Medicare: When You Must Enroll and
Coordinating with NYSHIP
(Taken from 2003's NYSHIP General Information Book)
Medicare: A federal program |
NYSHIP is primary for most active employees
| You and your dependents must have Medicare
in effect when first eligible for Medicare coverage that is primary
to NYSHIP | When you are no longer an
"active employee" | If you
are also covered by another employer's group plan | When
to enroll in Medicare | Planning to
retire: Avoid a gap in coverage | Medicare
premium reimbursement | Re-employment
| When to contact your agency Health Benefits
Administrator
This section explains when NYSHIP requires you to enroll in Medicare. NYSHIP requirements are not the same as Social Security or Medicare requirements. Do not depend on Social Security, Medicare, another employer or your HMO for information on NYSHIP requirements. If you have questions about NYSHIP requirements for enrolling in Medicare, contact your agency Health Benefits Administrator.
Medicare: A federal program
Medicare is a federal health insurance program for people who are age 65 or older, or have been entitled to Social Security disability benefits for 24 months, or have end stage renal disease (permanent kidney failure). Medicare is directed by the federal Centers for Medicare and Medicaid services (formerly Health Care Financing Administration). Local Social Security Administration offices take applications for Medicare and provide information about the program.
"Original" (fee-for-service) Medicare has two parts: Part A, hospital insurance which can help pay for inpatient hospital care, care in a skilled nursing facility, home health care and hospice care; and Part B, medical insurance which can help pay for medically necessary doctors' services, outpatient hospital services, home health services and a number of other medical services and supplies that are not covered by the hospital insurance part of Medicare.
Primary Coverage
A health insurance plan provides "primary coverage" when it
is responsible for paying health benefits before any other group health
insurance is liable for payment. Be sure you understand which plan provides
your primary coverage.
NYSHIP is primary for most active employees
NYSHIP (Empire Plan or HMO) provides primary coverage for you, your
enrolled spouse and other covered dependents while you are an active
employee, regardless of age or disability. There are exceptions: Medicare
is primary for your domestic partner at 65, and provides primary coverage
for an active employee or the dependent of an active employee when Medicare
eligibility is due to end stage renal disease, as explained below. Also
see "When an ‘active employee' is enrolled as a retiree's
dependent."
If you or your spouse or other dependent turns 65 or becomes disabled while you are an active employee, you may delay enrollment in Medicare Parts A and B until you retire, without penalty. Or, you may enroll as soon as you are eligible and delay activating your benefits until you retire. Or, you may enroll in Part A only, to be eligible for some secondary (supplemental) benefits from Medicare for hospital-related services. There is usually no premium for Medicare Part A.
As an active employee, eligible for Medicare because of age or disability, you can choose Medicare as your primary group insurer only by canceling your enrollment in NYSHIP. If you do so, there will be no further coverage for you and your dependents under NYSHIP. Your benefits will be drastically reduced with only Medicare coverage. While you are an active employee, your spouse or other dependent who becomes eligible for Medicare because of age or disability also may choose Medicare as primary insurer only by canceling enrollment in NYSHIP. However, their benefits would be drastically reduced because no benefits would be available through NYSHIP.
Exceptions: Medicare becomes primary for domestic partners at age 65
and for end stage renal disease
Domestic Partners: Under Social Security law, Medicare is primary for
an active employee's domestic partner who becomes Medicare-eligible
at age 65. The domestic partner must have Medicare Part A and Part B
in effect when first eligible at 65. However, if the domestic partner
becomes Medicare-eligible because of disability, NYSHIP remains primary.
An active employee, or the dependent of an active employee, who develops end stage renal disease becomes eligible for primary Medicare coverage and must enroll in Medicare Parts A and B under the following circumstances:
Medicare imposes a three-month waiting period after a patient is diagnosed with end stage renal disease before Medicare becomes effective. However, Medicare waives this waiting period if the patient enrolls in a self-dialysis training program within the first three months of the diagnosis or receives a kidney transplant within the first three months of being hospitalized for the transplant.
If there is a waiting period at the onset of end stage renal disease before Medicare becomes effective, NYSHIP continues to be the primary insurer for the three-month waiting period.
