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Participating Agencies with the Empire Plan: NYSHIP General Information Book

Retirees, Vestees, Dependent Survivors and their Covered Dependents

Retirees, vestees and dependent survivors | Plan ahead to avoid a gap in coverage | End-stage renal disease | When Medicare pays first, before NYSHIP | How and when to enroll | Medicare premium reimbursement | Expenses incurred outside the United States | Re-employment with your former agency

Note: If you are covered under Preferred List provisions, the Medicare rules presented in this section apply to you and your covered dependents.

NYSHIP requires Participating Agency retirees, vestees and dependent survivors to be enrolled in Medicare Parts A and B when first eligible. NYSHIP also requires your dependents to be enrolled in Medicare Parts A and B when first eligible. You/your dependents must be enrolled and entitled to receive Medicare benefits when first eligible even if also covered through another employer’s group plan. (“Entitled to receive Medicare benefits” means that the person has Medicare in effect and could submit claims to Medicare and receive reimbursements, not just being eligible by being over 65 or in a waiting period, for example.)

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Retirees, vestees and dependent survivors

You must be enrolled in Medicare Parts A and B when first eligible

As a retiree, vestee or dependent survivor, or as that enrollee’s dependent (spouse/domestic partner or child), you must be enrolled in Medicare Parts A and B and entitled to receive Medicare benefits by the first day of the month in which you reach age 65, or before age 65 if you are disabled and receiving Social Security Disability Insurance (SSDI) benefits for 24 months or have end-stage renal disease. You must have Medicare Parts A and B in effect when first eligible even if you also have coverage through another employer’s group plan.

As soon as you become eligible for Medicare, The Empire Plan will pay secondary to Medicare Parts A and B, even if you fail to enroll in Medicare or are in a waiting period for Medicare to go into effect. Empire Plan benefits may change and your share of The Empire Plan premium may change.

Because Medicare pays primary to The Empire Plan, your Participating Agency will reimburse you for the usual (base) cost of “original” Medicare Part B monthly premiums.

In addition, your Participating Agency will reduce your Empire Plan premium (if any) when you become covered under Medicare.

If you are not enrolled in Medicare Parts A and B when you are first eligible to enroll, you will be responsible for the full cost of medical services that Medicare would have covered.

If you join a Medicare Advantage plan (in addition to The Empire Plan), you will be locked into that plan for all services covered under the Medicare program. Please read about “Medicare Advantage plans and your Empire Plan coverage”.

Until you become eligible for Medicare, The Empire Plan (or your current employer’s plan) will generally provide primary coverage as explained in “When Medicare pays first”.

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Plan ahead to avoid a gap in coverage

If you/your dependent is under 65 when you retire or leave the payroll as a vestee, plan ahead. To avoid a gap in coverage check with your local Social Security office three months before you or your spouse turns age 65 to ensure that you are enrolled in Medicare Parts A and B. You must have Medicare coverage in effect on the first day of the month in which you reach age 65. (Or, if your birthday falls on the first of the month, you must have your Medicare coverage in effect on the first day of the month preceding the month in which you turn age 65.)

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 enroll during the three months preceding the month of 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 to you.

If you/your dependent is 65 or over when you retire or leave the payroll as a vestee, The Empire Plan will no longer be your primary insurer beginning the first day of the month after your employer group coverage ends. Ask your agency Health Benefits Administrator when your employer group coverage ends.

If you are already eligible for Medicare, but not yet enrolled in both Parts A and B, apply to Social Security for Medicare Parts A and B as soon as possible. If you do not enroll when you are first eligible, you must enroll during the next general enrollment period between January 1 and March 31. Your coverage will begin the following July 1. You are responsible for the premium surcharge Medicare adds for late enrollment.

If you began receiving Social Security payments before age 65, or you have qualified for Social Security Disability Insurance (SSDI) monthly payments for 24 months, Social Security will send you a Medicare card with an option to decline enrollment in Part B. Do not decline. Be sure you enroll in Part B. The monthly premium for Part B is withheld from your Social Security checks or SSDI allowance. If you already declined Part B when Social Security offered it to you, enroll now and send a photocopy of your new card to your agency Health Benefits Administrator.

