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What To Do For Insurance If Your Employer Was From Pa.

Question: What do I do for insurance now that I have retired from work and live in New York, but my employer was in Pennsylvania?

Answer: In our area, we have a significant number of people who cross state lines for work. This is a similar situation for working in one county and living in another county. When you age into Medicare, and are not working, your insurance options are determined by where you live. My answer would be the same for someone living in Pennsylvania and working in New York state.

I am also making the assumption that your employer did not offer retiree benefits. If retiree benefits are available, you should consider that option along with Original Medicare (Part A and B).

Original Medicare covers your health in the same way wherever you are. Original Medicare does not require referrals or restrictions, and allows you to access any doctors that participate regardless of where you live. If you want to see a specialist in Pennsylvania, or Ohio or in your area, go ahead.

It is the insurance products that work with Original Medicare that are different to you based on where you live. The Medicare Supplement Plans (Medigaps), the Medicare Advantage Plans, and the Part D Prescription Drug plans are different based on where you live.

If your insurance choice is Medicare with Medigap plus Part D plan, you can go to any physician, clinic, or hospital anywhere in the country that accepts or participates in Medicare. These Medigap policies come in many different levels of coverage, but are usually on the upper end of the monthly premium costs. If you choose a Medigap you need to remember to address your prescription drug coverage plan as well. This means you have three insurance cards and these are useful wherever you go.

Your other choice would be to enroll in a Medicare Advantage Plan, instead of a Medigap plus Part D plan. Medicare Advantage Plans come in a variety of styles; Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), or Private Fee For Service plans (PFFS). These plans all work differently outside your legal address area. A HMO does well with providing for emergency situations when away from home, but it will not cover medical care regularly when away from home. If you have an HMO plan and that plan is based in New York, your insurance coverage may not be as useful in Pennsylvania or vice versa. To determine your physician’s participation you should contact the doctor’s office, or call the HMO insurance company to verify participation.

The PPO, and PFFS plans work differently, and you could see physicians regularly if they accept your plan when out of area. Each of these categories has different rules and policies.

The PPO plans usually have a local network, and sometimes national network, of participating physicians and hospitals. So, depending on which PPO plan you chose, you may find it useful, but you must check with your providers.

The PFFS plans are designed to be national plans that are sold locally. Just because it is in the category of National Plans doesn’t mean that your physician participates. You must ask each office you go to if they participate prior to your appointment.

Each Medicare Advantage plan has physicians, labs, and hospitals, that participate with the plans. This participation status can change periodically, so I recommend checking regularly to be sure the office still participates in the plan.

The annual open enrollment period is Oct. 15 to Dec. 7. But since you just retired you have a Special Enrollment Period (SEP). This SEP allows you 60 days to find new insurance to add on to your Original Medicare Part A and B coverage. You still need a plan that is based where your legal address is. You can find this out by using medicare.gov, or (800) 633-4227. You can also access agencies in your home area to help you through this decision-making process.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 720-9797 or e-mail at SLM@lutheran-jamestown.org.

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