Medicare and NYSHIP
When you are no longer an active employee and become eligible for Medicare, it is the combination of your health insurance benefits under Medicare and NYSHIP that provides you with the most complete coverage. Understanding how Medicare and NYSHIP work together is the key to maximizing the benefits available to you.
Note: Medicare only provides coverage to enrollees living in the United States and its territories. If your permanent residence is located outside the United States and/or you need health care services while traveling internationally, NYSHIP will pay as your primary insurer.
Parts of Medicare
Medicare has several parts; see below for a brief description of each. For more detailed information, visit www.medicare.gov.
Medicare Parts A and B ("Original Medicare")
Medicare Part A covers inpatient care in a hospital or skilled nursing facility, hospice care and home health care.
Medicare Part B covers doctors' services, outpatient hospital services, preventive services, durable medical equipment and some other services and supplies not covered by Part A.
Note: NYSHIP requires you and your dependents to be enrolled in Medicare Parts A and B when first eligible for Medicare coverage that pays primary to NYSHIP. It is your responsibility to contact the Social Security Administration to enroll in Medicare at the appropriate time. See Medicare & NYSHIP for important information about when Medicare eligibility begins, when Medicare becomes primary to NYSHIP and how to enroll.
Medicare Part C (Medicare Advantage Plans)
All NYSHIP HMOs provide Medicare Advantage (Medicare Part C) coverage to Medicare-primary enrollees and dependents. When you enroll in a Medicare Advantage Plan, it replaces your original Medicare (Parts A and B) and all of your health care���except for emergency or out-of-area urgently needed care���is thereafter provided, arranged or authorized by the Plan.
Medicare Part D
Medicare Part D provides prescription drug benefits.
Coordination of Coverage
The Empire Plan and all NYSHIP HMOs provide broad coverage for Medicare-primary enrollees and their dependents. However, there are important differences in terms of how each plan type works with Medicare to coordinate your benefits.
If you are enrolled in The Empire Plan:
Your original Medicare (Parts A and B) is your primary coverage, and The Empire Plan is your secondary coverage. Medicare-primary retirees and dependents are enrolled automatically in Empire Plan Medicare Rx, a Part D prescription drug program with expanded coverage designed specifically for NYSHIP.
If you are enrolled in a NYSHIP HMO Medicare Advantage Plan:
Your HMO contracts directly with Medicare to provide all of your benefits (including Medicare Part D prescription drug benefits) through the Medicare Advantage Plan.
If you are already enrolled in a NYSHIP HMO at the time that you become eligible for Medicare and you have also enrolled in Parts A and B as instructed, your HMO will automatically move you into its Medicare Advantage Plan.
Note: Regardless of the type of NYSHIP plan you choose, if you are not enrolled in Parts A and B at the time that Medicare begins paying primary to NYSHIP, your NYSHIP coverage will be drastically reduced and/or canceled. Advance planning is critical!
Claims
If you are enrolled in The Empire Plan:
Providers (such as hospitals, doctors and laboratories) who accept Medicare are required by federal law to submit claims to Medicare for Medicare-primary patients. After Medicare processes a claim, The Empire Plan considers the balance for secondary (supplemental) coverage. You are responsible for any applicable copayments (deductible and coinsurance apply when using out-of-network providers).
If you are enrolled in a NYSHIP HMO Medicare Advantage Plan:
Your HMO provides both your Medicare benefits and your NYSHIP benefits, so there is no claims coordination.
Questions?
Additional information can be found in the following publications: