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Grievance and Appeal Information
How to file grievances and appeals and how to request coverage decisions and coverage determinations.
Medicare is health insurance run by the Federal government and is for people age 65 or older; under 65 with certain disabilities; and any age with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.
Medicare is made up of different “Parts.” Medicare Part A provides hospital coverage. Medicare Part B provides optional medical coverage. Together, Parts A and B are known as Original Medicare and form the basis of Medicare coverage.
Original Medicare consists of:
Medicare Part A helps cover:
- Inpatient care in hospitals
- Skilled nursing facility, hospice and home health care services
Medicare Part B helps cover:
- Doctor services and outpatient care
- Some preventive services
Medicare Part B helps pay for about 80 percent of the medical costs that Medicare covers.
Medicare Part D provides prescription drug coverage.
Medicare Part D Prescription Drug Plans add drug coverage to Original Medicare and other plans. If you have Original Medicare alone and want Medicare drug coverage, you must join one of these plans. Some Medicare Advantage Plans include Part D coverage.
Medicare Supplement Insurance adds to Original Medicare coverage.
These plans do exactly what their name says: they supplement Original Medicare — or in other words, make the coverage provided by Original Medicare more complete. The extra benefits of Medicare Supplements make these plans less affordable than Medicare Advantage Plans.
Medicare Advantage Plans (Part C) are a great combination of benefits and low costs.
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.
To be eligible for an EmblemHealth Medicare Advantage plan, you must 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.
- View EmblemHealth’s 2015 HMO and PPO Service Area maps which include the following counties in New York: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester.
Pre-existing conditions do not matter, and no physical is required.*
*Note: You will not qualify if you have End-Stage Renal Disease (permanent kidney disease requiring dialysis or a kidney transplant), except under certain limited circumstances.
There are several enrollment periods for those who are eligible.
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. Rules about when you can make changes and the type of changes you can make are different for each SEP. For more information, please see When can a person enroll.
Helpful Medicare resources
2015 EmblemHealth Medicare Made Simple Guide — A guide to help you make the right Medicare decisions. Y0026_124580r Accepted 09/24/2014
2015 CMS Medicare & You Brochure — Helpful information for beneficiaries and caregivers.
Medicare Rights Center — A national not-for-profit consumer service organization dedicated to ensuring that older adults and people with disabilities get affordable health care.
Administration on Aging — The Administration on Aging website is designed to provide a comprehensive overview of a wide variety of topics, programs and services related to aging.
Social Security Administration — 1-800-772-1213, Monday through Friday, 7 am to 7 pm. TTY/TDD users, call 1-800-325-0778.
EPIC Help Line — 1-800-332-3742, Monday through Friday, 8 am to 5 pm. TTY/TDD users should call 1-800-421-1220, Monday through Friday, 8 am to 5 pm.
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