Medicare end stage renal disease coordination
After the three-month waiting period, Medicare begins to count a 30-month
waiting period that the patient must satisfy before Medicare is primary.
The three-month waiting period, if not waived, plus the 30-month waiting
period, makes a total waiting period of 33 months.
During the waiting period, NYSHIP (or another employer's plan) continues to be the patient's primary insurer. At the end of the waiting period, Medicare becomes the patient's primary insurer and NYSHIP will be the patient's secondary coverage.
Since Medicare will provide only secondary benefits during the waiting period, NYSHIP does not require Medicare enrollment during this time and will not provide reimbursement for the Part B premium. At the end of the waiting period, when Medicare becomes the primary insurer, NYSHIP requires the patient to have Medicare in effect.
Notify your agency Health Benefits Administrator if you or your dependent is eligible for Medicare because of end stage renal disease. Once Medicare is primary, the State or your employer will reimburse you for the Medicare Part B premium, unless you or your dependent receives reimbursement from another source. Notify your agency Health Benefits Administrator if Medicare coverage for end stage renal disease ends; NYSHIP will again provide primary coverage for an active employee or the dependent of an active employee.
You and your dependents must have Medicare in effect when first eligible for Medicare coverage that is primary to NYSHIP
As soon as you or your covered dependent becomes eligible for Medicare
coverage that pays primary to NYSHIP (because of end stage renal disease
or domestic partner status), you or your covered dependent must be enrolled
in Medicare Parts A and B. You must have it in effect and be entitled
to receive Medicare benefits when first eligible even if you also have
coverage through another employer’s group plan. If you or a dependent
is eligible for Medicare coverage that is primary to NYSHIP, but has
failed to enroll when first eligible, you may have to pay for service
you receive from your HMO.
Contact your HMO to find out how your HMO coordinates with Medicare:
Under a Medicare+Choice (Risk) Contract, you assign your Medicare benefits
directly to the HMO. You will not receive any Medicare benefits if you
choose to receive care outside your HMO.
Under a Cost Contract or certain other arrangements, the HMO supplements
your Medicare benefits. If you choose to receive treatment outside the
HMO, you still qualify for Medicare benefits.
When an "active employee" is enrolled as a retiree's dependent
If an active employee of the State or a Participating Employer, age
65 or over, is enrolled in NYSHIP as the dependent of a retired spouse
(rather than in his or her own right as an employee), the employee has
"retiree" coverage in NYSHIP and must enroll in Medicare when
first eligible. Medicare will pay primary to NYSHIP, and the retired
spouse will be eligible to receive reimbursement for the Medicare Part
B premium on behalf of the active employee, unless reimbursement is
received from another source.
When you are no longer an "active employee"
When you are no longer an active employee of the State or a Participating
Employer, NYSHIP or Medicare will be primary as follows:
Retirees, vestees, dependent survivors, Preferred List enrollees and their dependents under age 65: NYSHIP continues to provide your primary coverage until you turn 65 or until you become eligible for Medicare due to disability; then Medicare becomes primary. If you develop end stage renal disease, NYSHIP will provide your primary coverage for the three-month waiting period plus the 30-month period described above; then Medicare becomes primary.
If you have Family coverage, NYSHIP will provide primary coverage for your covered dependents until they become eligible for primary Medicare coverage due to age, disability or end stage renal disease. If your spouse or other dependents are covered under other group health insurance, ask your HMO about primary coverage.
Retirees, vestees, dependent survivors, Preferred List enrollees and their dependents age 65 or over: If your employer continues NYSHIP coverage after age 65, Medicare provides coverage that pays primary to NYSHIP. If your spouse is also age 65 or over, Medicare provides coverage that is primary to NYSHIP for him or her. Your spouse under age 65 and/or your other enrolled dependents may be eligible for primary Medicare coverage because of disability or end stage renal disease. You and your dependents must have Medicare Parts A and B in effect when first eligible.
If you are also covered by another employer's group plan
If you are no longer an active employee of the State or a Participating
Employer and you have coverage under another employer's group plan,
the order of claims payment is 1) current employer plan; 2) Medicare;
and 3) NYSHIP.
When to enroll in Medicare
As an active employee, contact Medicare immediately if you, your spouse
or enrolled dependent is eligible for primary Medicare coverage due
to end stage renal disease. Also, the domestic partner of an active
employee must have Medicare Part A and Part B in effect by the first
of the month in which the domestic partner reaches age 65.
