Health Insurance
Balanced Billing
In New York State, a physician who doesn't accept Medicare assignment cannot charge more than 5% above the Medicare-approved amount for covered services. However, some routine office visits and any home visits are exceptions in which you must pay the Federal limit of 15% more than the Medicare-approved amount. For specific information on balanced billing, contact the Health Insurance Information, Counseling and Assistance Program (HIICAP) at 1-800-701-0501 or your local office for the aging.
Elderly Pharmaceutical Insurance Coverage (EPIC)
EPIC, administered by the New York State Department of Health, helps many elders cope with prescription drug costs. It covers those who do not have adequate insurance coverage for prescription drugs and who are not eligible for Medicaid. EPIC is being coordinated with Medicare prescription coverage. For more information, call the EPIC Help Line at 1-800- 332-3742.
Health Insurance Information, Counseling & Assistance Program (HIICAP)
About 500 trained HIICAP counselors located in county offices for the aging across the state are available to answer New Yorkers' questions about Medicare, Medicare Advantage programs (managed care), Medicare prescription drug coverage, Medigap and other health and long term care insurance. Counseling is also available through a toll-free HIICAP HelpLine at 1-800-701-0501.
Callers will be prompted to enter their zip code and will then be routed to their local office for the aging to talk with a trained counselor.
You can also find information about HIICAP.
Long Term Care Insurance Education & Outreach Program
Planning ahead for long-term care insurance secures your choices and peace of mind. As long-term care costs increase, quality long-term care insurance is a way to protect your financial independence.
Resource Centers are available in every county to inform and educate consumers about long-term care insurance, including policies available through the Partnership for Long-Term Care. These centers provide information as well as individual, unbiased counseling.
New York State does not endorse or recommend specific insurance products or insurers; this program is intended to educate consumers about their choices. Get more information on Long-Term Care Insurance or the phone number to the Resource Center in your county by calling 1-866-950-PLAN or visiting www.planaheadny.com
New York State Partnership for Long Term Care
The New York State Partnership for Long Term Care combines private long term care insurance with Medicaid to help people prepare financially for possible nursing home care, home care or other long term care services as specified under the policy.
It allows New Yorkers to protect assets while remaining eligible for Medicaid Extended Coverage if their long term care needs exceed the period covered by their private partnership insurance policy. For information about the New York State Partnership for Long Term Care
, or call 1-888-697-7582.
Medicaid
This program provides medical assistance for people 65 or older, blind or disabled who are eligible for SSI or for those who have too little income and resources to meet their medical needs. As of January 1, 2006, people who have Medicare and Medicaid will receive prescription drugs through plans overseen by Medicare, but they will continue to receive their other health care services under Medicaid. For more on the Medicare Prescription drug benefit, see our Health Care Page.
Medicaid also pays for long term care services for people after they "spend down" their assets to qualify for benefits. For information contact your local Social Services District (see p. 48) or log onto this website.
Medicare
Medicare provides health insurance for persons 65+, certain disabled persons and those in final stages of renal (kidney) disease. The Social Security Administration takes applications for Medicare and provides information (to avoid penalty, apply within 3 months before your birthday month and 3 months after your birthday month).
Medicare has four types of benefits:
- Hospital Insurance (Part A) - helps pay for inpatient hospital care, limited inpatient care in a skilled nursing facility, home health care and hospice care. Part A has deductibles and co-insurance, but most people do not have to pay premiums for Part A.
- Medical Insurance (Part B) - helps pay for doctor's services, outpatient hospital services,
durable medical equipment and a number of other medical services and supplies that are not
covered by Part A. Part B has premiums, deductibles and co-insurance that you must pay yourself
or through coverage by another insurance plan.
Medicare beneficiaries in many counties can choose to receive Medicare through "original" Medicare (also called fee-for-service or traditional Medicare), or join a Medicare Advantage Plan (also called a Medicare health maintenance organization or managed care plan). - Medicare Advantage Plans (Part C) - are health plan options that are approved by Medicare
and run by private companies. Some of these plans require referrals to see specialists. In many
cases, the costs of services (co-pays) can be lower in a Medicare Advantage Plan than they are
in the Original Medicare Plan with a Medigap policy.
Medicare Advantage Plans provide all of your Part A (hospital) and Part B (medical) coverage and must cover medically necessary services. They generally offer extra benefits, and many include Part D drug coverage. These plans often have networks, which means you may have to see doctors who belong to the plan or go to certain hospitals to get covered services. Some of these plans coordinate your care, using networks and referrals, more than others. This can help manage your overall care and can also result in savings to you. - Medicare Prescription (Part D) - is prescription drug coverage for everyone with Medicare.
This coverage may help lower prescription drug costs and help protect against higher costs in
the future. It can give you greater access to drugs that you can use to prevent complications of
diseases and stay well. If you join a Medicare drug plan, you usually pay a monthly premium.
These plans are administered by private companies approved by Medicare.
Part D is optional, but if you decide not to enroll in a plan when you are first eligible, you may pay a penalty if you join one later.
There are two ways to get Medicare prescription drug coverage:
- Join a Medicare Prescription Drug Plan that adds drug coverage to the Original Medicare Plan.
- Join a Medicare advantage plan that includes prescription drug coverage as part of the plan. You get all of your Medicare coverage through these plans, including prescription drugs.
Medicare Beneficiaries who have signed up for an Advantage Plan should check with their plan to see if they offer any benefits for hearing aids. Some Advantage Plans offer an allowance towards eyeglasses (which Original Medicare does not cover) and may have other limited benefits available.
Medicare Buy-in Programs
New York State and the federal government help low income Medicare beneficiaries with out-of-pocket expenses. Contact your local office for the aging to learn about Medicare Savings Programs.
Qualified Medicare Beneficiary Program (QMB)
is for people with limited resources whose incomes are at or below the national poverty level. It covers the costs of the Medicare premiums, co-insurance and deductibles that Medicare beneficiaries normally pay out of pocket. Contact your local department of social services (see p. 48) for more information.Specified Low Income Medicare Beneficiary Program (SLMB)
is for people whose incomes are up to 120 percent of the poverty level. If you qualify for assistance under the SLMB program, you will not have to pay the Medicare monthly Part B premium. Contact your local department of social services or HIICAP (see our Health Care Page).
Qualified Individual 1 (QI1)
is for Medicare beneficiaries of any age who have low income. This program pays your Medicare Part B premium. You do not need Medicaid to get QI-1. Contact your department of social services for income limits for one person and two-person households. If you qualify, you will not have to pay your Medicare Part B premium.
For help with Medicare, call:
- Your local office for the aging for the aging and ask to speak with a health insurance counselor; or
- the New York State Health Insurance Counseling and Assistance Helpline at 1-800-701-0501;
- or the national Medicare Help Line at 1-800-MEDICARE (1-800-633-4227) or TTY-TDD 1-877-486-2048.
For information about Medicare on the Web, go to the Medicare website.
Reporting Medicare or Medicaid Fraud
SMP is a federally funded program designed to combat health care waste, fraud and abuse. Every year Medicare/Medicaid loses billions of dollars to fraud. In New York State federal, state and local agencies work together to prevent this wasteful spending.
SMP's goal is to alert Medicare and Medicaid beneficiaries of illegal schemes and encourage them to examine their Medicare Summary Notices and report erroneous billing. SMP volunteers are trained to do presentations and help individuals who suspect charges to their accounts. To report suspicious activities in your accounts call the SMP hotline at 1-877-678-4697. This 24 hour hotline utilizes a Tele-interpreter service which can interpret up to 150 languages.
Medicare Preventive Health Screening Test and Benefits
Medicare helps pay for a wide range of preventive health exams and screenings. Following is a list with the name of each test/screening (in bold), followed by the frequency with which they can be administered (in italics), and the cost to the patient and deductible, if any.
- Flu Shot - once per flu season - Medicare pays 100%
- Pneumonia Shot - usually needed once - Medicare pays 100%
- Cardiovascular Screening - once every 5 years - Medicare pays 100%
- Diabetes Screening - based on risk factors, ask your doctor - ' Medicare pays 100%
- Pap Test and Pelvic Exam - once every 24 months - you are responsible for a 20% coinsurance amount for this service (no deductible)
- Mammogram Screening - once every 12 months for women 40+ - you are responsible for a 20% coinsurance amount for this service (no deductible)
- Colorectal Cancer Screening - ask your doctor - you are responsible for a 20% coinsurance amount for this service (no deductible)
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