Medicare and NYSHIP

NYSHIP coverage and Medicare coverage work in tandem to provide you with robust coverage.

Medicare is a federal health insurance program. It helps people over 65 and those with specific medical conditions. If you’re retired or not working, you and your dependents must enroll in Medicare when eligible. This is mandatory to keep your NYSHIP coverage.

Medicare Overview

Medicare consists of four unique parts, commonly known as Part A, Part B, Medicare Advantage (Part C) and Part D. Visit the Social Security Administration’s website to learn more.

Part A

Hospital insurance

Part D

Prescription drug coverage

Part B

Medical insurance

Medicare Advantage (Part C)

Replaces Part A and B through an HMO

Enrollment

The best time for you or your dependents to enroll in Medicare depends on how you are eligible:

  • If you are diagnosed with ALS or ESRD, apply for Medicare as soon as possible.
  • If you’re turning 65, you can enroll in Medicare up to three months before your birthday. Don’t wait later than one month before or you may have a gap in coverage.
    • If your birthday is on the first of the month, you can apply for Medicare one month earlier than normal.

For more information on when you can enroll in Medicare, visit the Social Security Administration website.

If you’re eligible for Medicare but not enrolled, you can apply up to three months before you retire. When you apply, let the Social Security Administration know that you didn’t sign up earlier due to having employer group health coverage through NYSHIP. 

If you don’t sign up within eight months of retirement, you’ll have to wait for the next general enrollment period for Medicare. You’ll face a late enrollment penalty that NYSHIP won’t reimburse. 

Already enrolled in NYSHIP?

Select your plan type to learn more about how Medicare and NYSHIP work together.

Who Pays First?

If you are currently an active employee, oftentimes NYSHIP will be the primary coverage for you and your dependents. This means your NYSHIP coverage will pay for care before Medicare.

There are some exceptions:

  • Exception 1: If you or your dependent is diagnosed with ESRD, there is a 30-month coordination period between NYSHIP and Medicare. Afterwards, that person will have Medicare as their primary coverage, regardless of your employment status.
  • Exception 2: If you are an active employee with a domestic partner, your domestic partner's primary coverage will be Medicare when they are 65 or older. This is regardless of your employment status.

Once someone becomes Medicare-primary (oftentimes when you retire and you're 65 or older), NYSHIP will not cover the portion of claims that Medicare will–or would–pay. For example:

  • If you have The Empire Plan but don’t have Medicare Part A or B despite being eligible, The Empire Plan won’t cover the portion of medical expenses that part of Medicare would have paid. This can be up to 80% of your bill. 
  • If you choose a provider that doesn’t accept Medicare, The Empire Plan might may cover the service, but will deduct what Medicare would have paid the provider. You will be responsible for the rest.

Yes. Once you or your dependents become Medicare-primary, you/they must enroll in Medicare to keep NYSHIP coverage.

  • If you have a NYSHIP HMO, you must enroll in both Medicare Part A and Part B if eligible. 
  • If you have The Empire Plan, you may enroll in only Part A or Part B, but this is strongly discouraged.

Do not enroll in a non-NYSHIP Medicare Advantage plan or else NYSHIP coverage will be terminated for you and your dependents.

Exceptions apply if you live outside the U.S. or its territories, are not a U.S. citizen, or are ineligible for premium-free Part A or for Medicare as a whole. Contact EBD if these apply.

You may receive some Medicare reimbursements from NYSHIP. This can happen through either Part B premium or Part B IRMAA reimbursements.

  • Part B premium reimbursement happens when Medicare is primary. In this case, NYSHIP will reimburse their Part B premiums, but not any late enrollment penalties.
  • Part B IRMAA reimbursement occurs if your income exceeds a set federal limit. In this case, you must pay Medicare an Income Related Monthly Adjustment Amount (IRMAA) for Part B and Part D coverage. When Medicare is primary, you may apply for NYSHIP reimbursement of Part B IRMAA each January.
    IRMAA

NYSHIP does not reimburse Part D premiums or Part D IRMAA. However, you may receive reimbursement of your Part D premiums through Medicare’s Extra Help program.

If you use the NYSHIP provider network, NYSHIP will cover your Medicare Part A and Part B deductible and coinsurance costs. 

Most people eligible for Medicare at age 65 will need to apply for coverage on their own.

To apply for Medicare: 

  • Visit ssa.gov/medicare/sign-up
  • Call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778)
  • Visit your local Social Security Administration office

Once you receive your new Medicare card, mail EBD a letter with a photocopy of the front and back.