If you are planning to retire or otherwise leave service with your employer, and you or your spouse is 65 or older, contact your Social Security office three months before active employment ends to arrange for Medicare Parts A and B. If you are 65 or over when you retire or otherwise leave service with your employer, NYSHIP will no longer be your primary insurer beginning the first day of the month after the last day of the month in which your employer group coverage ends. Ask your agency Health Benefits Administrator when your employer group coverage ends. Be sure you have Medicare in effect at that time.
Planning to retire: Avoid a gap in coverage
If you are planning to retire or otherwise leave service with your employer
and are under 65, Medicare becomes primary to NYSHIP on the first day
of the month in which you reach age 65. Contact Social Security three
months before you reach age 65 to be sure of having Medicare in effect
at that time.
Although Medicare allows you to enroll up to three months after your 65th birthday, NYSHIP requires you to have Medicare Parts A and B in effect on the first day of the month in which you reach 65. If you do not apply three months before your birthday, you will have a waiting period before Medicare becomes effective. During that waiting period, you will have a gap in your coverage that could be very costly for you.
Regardless of age, contact your Social Security office if you are planning to retire or otherwise leave service with your employer and you or your spouse or dependent is disabled.
How to enroll
You can sign up for Medicare by telephone and mail. Contact your local
Social Security office at 1-800-772-1213. Ask for a Teleclaim appointment.
Information about applying for Medicare is also available on the Web
at http://www.medicare.gov.
Medicare premium reimbursement
If you or your dependent is Medicare primary, the State or your Participating
Employer will reimburse you for the usual (base) cost of "original"
Medicare Part B monthly premiums ($50 per month in 2001) unless you
are receiving reimbursement from another source. Retirees, vestees,
dependent survivors and enrollees covered under Preferred List provisions
and COBRA enrollees who become Medicare primary at age 65 are reimbursed
automatically. Domestic partners and enrollees who become Medicare primary
before age 65 because of disability or end stage renal disease must
apply for reimbursement.
Reimbursement for dependents not automatic
If your dependent is eligible for primary Medicare coverage (as described
above for domestic partners and end stage renal disease), reimbursement
for the dependent's Medicare Part B premium is not automatic. You must
take a photocopy of your dependent's Medicare identification card to
your agency Health Benefits Administrator. Be sure to include your name
and identification number on the photocopy. If you are not an active
employee, contact the Employee Benefits Division at (518) 457-5754 (Albany
area) or 1-800-833-4344.
Loss of eligibility for Medicare premium reimbursement
If you or a dependent loses eligibility for Medicare premium reimbursement
(for example, you return to work for New York State or a Participating
Employer in a benefits-eligible position, you move out of the country
or your spouse dies), you must contact your agency Health Benefits Administrator
or the Employee Benefits Division. You will be liable for premiums that
are incorrectly reimbursed.
Medicare+Choice (Risk) HMOs
As a retiree, be sure you understand that if you or your dependent enrolls
in an HMO under a Medicare+Choice (Risk) Contract, the Medicare+Choice
(Risk) HMO replaces your traditional Medicare coverage. You will not
receive any Medicare benefits if you choose to receive care outside
your HMO. In contrast, under a Medicare Cost Contract, or under supplemental
arrangements, you still qualify for Medicare benefits if you choose
to receive treatment outside your HMO. Ask the HMO for details of their
plans for Medicare enrollees if you will be retiring and Medicare eligible
before the next Option Transfer Period.
Re-employment
If you return to active employment in a benefits-eligible position with
the State or a Participating Employer, for example, from retirement,
and meet the health benefits eligibility requirements for active employees,
NYSHIP again provides primary coverage for you, your spouse and other
enrolled dependents. Medicare is primary, however, for the domestic
partner age 65 or over of an active employee, unless the domestic partner
is disabled.
When to contact your agency Health Benefits Administrator
At the time of your re-employment, ask your agency Health Benefits Administrator
to arrange to notify the Empire Plan carriers or your HMO of your re-employment.
Be sure to find out the effective date for your NYSHIP plan to resume
providing coverage that is primary to Medicare.
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