If you are a retiree receiving Workers’ Compensation health insurance benefits for work-related medical conditions or injuries, you must still be enrolled in Medicare when first eligible so that Medicare can cover non work-related medical expenses as primary insurer.

If you have “retiree” coverage in The Empire Plan, and your spouse who is an active employee of a Participating Agency is enrolled in The Empire Plan as a dependent on your policy, please read “When an ‘active employee’ is enrolled as a retiree’s dependent”.

When you are eligible

As a retiree, vestee or dependent survivor eligible for Medicare, you must be enrolled in Parts A and B when you:

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End-stage renal disease

Medicare imposes a three-month waiting period after a patient is diagnosed with end-stage renal disease. However, Medicare waives the three-month waiting period if the patient:

Medicare end-stage renal disease coordination

If there is a waiting period at the onset of end-stage renal disease before Medicare becomes effective, The Empire Plan continues to be the primary insurer for the three-month waiting period.

After the three-month waiting period, Medicare begins to count a 30-month coordination period that the patient must satisfy before Medicare is primary. The three-month waiting period, if not waived, plus the 30- month coordination period, makes a total waiting/coordination period of 33 months.

During this period, The Empire Plan (or another employer’s plan) continues to be the patient’s primary insurer. At the end of the period, Medicare becomes the patient’s primary insurer and The Empire Plan will be the patient’s secondary coverage.

Since Medicare will provide only secondary benefits during the waiting/coordination period, The Empire Plan does not require Medicare enrollment during this time and will not provide reimbursement for the Part B premium. At the end of the period, when Medicare becomes the primary insurer, The Empire Plan requires the patient to have Medicare in effect and your Participating Agency will begin providing reimbursement for the Part B premium, unless reimbursement is available from another source.

When Medicare coverage for end-stage renal disease ends, The Empire Plan (or another employer’s plan) will again provide primary coverage for an enrollee or dependent who is under age 65 and not disabled. Notify your agency Health Benefits Administrator if you or your dependent is eligible for Medicare due to end-stage renal disease, or if Medicare coverage ends.

If your spouse or other dependents are covered under other group health insurance, ask The Empire Plan carriers about primary coverage.

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When Medicare pays first, before NYSHIP

When you are no longer actively employed by your Participating Agency, Medicare is primary to NYSHIP as follows:

Retirees, vestees and dependent survivors, and their dependents under age 65: Medicare becomes primary when you turn 65 or before 65 if you become eligible for Medicare because of disability. Until then, The Empire Plan remains primary. If you develop end-stage renal disease, The Empire Plan will provide your primary coverage for the three-month waiting period plus the 30-month coordination period described above; then Medicare becomes primary to The Empire Plan.

If you have Family coverage, Medicare becomes primary to The Empire Plan for your covered dependents as soon as they become eligible for Medicare for any reason. Until then, The Empire Plan remains primary for the dependent. If your spouse or other dependents are covered under other group health insurance, ask The Empire Plan carriers about primary coverage.

Retirees, vestees, dependent survivors and their dependents age 65 or over: Medicare provides coverage that pays primary to The Empire Plan. If your spouse is also age 65 or over, Medicare provides coverage that is primary to The Empire Plan 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.

NYSHIP requires you to be enrolled in Medicare Parts A and B and have both parts in effect as soon as you are eligible for Medicare coverage that is primary to your Empire Plan coverage (pays first, before NYSHIP).

You must enroll in Medicare and have it in effect (be entitled to receive Medicare benefits) when you are first eligible even if you have coverage through another employer’s group plan.

If there is a charge for Part A

If there is a charge for your Medicare Part A coverage because you did not meet the Social Security eligibility requirements for no-cost Part A, you may keep The Empire Plan as your primary coverage and you need not enroll in Medicare Part A. Please send the statement you receive from Social Security confirming your ineligibility for Medicare Part A to your agency Health Benefits Administrator. However, you still must enroll in Part B.

Dependents and Medicare

A dependent who is covered under The Empire Plan policy of a retiree, vestee, dependent survivor or enrollee covered under Preferred List provisions must also be enrolled in Medicare Parts A and B when first eligible for Medicare coverage that is primary to The Empire Plan. A dependent is eligible for Medicare when he or she:

Even if the dependent is working and has coverage through an employer other than an agency that participates in NYSHIP, the dependent must be enrolled in Medicare Parts A and B when first eligible.

