NYS and PE Retirees Medicare & NYSHIP · 2015-08-27 · Empire Plan and a Medicare D plan, you will...

Medicare & NYSHIP

November 2009NYS and PE Retirees

Important Health Insurance Information for Retirees, Vestees,

Dependent Survivors, Preferred List Enrollees and their

Enrolled Dependents covered under the New York State

Health Insurance Program (NYSHIP) through New York

State Agencies and Participating Employers

State of New York Department of Civil Service, Employee Benefits Division

Medicare & NYSHIP for NY/PE Retirees / November 09

When you are no longer anactive employee and becomeeligible for Medicare, it is thecombination of your healthbenefits under the New York StateHealth Insurance Program(NYSHIP) and Medicare thatprovides you with the mostcomplete coverage. To avoid a

reduction in your overall level of benefits, it isimportant to understand how NYSHIP and Medicarework together as well as NYSHIP’s requirements forenrollment in Medicare. Please read the followinginformation about Medicare and NYSHIP carefully.

The NewYork StateHealth Insurance ProgramThe New York State Health Insurance Program(NYSHIP) provides health insurance benefits toNew York State employees and retirees and theireligible dependents and to those of ParticipatingEmployers. NYSHIP offers coverage under The EmpirePlan or through HMOs that participate in NYSHIP.

As a retiree, your rights under NYSHIP, for the mostpart, remain the same as when you were an activeemployee. For example, you may change options,change between individual and family coverage, andadd/delete dependents, as permitted under NYSHIPrules. However, when eligible for Medicare, NYSHIPrequires retirees, vestees, dependent survivors andPreferred List enrollees to be enrolled in MedicareParts A and B when first eligible for Medicarecoverage that is primary* to NYSHIP.

Under NYSHIP, The Empire Plan and some HMOscoordinate your benefits with Medicare; mostNYSHIP HMOs (Medicare Advantage plans) becomeyour Medicare coverage. Be sure to check withyour NYSHIP HMO to see if your benefits arecoordinated with Medicare or if your NYSHIP HMOis a Medicare Advantage HMO and becomes yourMedicare benefits.

NYSHIP also requires your dependents to beenrolled in Medicare Parts A and B when first eligiblefor primary Medicare coverage.

Since NYSHIP requires enrollment in Medicare PartsA and B, NYSHIP reimburses the Medicare Part Bpremium for you and your Medicare eligibledependents. (See page 7 for details.)

This report has important health insurance informationabout Medicare and NYSHIP. Do not depend onSocial Security, Medicare, an HMO or anotheremployer for information on NYSHIP requirements.

Participating Employer enrollees: Ask your agencyHealth Benefits Administrator when NYSHIP will nolonger be your primary coverage.

MedicareMedicare is the federal health insurance programfor people age 65 and older, disabled andreceiving Social Security Disability Insurance (SSDI)for 24 months, with end-stage renal disease orwith amyotrophic lateral sclerosis (ALS). It isadministered by the Centers for Medicare &Medicaid Services (CMS).

As soon as you, as a NYSHIP retiree, vestee,dependent survivor or Preferred List enrollee,become eligible for Medicare coverage that paysprimary* to NYSHIP, your NYSHIP coverage becomessecondary to Medicare Parts A and B. The EmpirePlan and some NYSHIP HMOs ** coordinate benefitswith Medicare and will not pay for any hospital andmedical expenses that Medicare would cover.NYSHIP HMOs that are HMO Medicare Advantageplans become your Medicare coverage.

The same rule applies to each dependent(spouse/domestic partner or child) covered underyour NYSHIP policy. As soon as your dependent iseligible for primary Medicare coverage, The EmpirePlan and some NYSHIP HMOs** will not pay for anyexpenses for the dependent that Medicare wouldhave covered.

Medicare and the New York StateHealth Insurance Program

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*A health insurance plan provides“primary”coverage when it is responsible for paying health benefits before any othergroup health insurance.

