Medicare: When You Must Enroll and Coordinating with NYSHIP
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.
"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.
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 employers 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.
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.
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.