If a dependent does not enroll in Medicare and have both Part A and Part B in effect when first eligible, the dependent’s Empire Plan benefits will be drastically reduced. The Empire Plan will not provide any benefits for services that Medicare would have paid.

If the dependent also has Individual coverage as an active employee of a Participating Agency, The Empire Plan remains primary to Medicare for the active employee and your Participating Agency will not provide reimbursement for the active employee’s Part B premium.

If you don’t enroll

If you do not enroll in Medicare Parts A and B, your benefits under The Empire Plan will be drastically reduced. The Empire Plan will not provide any benefits for coverage available under Medicare. If you fail to have Medicare in effect when first eligible, you will be responsible for the full cost of medical services that Medicare would have paid.

You need both Medicare and The Empire Plan

It’s the combination of coverages under Medicare and The Empire Plan that protects you. After Medicare processes the claim, The Empire Plan considers the balance for secondary (supplemental) coverage. The Empire Plan covers the Medicare Part A hospital deductible ($992 per hospital stay in 2007; amount may change yearly), prescription drugs and other medical expenses Medicare does not cover. If you do not have Medicare Parts A and B in effect, you (not The Empire Plan) will be responsible for Medicare-covered expenses. If you drop out of The Empire Plan, the Participating Agency is no longer required to reimburse you for the monthly premium for Medicare Part B ($93.50 per month in 2007; amount may change yearly). And, if you die while not enrolled in The Empire Plan, your dependents will not have the right to re-enroll in The Empire Plan as dependent survivors.

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How and when 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 www.ssa.gov.

Contact your local Social Security office three months before turning age 65. See “Plan ahead to avoid a gap in coverage”. Contact your local Social Security office immediately, regardless of age, if you, your spouse or enrolled dependent is eligible for primary Medicare coverage due to a disability or end-stage renal disease. Effective dates vary when Medicare eligibility is due to disability or end-stage renal disease.

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Medicare premium reimbursement

Note: Since reimbursement practices vary from agency to agency, you should contact your agency Health Benefits Administrator for information.

Social Security deducts the Medicare Part B premium from the monthly Social Security check. (There is usually no charge for Part A.)

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is a Federal law that requires some people to pay a higher premium for their Medicare Part B coverage based on their income. If you are required to pay an income-related monthly adjustment amount in addition to the standard Medicare Part B premium, you are eligible to be reimbursed for this additional premium by your agency. To claim the additional IRMAA reimbursement, eligible enrollees are required to apply for and document the amount paid in excess of the standard Medicare Part B premium. Contact your agency Health Benefits Administrator for information on how to apply, a list of documents required or questions on IRMAA.

If you are a retiree, vestee, dependent survivor, enrollee covered under Preferred List Provisions or a COBRA enrollee – or that person’s spouse/domestic partner – the Participating Agency will reimburse you for the usual (base) cost of “original” Medicare Part B monthly premiums when Medicare becomes primary to your NYSHIP coverage at age 65. If you or your spouse or other dependent is eligible for Medicare before age 65 because of disability or end-stage renal disease, the agency will reimburse you for the usual (base) cost of “original” Medicare Part B coverage. Your Participating Agency may require a photocopy of your Medicare card as proof of Medicare coverage. Your agency may also require proof to begin the reimbursement for your enrolled dependent. Ask your agency Health Benefits Administrator how your agency handles Medicare Part B reimbursement. You are not eligible to receive reimbursement if you are receiving reimbursement from another source.

NYSHIP does not require your agency to reimburse you for extra charges (above the usual base cost of Part B) imposed by Social Security as penalties for late enrollment in the Medicare program. Extra charges are not reimbursable under NYSHIP. The Participating Agency does not reimburse you for Medicare Part A premium costs, if any. If your dependent receives partial reimbursement of the Medicare Part B premium from another source, the Participating Agency must ensure that your dependent receives the full Medicare Part B (usual base cost) reimbursement.

