Medicare Part D in New York is relatively new. It was first introduced in 2006, the result of the Medicare Prescription Drug, Improvement, and Modernization Act, more commonly known as MMA. Passed by Congress in 2003, MMA sought to lower drug costs and enhance healthcare options for seniors. This page describes Medicare's prescription drug plan options in New York.
How Medicare Part D works in New York
If you're a senior looking for prescription drug coverage in New York, Medicare Part D is how you get it. Medicare prescription drug plans (PDPs), are available in two forms.
First is a standalone Medicare Part D plan. You may add a standalone plan to your Original Medicare coverage (Part A, hospital insurance, and Part B, medical insurance). You may also add Part D to a Medicare Advantage (MA) plan that does not include prescription drug coverage.
Medicare Advantage plans must offer the same benefits you get with Original Medicare. However, most additional coverage. Common add-ons include prescription drug benefits, routine vision and dental care, and fitness programs.
Your second Part D option is a Medicare Advantage Prescription Drug plan (MA-PD). Also known as an all-in-one plan, MA-PDs combine the benefits of Original Medicare with a standalone Part D plan.
If you want an Advantage plan that includes prescription drug coverage, look for the MA-PD designation.
Please note that you cannot have both an MA-PD and a Part D plan. If you sign up for a standalone PDP after enrolling in an MA-PD plan, you will lose your Advantage plan and be returned to Original Medicare.
How do you qualify for Medicare Part D in New York?
If you qualify for Original Medicare AND are enrolled in Part A and/or Part B, you qualify for Part D. You must also live within the plan's service area.
Around 85% of Medicare beneficiaries became eligible when they turned 65. But unless you began receiving Social Security benefits at least 4 months before your 65th birthday, you will not be automatically enrolled in Medicare Parts A and B.
The remaining 15% of beneficiaries qualify for Medicare due to a disability. For them, enrollment in Parts A and B occurs automatically in month 25 of receiving Social Security disability benefits.
Whether you qualify for Medicare due to your age or disability status, nobody is ever automatically enrolled in Part D. You must choose to join a Part D plan during specific enrollment periods.
When can you join a Medicare prescription drug plan in New York?
Medicare Part D enrollment periods in New York are the same as in the rest of the country.
Your Initial Enrollment Period (IEP) occurs when you first become eligible for Medicare. It starts 3 months before the month you become eligible for Medicare and lasts for 7 full months. So, if your 65th birthday or 25th month of disability benefits occur in June, your IEP opens on March 1 and extends through September 30.
Once you sign up for Part A and/or Part B, you may enroll in either an MA-PD or prescription drug plan during your Initial Enrollment Period.
If you don't sign up for Medicare during your IEP and you don't qualify for a Special Enrollment Period (SEP), you must wait for the General Enrollment Period to sign up for Part A and/or Part B. This occurs every year from January 1 through March 31. Once General Enrollment ends, you have from April 1 through June 30 to sign up for a Part D plan.
The Medicare Annual Enrollment Period (AEP) is available every year to current Medicare beneficiaries. It lasts from October 15 through December 7 and allows you to make any changes you want to your Medicare coverage, including choosing a new prescription drug plan in New York.
If you have an Advantage plan, the Medicare Advantage Open Enrollment Period lets you make changes to your coverage from January 1 through March 31. Your choices are limited to changing from one MA plan to another OR leaving your Advantage plan to return to Original Medicare. But, if you lose your prescription drug coverage due to making said change, you may also join a standalone Part D plan.
Finally, Medicare offers Special Enrollment Periods to beneficiaries who meet certain criteria, such as losing their current coverage or moving. There are dozens of ways to qualify for an SEP. Find the full list on Medicare.gov here.
Comparing Medicare Part D plans in New York
Private insurance companies contract with Medicare to provide prescription drug coverage. Therefore, coverage options vary according to the plan and provider you choose. It's smart to compare your options carefully, as benefits and costs differ from plan to plan.
Start by creating a list of the prescription medications you take. Then, compare your list to the plan's drug formulary. This is the list of medications covered by the plan. If the formulary doesn't include one or more of your medications, look for a different plan. If none of the prescription drug plans in New York include your prescriptions, talk to your doctor about alternatives or whether an exception request can be filed.
While reviewing the formulary, look at the drug tiers. Nearly every Part D plan uses drug tier pricing. This helps you estimate what your actual annual costs would be, since the higher the tier, the higher your out-of-pocket will be for that drug.
Speaking of costs, you need to look beyond the monthly premium to estimate your true out-of-pocket under any Part D plan. This includes the annual deductible and any copays or coinsurance. Again, the Part D plan's drug tiers can help you estimate what your copayments will be.
Extra Help is a Medicare program that helps beneficiaries pay some (or all) of their out-of-pocket costs for prescription medications. Some people receive notification from Medicare that they qualify automatically. You may also be notified by Social Security. This is usually because you have Medicaid. If you think you should qualify for Extra Help but have not been notified that you do, call your plan.
Do you have to have prescription drug coverage in New York?
Currently, there are no laws requiring you to have any type of healthcare coverage. However, Medicare encourages eligible seniors to sign up by charging late penalties for those who delay enrollment. If you go 63 days or more without creditable drug coverage (i.e. comparable to Medicare), you may owe late penalties once you do sign up for Part D. You have to pay this penalty for the entire time you have Medicare.