cost for the drug will be.

How much will a Medicare Part D plan cost?
To join, you simply pay a monthly amount, or “premium,” to the plan you choose. Some Medicare Advantage plans include the Part D cost in their monthly plan premium, like EmblemHealth. Depending on your plan, you may also pay deductible and coinsurance costs. If you need help paying for your drugs, you may qualify for “Extra Help.”

Companies that offer Medicare Part D may cover different drugs or charge different amounts for them. So, choose a plan that offers you the best solution for your own needs.

Medicare Savings Programs

If you have limited income and resources, you may be able to get help from your state to pay your Medicare costs. Some of the programs may help to pay your Medicare Part B premium, or some of your costs to get services, like deductibles, coinsurance or copays.

 

Medicaid

Medicaid is a health plan for low-income and disabled people. Each state runs its own program. The federal government and each state government share the costs of this program. Some people have both Medicare and Medicaid. They are called “dual eligibles.” As a dual eligible, most of your health care expenses will be covered.

 

What is “Extra Help”?

Extra Help is a Medicare program to help people with limited income and resources pay Part D drug plan costs. It can help pay monthly premium fees, deductibles, and coinsurance.

You can get Extra Help if:

  •  You have full Medicaid coverage.
  •  You get help from your state Medicaid program to pay your Part B premiums in a Medicare Savings Program.
  •  You get Supplemental Security Income (SSI) benefits.
  • If you get Extra Help, what you pay for your plan and what you pay at the pharmacy will be lower. It may even lower your premium and deductible costs to $0. You will also have no coverage gap, pay no late enrollment penalties, and you can switch plans at any time.
  • If you have any questions about any of these programs or to see if you can get Extra Help, an EmblemHealth Medicare specialist can help you.

 

How can My Advocate help you save money?

EmblemHealth is proud to partner with My Advocate, a service of Change Healthcare. My Advocate helps seniors and disabled individuals apply for Medicare Savings Programs, Extra Help and other community assistance programs. Through My Advocate, we provide programs that can help eligible Medicare beneficiaries to save money on their monthly Part B premium (the amount you pay each month for health care) and prescription drugs.

My Advocate will guide you through the step of getting help by completing and submitting the forms to the right New York State agency. My Advocate also helps eligible members sign up in for community-based programs which offer prescription drug discounts, energy and nutrition help and phone discounts, to name a few.

There are more than 1,300 public and privately-sponsored social programs available in New York State. These programs will help you save money, enrich your life, improve your well-being, and connect you to support in your own community.

My Advocate services are a smart way to manage your health. Learning if you may qualify for one of these programs is quick and easy. There is no cost for you to apply. The products or services that your health plan covers will not be changed because you are in these programs.

Find out more about how My Advocate can help you save money:

  • EmblemHealth HMO members, please call My Advocate at 866-311-6629 TTY: 855-368-9643), Monday through Friday, 9 am to 6 pm.
  • EmblemHealth PDP members, please call My Advocate at 866-761-5934 (TTY: 855-368- 9643), Monday through Friday, 9 am to 6 pm.

For more information on programs available or how to qualify, Visit MyAdvocate.

Moving from a Marketplace or SHOP plan to a Medicare Plan 

Do You Have Questions? We've Got Answers.

What if I have a Marketplace Qualified Health Plan (QHP) plan but will qualify for Medicare soon?

If you joined a plan through NY State of Health, you can keep your coverage active until your Medicare coverage starts. Then you can cancel your marketplace plan without penalty.

Once you qualify for Medicare, you’ll have a limited time (an initial enrollment period) to sign up. For most people, the enrollment period starts three months before their 65th birthday and ends three months after their 65th birthday.

In most cases, it’s to your advantage to sign up for Medicare when you’re first eligible because:

  1. Once your Medicare Part A (hospital costs) coverage (which is free for most people) starts you won’t be able to keep any premium tax credits or lower out-of-pocket costs for a Marketplace plan based on your income. If you like, you can keep your Marketplace plan too, but you’ll have to pay full price for the Marketplace plan.