Order of payment

When a retiree, vestee or dependent survivor, or that person’s dependent, becomes eligible for Medicare coverage, benefits are paid in the following order even if you are still in a waiting period for Medicare coverage to become effective because you failed to apply three months before your 65th birthday:

Pays First: Medicare

Pays Second: NYSHIP (Empire Plan)

Note: If you and/or your dependent also has coverage as an active employee under the group plan of an employer other than the Participating Agency, that plan pays first, Medicare second, and The Empire Plan third.

Other members of the family

NYSHIP remains primary for the other members of the family until they become eligible for Medicare or otherwise lose coverage. If your spouse or other dependents are covered under other group health insurance, ask The Empire Plan carriers about primary coverage.

Medicare Advantage plans and your Empire Plan coverage

As a retiree, be sure you understand that if you or your dependent enrolls in a Medicare Advantage plan, in addition to your Empire Plan coverage, The Empire Plan will not provide benefits for any services available through your Medicare Advantage plan or services that would have been covered by your Medicare Advantage plan if you had complied with the plan’s requirements for coverage. Covered medical expenses under The Empire Plan are limited to expenses not covered under your Medicare Advantage plan. If your Medicare Advantage plan has a Point-of-Service option that provides partial coverage for services you receive outside the plan, covered medical expenses under The Empire Plan are limited to the difference between the Medicare Advantage plan’s payment and the amount of covered expenses under The Empire Plan.

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Expenses incurred outside the United States

Medicare does not cover medical expenses incurred outside the United States. The Empire Plan becomes your primary insurer. If you will be traveling outside the United States, you should file claims for services abroad directly with The Empire Plan carriers.

If you will be residing outside the United States, you must notify your agency Health Benefits Administrator. NYSHIP does not require you to enroll in Medicare if you live abroad permanently. The Participating Agency discontinues your Medicare Part B reimbursement. The Empire Plan becomes your primary insurer, even if you return temporarily to the United States for medical treatment. File your claims for covered services directly with The Empire Plan carriers.

When you know that you will be residing outside the United States, you must also notify your Social Security office. Social Security will send you a form to sign and return, indicating your desire to resume Medicare coverage when you return.

When you return from residing abroad, and wish to re-enroll in Medicare, you must contact your Social Security office. You must re-enroll during the next general enrollment period, which is January 1 through March 31 each year. The effective date of your coverage will be July 1. However, there may be a penalty imposed by Medicare for late enrollment. The Participating Agency is not required to reimburse you for your late enrollment penalties. Notify the agency Health Benefits Administrator that you have re-enrolled in Medicare. Reimbursement for the usual Part B premium will resume.

Provide notice if Medicare eligibility ends

If Medicare eligibility ends for you or your dependent (because, for example, you move outside the United States or your dependent dies), you must notify your agency Health Benefits Administrator.

You may be required to refund Medicare credits you were not eligible to receive

If you receive reimbursement for the Medicare Part B premium for yourself or a dependent when you are not eligible, your agency has the right to require a refund of amounts that were incorrectly reimbursed.

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Re-employment with your former agency

After you have retired, if you return to service in a benefits-eligible position with your former agency and you meet the health insurance eligibility requirements for active employees, The Empire Plan again provides primary coverage for you, your spouse and other enrolled dependents. Medicare is primary to The Empire Plan, however, for the domestic partner age 65 or over of an active employee, unless the domestic partner is disabled.

At the time of your re-employment, contact your agency Health Benefits Administrator to find out your effective date for Empire Plan primary coverage in order to avoid claims problems. You are not eligible for Medicare Part B premium reimbursement when The Empire Plan is primary.

If you work for another employer

If you are enrolled in The Empire Plan as a Participating Agency retiree and you work for an employer other than a Participating Agency, Medicare pays primary to The Empire Plan whether or not you have health insurance coverage through that other employer’s group plan. Medicare also pays primary to The Empire Plan if you work for a New York State agency or NYSHIP Participating Employer but remain enrolled in NYSHIP as a Participating Agency retiree. Therefore, you must be enrolled in Medicare Part A and Part B or you will have a gap in your coverage. If you are a Participating Agency retiree planning to work for another agency that participates in NYSHIP, talk with the agency that is hiring you to determine your status in NYSHIP and Medicare.

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