**See Medicare and Your NYSHIP HMO on page 8.

2Medicare & NYSHIP for NY/PE Retirees / November 09

You and your dependents are eligible for primaryMedicare when you:

• are age 65 or older, or

• regardless of age, have been receiving Social SecurityDisability Insurance (SSDI) benefits for 24 months, or

• regardless of age, have end-stage renal disease(permanent kidney failure requiring dialysis orkidney transplant) and have completed Medicare’swaiting period of up to 3 months and 30-monthcoordination period, or

• have amyotrophic lateral sclerosis (ALS) andare receiving Social Security Disability Insurance(SSDI) benefits

You and your dependents each must enroll inMedicare Parts A and B as soon as each of youbecomes eligible for any of these reasons. (UnlikeNYSHIP, Medicare does not offer family coverage.)When you are eligible for primary Medicare benefits,Medicare becomes primary to NYSHIP for you;NYSHIPremains primary for your dependents until they areeligible for Medicare.

Medicare Parts A and B CoverageTogether, Parts A and B are known as theoriginal Medicare plan, which is a fee-for-service plan. NYSHIP requires you and yourdependents to enroll in Parts A and B.

Medicare Part A covers inpatient care in a hospitalor skilled nursing facility, hospice care and homehealth care.

Medicare Part B covers doctors’ services,outpatient hospital services, durable medicalequipment and some other services and suppliesnot covered by Part A.

Medicare Part CMedicare Part C, orMedicareAdvantage, offersmanaged care options through local HMO plansand some private fee-for-service options. A MedicareAdvantage plan replaces your original Medicare PartsA and B benefits and provides Medicare Part Dprescription drug benefits (see page 3).

Eligibility for Medicare

Therefore, you and each of your covereddependents must haveMedicare Parts A and B ineffect by the first day of themonth in which eachof you reaches age 65 (or, if the birthday falls onthe first of themonth, in effect on the first dayof the precedingmonth) or before reachingage 65 if Medicare-primary eligible because ofdisability, end-stage renal disease oramyotrophic lateral sclerosis (ALS).

Note:The requirement to enroll in MedicarePart A and Part B applies if you live in one of the 50United States or Puerto Rico, Guam, the U.S. VirginIslands, Northern Marianas or American Samoa.

Since NYSHIP becomes secondary to Medicare PartsA and B as soon as you are eligible for primary

Medicare coverage, if you fail to enroll in Medicareor are still in a waiting period for Medicare to go intoeffect, you will be responsible for hospital andmedical expenses that Medicare would havecovered if you had enrolled on a timely basis.

The responsibility is yours: To avoid a reductionin your benefits, you must make sure that youand each of your dependents are covered underMedicare Parts A and B when first eligible, evenif you also have coverage through anotheremployer’s group plan.

3 Medicare & NYSHIP for NY/PE Retirees / November 09

NYSHIP offers several MedicareAdvantage HMOs in many areasof New York State to enrolleesand dependents who areMedicare-primary. Check thecurrent Health Insurance Choicespublication to see if any are offeredin your area. If you or yourdependent joins a NYSHIP Medicare

Advantage plan, you receive both your Medicare andNYSHIP benefits from that plan.

Some Medicare Advantage HMOs are not part ofNYSHIP. Be sure you understand how enrolling ina Medicare Advantage plan outside of NYSHIPwill affect your NYSHIP benefits. If you or yourdependent enrolls in a Medicare Advantage planthat is not a part of NYSHIP, you may have very fewor no benefits except the benefits available throughthat plan.

Medicare Part DMedicarePartD is theMedicareprescriptiondrugbenefit.NYSHIP provides prescription drug benefits toyou and your dependents under The Empire Plan or aNYSHIP HMO. Enrolling in a Medicare Part D planseparate from your NYSHIP coverage may drasticallyreduce your benefits overall. For example:

• If you are Medicare-primary and enrolled in both TheEmpire Plan and a Medicare D plan, you will not beable to use your Empire Plan coverage to receive

benefits at the pharmacy. You must use your Medicaredrug coverage first. To receive secondary drugcoverage, you must submit a claim toThe Empire PlanPrescription Drug Program along with documentationof the amount covered by Medicare.