  2. If you miss the seven-month sign-up window for Medicare Part B* (doctor costs), you'll have to wait until the next "general enrollment period" which runs from Jan. 1 to March 31 with benefits beginning the following July 1. If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty.

    *(or Part A if you have to pay a premium for it)

Once my coverage in Medicare starts, can my Marketplace Qualified Health Plan (QHP) disenroll me without my consent?

No, your plan may not terminate (end your coverage) you if you are enrolled in Medicare unless you request it.

If I sign up for Medicare, when do I cancel my QHP?

Once your Medicare coverage starts, you can cancel your Marketplace health plan without penalty by contacting the Marketplace call center or cancelling online. If you have Medicare coverage, you’re considered covered under the health care law. You won’t have to pay the fee that some people without insurance must pay. Be sure not to cancel your Marketplace plan before your Medicare coverage begins. Otherwise your coverage may be delayed.

Can Medicare beneficiaries with coverage under SHOP plans delay enrollment in Medicare Part B without penalty?

Yes. A Medicare beneficiary who is enrolled in employer purchased SHOP coverage is treated the same as any other person with employer group health plan coverage. You can delay enrollment if you are covered under an employer’s health plan for you or your spouse current employment.

If you’re covered under an employer’s plan, you can sign up for Part B without penalty:

  • Any time you are still covered by the plan.

  • During the eight-month period that begins the month after the employment ends or the coverage ends, whichever happens first.

If you do not sign up during this special enrollment period, late enrollment penalties may apply, and you will only be able to sign up during the General Enrollment Period, which occurs annually from January through March with coverage beginning July 1.

I want to purchase health insurance through the Marketplace. What if I have Medicare?

It’s against the law for someone who knows that you have Medicare to sell or issue you a Marketplace policy.

Medicare isn’t part of the Health Insurance Marketplace, so you don’t need to do anything. If you have Medicare, you’re considered covered. The Marketplace won’t affect your Medicare choices or benefits. No matter how you get Medicare, whether through Original Medicare or a Medicare Advantage Plan (like an HMO or PPO), you won’t have to make any changes.

Why should I join a Medicare Advantage Plan (Part C)?

Medicare Parts A and B offer the most basic Medicare coverage available. To get more complete coverage, you have a number of options, including Medicare Advantage Plans, which offer more benefits than Original Medicare, usually for the same cost. EmblemHealth offers both HMO and PPO plans and most of our plans also offer prescription drug coverage and Original Medicare does not. Plans also offer coverage for eyeglasses, annual checkups, chiropractic care, hearing and dental.

View an EmblemHealth plan in your area.

There are some exceptions and we know that each person’s situation is different. We have representatives to help you with additional information, 800-447-9169 (TTY: 711) October 1 through March 31: 8 am to 8 pm, seven days a week. April 1 through September 30: 8 am to 8 pm, Monday through Friday.

Helpful Resource

Changing from the Marketplace to Medicare - Healthcare.gov provides information for people who are changing to Medicare.

2020 EmblemHealth Medicare Made Simple Guide

Download PDF  English  |   Español  |  繁體中文)

Get our Medicare Made Simple Guide — An EmblemHealth guide to help you make the right Medicare decisions.

 

2020 CMS Medicare & You Brochure 

Download PDF English |   Español

Helpful information for people eligible for Medicare and their caregivers.

 

Official U.S. Government website for people with Medicare General information and helpful tools.

Medicare Rights Center
A national not-for-profit consumer service organization dedicated to making sure that older adults and people with disabilities get affordable health care.

Administration for Community Living
The Administration for Community Living educates people and their caregivers about the benefits and services available to help them.

Social Security Administration
800-772-1213 (TTY: 800-325-0778), Monday through Friday, 7 am to 7 pm.

Elderly Pharmaceutical Insurance Coverage EPIC Help Line
800-332-3742, Monday through Friday, 8 am to 5 pm. (TTY: 800-421-1220).
This program helps income-eligible people 65+ to supplement their out-of-pocket Medicare Part D drug plan costs. The Administration for Community Living educates people and their caregivers about the benefits and services available to help them.

Last Updated 10/1/19

Y0026_ 127364 Accepted 10/1/19