Department of Civil Service

NY96-19
PE96-09
PA96-04

TO: NY, PE, PA Health Benefit Administrators
FROM: Employee Benefits Division
SUBJECT: Medicare Crossover
DATE: April 24, 1996

Over the next several months the Employee Benefits Division and MetraHealth will phase in Medicare Crossover for all Empire Plan retirees who are Medicare-primary. The pilot program for Medicare-primary Empire Plan enrollees in Florida has been working very smoothly. Many claims are already being processed through the system, and enrollees are pleased with the convenience. In April a Medicare Crossover mailing will go out to Medicare- primary retirees in Western New York State. Then, at approximately three-week intervals, Met will mail information to retirees in each of six other broad geographic areas, until all Empire Plan Medicare-primary enrollees have been contacted.

Please refer to your HBA Memorandum NY95-39, PE95-25, PA95-11 of November 3, 1995. That memo briefly explained Medicare Crossover and enclosed a copy of the materials prepared by MetraHealth for the mailings to retirees. Attached is a copy of the insert Met is including in the Medicare Crossover mailing.

Please reassure enrollees with questions about the program that Medicare Crossover will in no way change the benefits available to retirees under the NYSHIP. Also, please ask employees who retire and become Medicare-eligible after this initial notification to fill out the Medicare Crossover Enrollment form and send it to Met. A copy is attached for your convenience; please copy it as needed.

NEW YORK STATE HEALTH INSURANCE PROGRAM
MEDICARE CROSSOVER ENROLLMENT FORM
EMPIRE PLAN GROUP #30500

Yes! I want to participate in the Medicare Crossover Program.

Enrollee: (Please complete even if employee or retiree is deceased) (PLEASE PRINT)

Name

Empire Plan ID#

Soc. Sec. #

Date of Birth

Address

City

State

Zip*

Medicare Claim #

(Fill in all 10 characters from your Medicare Health Insurance Card)

Dependent:

Name

Soc. Sec. #

Date of Birth

Medicare Claim #

(Fill in all 10 characters from your Medicare Health Insurance Card)

*If you live part-time in other states where you might incur medical expenses, please indicate these additional states below (maximum of two additional states):

Additional State 1

Additional State 2

Medicare Crossover for Empire Plan Enrollees

Medicore Crossover is provided with:

No Cost To You
No Change In Your Empire Plan Benefits

And:

Your covered spouse may also participate in Medicare Crossover if he/she is eligible for Medicare Part B and does not have medical coverage from another source in addition to the Empire Plan.
Please read the brochure for more information.

Important Update

Automatic filing of your claims through Medicare Crossover is now available in all areas of the United States. (This updates the list of regions in the brochure.)