• If you are enrolled in a NYSHIP Medicare AdvantageHMO and then enroll in a Medicare D plan oranother Medicare Advantage plan outside ofNYSHIP, Medicare will terminate your enrollmentin the NYSHIP HMO.

If you are eligible for the extra help from theMedicare Part D Low Income Subsidy, or if you areinterested in additional drug coverage offered by aMedicare Part D plan, be sure you understand howjoining a Medicare prescription drug plan willchange your NYSHIP coverage before enrolling. Ifyou do enroll in Medicare Part D, you will not bereimbursed for the Medicare Part D premium.

If you receive prescription drug coverage through aunion Employee Benefit Fund, contact the fund forinformation about Medicare Part D.

Individuals with limited income and resources areeligible for prescription drug benefits at no cost or areduced cost under the Medicare Part D Low IncomeSubsidy. If you qualify for this extra help fromMedicare, your out-of-pocket cost for prescription drugbenefits may be much lower through Medicare thanunder NYSHIP. Therefore, you should consider joininga Medicare prescription drug plan.

Eligibility for Medicare (cont.)

I am in a coordination perioddue to end-stage renal disease(ESRD). Is NYSHIP or Medicaremy primary insurer duringthis time?

NYSHIP provides your primary health insurancecoverage during Medicare’s coordination periodunless you were Medicare-primary when diagnosedwith end-stage renal disease. At the end of thecoordination period, Medicare becomes the primaryinsurer and NYSHIP the secondary coverage.

If I return towork for NewYorkState, will NYSHIP or Medicarebemy primary insurer?If you return to work for New York State oryour former Participating Employer in abenefits-eligible position after retiring,

NYSHIP is primary for you as an active employee and,in most cases, for your Medicare-eligibledependents.

There are exceptions, for example, if you have adomestic partner age 65 or over or if Medicare isprimary because of end-stage renal disease. You willnot be reimbursed for the cost of Medicare Part Bwhile NYSHIP is primary because you are working.You may choose to suspend Medicare Part Bcoverage during this period.


If you are eligible for both Medicare and Medicaid,you may be required to enroll in Medicare Part D tokeep your Medicaid benefits.

If you are approved for the Low Income Subsidy underMedicare Part D, contact the Employee BenefitsDivision for information about dropping your NYSHIPdrug coverage and reducing your NYSHIP premium(see page 11 for contact information). If you havequestions about the extra help or how to apply, callSocial Security at 1-800-772-1213 or visit www.ssa.gov.

Why do I needMedicareParts A and Bwhen I alreadyhave NYSHIP health insurancecoverage?It’s the combination of coverages under

Medicare Parts A and B and NYSHIP that protects you.

If you are in The Empire Plan or in a NYSHIP HMOthat coordinates with Medicare, your NYSHIP planbecomes secondary (pays after Medicare). YourNYSHIP plan covers much of the Medicare Part Aand Part B deductible and coinsurance amounts andsome other medical expenses Medicare does notcover. For example, hearing aids are not coveredunder Medicare Part A or Part B, but The Empire Planoffers an allowance for hearing aids. Also, Empire Planbenefits are available worldwide while Medicare doesnot pay for medical services outside the United States.

So I should stay in NYSHIPafter enrolling inMedicare?Yes, you should stay in NYSHIP. If you dropout of NYSHIP, you won’t have secondarycoverage. The State will no longerreimburse you or your dependents for the

monthly premium for Medicare Part B, a cost thatusually increases annually. If you decide to reenroll inNYSHIP, you will have a three-month waiting period.And, if you die during the period your NYSHIPcoverage is cancelled, your dependents will not havethe right to NYSHIP coverage as dependent survivors.

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When you needMedicare Parts A andBIf under age 65 at retirementand not otherwise eligible forMedicare:After you retire orotherwise terminate youremployment, Medicare Parts A andB coverage must be in effect on thefirst day of the month in which

you/your dependent turns age 65. Or, if the birthdayfalls on the first of the month, Medicare must be ineffect on the first day of the preceding month.

Although Medicare allows you to enroll up to threemonths after your 65th birthday, NYSHIP requiresyou to have Medicare Parts A and B in effect on thefirst day of the month in which you are eligible forMedicare coverage that is primary to NYSHIP.

Social Security may automatically mail a Medicare cardto you about three months before you becomeeligible for Medicare. It will show both Part A coverageand Part B coverage, with an option to decline Part B.Donot decline! Be sure to enroll in Part B. If you donot receive a card, call Social Security.

If under age 65 and disabled: If you or yourdependent becomes Medicare eligible before age 65because of disability, end-stage renal disease oramyotrophic lateral sclerosis (ALS), Medicare must bein effect as soon as you or your dependent is eligiblefor Medicare coverage that is primary to NYSHIP.

If you or your dependent is under age 65 andeligible for Medicare because of end-stage renaldisease, contact Medicare at the time of diagnosis.Be sure you have Medicare in effect as soon as youcomplete Medicare’s 30-month coordination period.

If under age 65 and receiving Social Securitybenefits: If you or your dependent is already receivingSocial Security Retirement benefits or Social SecurityDisability Insurance benefits before age 65, SocialSecurity may automatically mail a Medicare card toyou about three months before you become eligiblefor Medicare. It will show both Part A coverage andPart B coverage, with an option to decline Part B.

Donot decline! Be sure to enroll in Part B. If you donot receive a card, call Social Security.

If over age 65 at retirement: When you retire orotherwise terminate your employment, if you oryour dependent is already age 65 or over, orMedicare eligible because of disability,NYSHIP willno longer be the primary insurer beginning thefirst day of themonth following a“runout”of 28days after the last day of the last payroll periodfor which you were paid. NYSHIP becomessecondary to Medicare at that time, even if you failto enroll. If your domestic partner is Medicareeligible due to disability, NYSHIP is primary.

If you or your dependent is over age 65 when youretire or otherwise terminate your employment,apply for Medicare Part A and Part B three monthsbefore leaving the payroll (or as far ahead of yourretirement date as possible). Explain to Social Securitythat you did not sign up for Medicare Part B at age 65because you still have primary coverage through youremployer group plan with New York State. You willnot be charged Medicare’s late enrollment penalty.

Participating Employer enrollees: If you/yourdependent is 65 or over when you retire from activeservice or leave the payroll as a vestee, NYSHIP will nolonger be your primary insurer beginning the first dayof themonth after the end of themonth in which youremployer group coverage ends. Ask your agencyHealth Benefits Administrator when your employergroup coverage ends.

How to apply for Medicare:Visit yourlocal Social Security office or callSocial Security at 1-800-772-1213.Information about applying for Medicare is alsoavailable on the web at www.ssa.gov. Medicareaccepts applications online under certaincircumstances. Teletypewriter (TTY) is available forcallers using a TTY device because of a hearing orspeech disability: 1-800-325-0778 for TTY Only.

Medicare Enrollment

General Enrollment PeriodIf you do not enroll in Medicare Parts A and B whenyou are first eligible, you must enroll during the nextannual general enrollment period between January 1and March 31. Your coverage will begin the followingJuly 1. NYSHIP will not reimburse you for any extracharges (above the usual base cost) imposed by SocialSecurity as penalties for late enrollment in theMedicare program.

Your benefits will be drastically reduced until youhaveMedicare in effect.

I’m 62 and retired. My spouseis going to be 65 soon. What dowe have to do?Since you are no longer actively employed,Medicare becomes primary to NYSHIP

for your spouse at age 65, while NYSHIP remainsprimary for you until you reach age 65 or otherwisebecome eligible for Medicare. If you or your spouseis receiving Social Security benefits prior to turning65, Social Security should automatically mail aMedicare card to each of you about three monthsbefore your 65th birthday(s). Do not declineMedicare Part B. If you do not receive a card, callSocial Security (see page 11 for contact information).The State will automatically reimburse you for yourand your spouse’s Medicare Part B premium.

What if I and/or my spousealso have coverage throughan employer other thanNewYork State?Group coverage you may have as an active

employee (not as a retiree) is primary to Medicare. Toavoid a reduction in your NYSHIP benefits, even if youalso have coverage through another employer’s groupplan, you or your dependent must be enrolled inMedicare Parts A and B when first eligible for Medicarecoverage that is primary to NYSHIP. If you or yourspouse is actively employed, the other employer’s planpays first, Medicare second, and NYSHIP third.

What if I’m retired andmy dependent is anactive employee?If your spouse/domestic partner is anactive employee of NewYork State or a

Participating Employer, and is enrolled in NYSHIP asyour dependent, your spouse/domestic partner hasyour“retiree”coverage in NYSHIP and must be enrolledin Medicare Parts A and B when first eligible. Medicarewill pay primary to NYSHIP, and you will be eligibleto receive reimbursement for the Medicare Part Bpremium on his or her behalf, unless reimbursementis received from another source.

How about coverage underWorkers’Compensation,or COBRA?You or your dependent must be enrolled inMedicare Parts A and B if you are receiving

Workers’ Compensation benefits and are no longeron the payroll as an active employee.

If you are continuing coverage in NYSHIP underCOBRA, contact the Employee Benefits Divisionfor information when you become eligible forMedicare. Special rules apply.

I amanactive employeewith adomestic partnerwho is enrolledinNYSHIPasmydependent andwho is turning65. Are theMedicare rules different fordomestic partners?

Yes, because Medicare is a federal program that doesnot recognize domestic partnerships. Medicarebecomes primary for your domestic partner at age 65even though you are still working. Therefore, yourdomestic partner must have Medicare Parts A and Bin place when first eligible for Medicare, regardless ofwhether you are in active or non-active status.


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You pay for Medicare Part B,but NYSHIP reimburses youfor the Medicare Part B premium(excluding any penalty for lateenrollment), unless you receivereimbursement fromanother source.

If you have family coverage underNYSHIP, you will also be reimbursed

for the Part B premium for any dependent eligible toreceive primary coverage from Medicare, providedthe dependent is not reimbursed by another source.

You are not eligible for the Medicare Part B premiumreimbursement when NYSHIP is primary.

How reimbursement works, in most cases

Social Security deducts the Medicare Part B premium,which usually changes annually, from your monthlySocial Security check. If you are not receiving aSocial Security check, you pay the Medicare Part Bpremium directly to Social Security. New York Stateadds the standard cost to your monthly Statepension check.

If you are paying for NYSHIP coverage by makingdirect payments each month to the EmployeeBenefits Division, instead of by pension deductions,reimbursement is made as a credit that reduces yourmonthly payments. If the Medicare credit is greaterthan your monthly premium, you will receive aquarterly refund check from the Office of theState Comptroller.

If you live permanently outside the United States oroutside Puerto Rico, Guam, the U.S. Virgin Islands,Northern Marianas or American Samoa, you are notrequired to enroll in Medicare Part B and are notentitled to Medicare Part B premium reimbursement,since Medicare does not cover services outside theUnited States.

Medicare enrollees with a Modified Adjusted GrossIncome (MAGI) above specified amounts must pay anincome-related monthly adjustment amount (IRMAA)in addition to the standard cost of Medicare Part B. Ifyou are required to pay more than the standard costfor your Medicare Part B coverage, the State will

reimburse you for the IRMAA if you are eligible for itand apply. Please follow the instructions that theEmployee Benefits Division mails to you on an annualbasis regarding IRMAA.

Should I apply forreimbursement?NYSHIP automatically begins reimbursementfor the standard cost of original MedicarePart B when Medicare becomes primary toNYSHIP coverage at age65 for retirees,

vestees, dependent survivors, and enrollees coveredunder Preferred List provisions. NYSHIP also begins thePart B reimbursement automatically for spouses whobecome 65 years old after January 1, 2000.

However, the reimbursement is not automaticfor spouseswhobecame65years oldbeforeJanuary1, 2000. The reimbursement also is notautomatic for adomestic partner or for any enrollee orcovered dependent who isunder age65 and eligiblefor Medicare because of disability, end-stage renaldisease or amyotrophic lateral sclerosis (ALS).Youmust notify theEmployeeBenefitsDivision inwriting and send a photocopy of the Medicare card tobegin the reimbursement in these cases. Please alsoinclude the NYSHIP enrollee’s identification numberand the request for a monthly credit. You may find itconvenient to use the sample letter in theNYSHIPGeneral InformationBook for Retirees.

What about Medicare Part A?There is usually no cost for Medicare Part A.If there is a charge for your Medicare Part Acoverage because you did not meet theSocial Security eligibility requirements, youmay keep NYSHIP as your primary coverage

for Medicare Part A expenses and you do not need toenroll in Medicare Part A. However, you still mustenroll in Medicare Part B. If you receive a statementfrom Social Security confirming your ineligibility forMedicare Part A at no cost, please send a copy to theEmployee Benefits Division.

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Medicare Part B Reimbursement

Order of paymentWhen you or your dependent becomes eligible forprimary Medicare coverage, claims are paid in thefollowing order:

1. Medicare pays first (primary)

2. NYSHIP (Empire Plan or HMO) pays second(secondary)

Note: If you and/or your dependent also have othercoverage as an active employee, that plan pays first,Medicare second, and NYSHIP third.

If Medicare denies your claim because yourMedicare coverage is not yet in effect, you areresponsible for those expenses.

Medicare andYour NYSHIP HMOIf you are enrolled in a NYSHIP HMO, contact yourHMO to find out if benefits will change whenMedicare is primary. Most NYSHIP HMOs areMedicare Advantage HMOs. Find out from yourHMO or the NYSHIP Health Insurance Choices guideif your NYSHIP HMO coordinates with Medicare oris a Medicare Advantage HMO:

•NYSHIP Medicare Advantage HMOWith aMedicare Advantage plan, you have nobenefits outside the NYSHIP HMO. The MedicareAdvantage HMO replaces your original Medicarecoverage. If you enroll in a NYSHIP MedicareAdvantage HMO, all your Medicare and NYSHIPbenefits must be received from that plan.

•NYSHIP HMO coordinates withMedicareIf your HMO coordinates coverage with Medicare,you have benefits available outside the NYSHIPHMO. You can choose to receive treatment outsidethe HMO and still use your original MedicareParts A and B coverage. You will be responsible forMedicare’s deductibles, coinsurance and othercharges. Several NYSHIP HMOs coordinatecoverage with Medicare Parts A and B.

If you receive services out of the country whereMedicare does not provide coverage, The EmpirePlan will pay as primary.

Medicare andThe Empire PlanProviders (such as hospitals, doctors and laboratories)who accept Medicare are required by federal law tosubmit claims to Medicare for Medicare-primarypatients. After Medicare processes the claim,The Empire Plan considers the balance for secondary(supplemental) coverage.

For hospital inpatient expenses, the hospital willfile claims first with Medicare and then with TheEmpire Plan (Empire BlueCross BlueShield). Youshould not be billed for any charges covered undereither program. For hospital outpatient expenses,you are responsible only for The Empire Planhospital outpatient copayment, if any, in additionto any separate bills for doctor’s services (seemedical/surgical benefits below). When a hospitaldoes not submit claims directly to Empire BlueCrossBlueShield after receiving primary payment fromMedicare, it is your responsibility to submit the claim.

For medical/surgical or mental health/substanceabuse expenses, you generally have no claims to fileif you are enrolled in The Empire Plan’sMedicareCrossover program (see below). Medicare Crossoveris the process by which Medicare, as primaryinsurance carrier, automatically forwards MedicarePart B medical claims to a secondary carrier forprocessing. UnitedHealthcare (for The Empire Planmedical/ surgical expenses) or OptumHealth asadministrator for UnitedHealthcare (for The EmpirePlan mental health/substance abuse expenses) willsend you an Explanation of Benefits that will showyou what Medicare paid, what The Empire Plan paid,and the amount you are responsible for paying. If theprovider participates in Medicare and The EmpirePlan, you are responsible only for up to yourcopayment, if any.

Retirees, vestees and dependent survivors whobecomeMedicare eligible at age 65: You areautomatically enrolled in The Empire Plan’s MedicareCrossover in the state where you reside unless youdecline by contacting The Empire Planat 1-877-7-NYSHIP (1-877-769-7447) and choosingUnitedHealthcare on the phone menu.


Claims Coordination


Dependents are automaticallyenrolled inMedicareCrossover. If you or yourdependent becomes Medicare-primary before age 65 because ofdisability, end-stage renal diseaseor amyotrophic lateral sclerosis(ALS), you are automaticallyenrolled in Medicare Crossover if

The Empire Plan is your secondary coverage.

If you are a Medicare-primary Empire Plan enrolleeor dependent, you are automatically enrolled in theMedicare Crossover program, but you mayexperience a delay in your enrollment whileUnitedHealthcare and Medicare exchange yourHealth Insurance Claim (HIC) number assigned byMedicare and your secondary carrier information.You will know you are enrolled when Medicare hassent your claim to The Empire Plan and you receivean Explanation of Medicare Benefits (EOMB) thatstates your claim has been forwarded to yoursecondary carrier. If the EOMB does not state thatyour claim was forwarded to your secondary carrier,you or your provider will have to submit a claim toThe Empire Plan. If you are a Medicare-primaryEmpire Plan enrollee or dependent and are havingproblems with your claims, call The Empire Planat 1-877-7-NYSHIP (1-877-769-7447) and selectUnitedHealthcare.

If Medicare is your primary coverage but yoursecondary coverage is from a source other thanThe Empire Plan, sign up for Medicare Crossoverwith your secondary plan, not with The Empire Plan.Notify UnitedHealthcare not to enroll you in TheEmpire Plan’s Medicare Crossover. It is yourresponsibility to submit claims to The Empire Planfor processing as your third coverage.

Will The Empire Plan sendmean Explanation of Benefits?You should receive an Explanationof Benefits (EOB) showing that bothMedicare and The Empire Plan processed

the claim. If you do not receive this EOB, submit aclaim to The Empire Plan carrier for secondarypayment. Be sure to include supporting bills,receipts and Medicare’s Summary Notice.

Please see your NYSHIP General Information Book andEmpire Plan Certificate for details on how to fileclaims, including deadlines.

How can I be sureMedicaresentmy claim toThe Empire Planfor payment?Medicare will send you an Explanation ofMedicare Benefits (EOMB) that will note

whether or not your claim was sent to The Empire Plan.If the EOMB does not have this note, submit your claimalong with a copy of your EOMB to UnitedHealthcare(for medical/surgical services) or to OptumHealth(for mental health/substance abuse services).

Do I have to file a claimwithThe Empire Plan if I receiveservices that Medicare doesnot cover?If you receive services (such as hearing

aids) from a provider who does not participate inThe Empire Plan, and these services are coveredunder The Empire Plan but not under Medicare,it is your responsibility to file a claim with theappropriate Empire Plan carrier for Basic Medicalor non-network benefits.

