What Are Medicare Advantage Plans in New York?

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans combine Part A (hospital) and Part B (medical) coverage and often include Part D (prescription drug coverage). Many Medicare Advantage plans in New York also offer additional benefits like dental, vision, hearing, telehealth services, and fitness memberships.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first enroll in Original Medicare (Parts A and B). Most individuals become eligible for Medicare enrollment at age 65, though people with disabilities or conditions like ALS or ESRD may qualify earlier.

Key enrollment periods include:

• Initial Enrollment
• General Enrollment
• Special Enrollment

Late enrollment or failure to qualify for premium-free Part A may result in penalties.

What Types of Medicare Advantage Plans Are Available in New York?

New York offers the following Medicare Advantage (MA) plan types:

• Health Maintenance Organizations (HMOs): Require in-network care; referrals usually needed for specialists.
• Preferred Provider Organizations (PPOs): Allow out-of-network care at higher costs; typically no referral needed.
• Private Fee-for-Service (PFFS): Can use any Medicare-approved provider who accepts plan terms; some have provider networks.
• Special Needs Plans (SNPs):
  • C-SNPs: Designed for those with chronic conditions like diabetes, cancer, or dementia.
  • I-SNPs: For individuals in institutions or who need nursing care at home.
  • Dual Eligible Special Needs Plans (D-SNPs): For people who qualify for both Medicare and Medicaid. These often provide extra benefits with minimal costs.
• Medical Savings Accounts (MSAs): Combine a high-deductible health plan with a medical savings account funded by your insurer.

What Are Your Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans include Part D drug coverage. However, MSAs and some PFFS plans do not. If your plan doesn’t include drug coverage, you may:

• Enroll in a standalone Part D plan (allowed only for certain plan types).
• Incur a late enrollment penalty if you delay obtaining drug coverage without creditable coverage.

How Do You Choose a Medicare Advantage Plan?

Understand Medicare Advantage costs when comparing plans. Important factors include:

• Premiums: Many plans offer $0 premiums; others charge monthly fees based on plan features.
• Deductibles, Coinsurance & Copays: Evaluate what you’ll pay for medical visits, services, or prescriptions.
• Out-of-Pocket Maximums: These caps protect you from excessive annual costs for covered services.
• Extra Benefits: Look for value-added services like dental, vision, hearing, telehealth, wellness programs, and gym memberships.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during the following specific enrollment periods:

• Initial Enrollment: Three months before, during, and after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop a Medicare Advantage plan.
• General Enrollment (Jan 1–Mar 31): For those signing up for Part B.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch to another MA plan or return to Original Medicare.
• Special Enrollment Periods: Apply when you:
  • Move out of your plan’s service area
  • Lose other coverage (e.g., employer or Medicaid)
  • Experience plan termination or qualifying health events

What If You Want to Change Your Medicare Advantage Plan?

You can switch Medicare Advantage plans during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

Enroll in a new plan and your current coverage will be automatically replaced when the new plan becomes active.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in New York?

New York offers helpful programs and support for Medicare beneficiaries:

• HIICAP (Health Insurance Information, Counseling and Assistance Program): Provides free Medicare counseling.
• New York SMP Program: Teaches beneficiaries how to prevent Medicare fraud and abuse.
• New York Department of Financial Services: Regulates insurance and handles complaints.
• Medicaid and Medicare Savings Programs: For low-income individuals. Visit health.ny.gov or call 1-855-355-5777. Learn about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans, or Medigap, are policies that help pay for out-of-pocket costs not covered by Original Medicare.

• You must have Medicare Parts A and B to qualify.
• The ideal time to enroll is during your six-month Medigap Open Enrollment Period, which begins when you sign up for Part B.
• After this window, you may be subject to medical underwriting.
• Medigap doesn’t include drug coverage—you’ll need a standalone Part D plan.
• 10 standardized Medigap plans are available. Medicare Supplement Plan G was the most popular in 2023 and continues to grow, along with Plan N.
• Plan F is not available to those newly eligible after January 1, 2020.
• Medigap plans offer consistent coverage, nationwide provider access, and no referrals.

Learn more about Medicare Supplement plans in New York.

Next Steps

If a Medicare Advantage plan in New York meets your needs, compare plans in your area. Evaluate premiums, provider networks, coverage options, and extra benefits. Be ready to enroll during your eligibility period or the next available enrollment window.