You do not have to file a claim if you receive servicesfrom a provider who participates in The Empire Plan.

What if I incurmedical expensesoutside theUnited States?Medicare does not cover medical expensesfor services outside the United States(except Puerto Rico, Guam, the U.S. VirginIslands, Northern Marianas and American

Samoa). NYSHIP pays as your primary insurer. If you

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Claims Coordination (cont.)

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Continued on back cover

This publication was printed using recycled paper and environmentally sensitive inks.

State of New York Department of Civil ServiceEmployee Benefits Division

Albany, New York 12239518-457-5754 (Albany area) 1-800-833-4344 (U.S.,

Canada, Puerto Rico, Virgin Islands)https://www.cs.state.ny.us

Medicare & NYSHIP is published by the EmployeeBenefits Division of the State of New York Department ofCivil Service. The Employee Benefits Division administersNYSHIP. NYSHIP provides your health insurance benefits

through The Empire Plan or a NYSHIP HMO.

are in The Empire Plan and will be travelingtemporarily outside the United States, file claimsdirectly with The Empire Plan carriers. If you areenrolled in an HMO, check with your HMO before youtravel about requirements for authorizing treatmentoutside the service area.

If you will be residing permanently outside theUnited States, you must notify the Employee BenefitsDivision in writing. The State will discontinue yourMedicare Part B reimbursement.

What if I use a provider whohas opted-out of Medicare?If you are eligible for Medicare-primarycoverage and you receive covered servicesfrom a provider who has elected to opt-outof Medicare, or whose services are

otherwise not covered due to failure to followapplicable Medicare program guidelines, The EmpirePlan will estimate the Medicare benefit that wouldhave been paid and subtract that amount from theallowable expenses under the Plan.

Write if Medicare status changes

If Medicare eligibility ends for you or yourdependent (because, for example, you moveoutside the United States or your dependent dies),you must write to the Employee Benefits Division.You must also notify us of a divorce. If you receivereimbursement for the Medicare Part B premiumfor yourself and/or dependent when not eligible,you will be required to return the amounts that

were paid incorrectly. If you move back to theUnited States temporarily for medical care,contact us about resuming your Medicarepremium reimbursement temporarily.

If you have questions

If you have questions about Medicare and NYSHIPor if you need a NYSHIP publication mentionedin this booklet, please call the Employee BenefitsDivision at (518) 457-5754 or 1-800-833-4344(U.S., Canada, Puerto Rico, Virgin Islands). CallMonday through Friday between 9 a.m. and 3 p.m.Eastern time. You may also check our web siteat https://www.cs.state.ny.us. Or write to:TheEmployee Benefits Division, State of New YorkDepartment of Civil Service, Albany, NY 12239.

Information in this flyer is provided to help you havethemost complete health insurance coverage possible.Care has been taken to ensure accuracy. However,the HMO contracts and the certificate of insurance fromThe Empire Plan carriers with amendments are thecontrolling documents for benefits availableunder NYSHIP.

If you have questions aboutMedicare eligibilityor enrollment, contact Social Security at1-800-772-1213. TTY users should call1-800-325-0778. Or, check theweb site,www.ssa.gov.

For Medicare benefits, call Medicare at1-800-MEDICARE (1-800-633-4227). TTY usersshould call 1-877-486-2048. Medicare’s web site,www.medicare.gov, also has information.

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It is the policy of the State of New York Department ofCivil Service to provide reasonable accommodation toensure effective communication of information in benefitspublications to individuals with disabilities. Thesepublications are also available on the Department of CivilService web site (https://www.cs.state.ny.us). Check the website for timely information that meets universal accessibilitystandards adopted by New York State for NYS agency websites. If you need an auxiliary aid or service to make benefitsinformation available to you, please contact the EmployeeBenefits Division at (518) 457-5754 (Albany area) or1-800-833-4344 (U.S., Canada, Puerto Rico, Virgin Islands).

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