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When is one eligible for medicare

when is one eligible for medicare

(Retirees over age 65)

Medicare - Your First Level of Health Benefits

When you or one of your dependents becomes eligible for Medicare at age 65 (and thereafter) or through special provisions of the Social Security Act for the Disabled, your first level of health benefits is provided by Medicare.

The Health Benefits Program provides a second level of benefits intended to fill certain gaps in Medicare coverage. In order to maintain maximum health benefits, it is essential that you join Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) at your local Social Security Office as soon as you are eligible. If you do not join Medicare, you will lose whatever benefits Medicare would have provided.

The City’s Health Benefits Program supplements Medicare but does not duplicate benefits available under Medicare. Medicare-eligibles must be enrolled in Medicare Parts A and B in order to be covered by a Medicare HMO plan.

A.   Medicare Enrollment (Retirees Only)

To enroll in Medicare and assure continuity of benefits upon becoming age 65, contact your Social Security Office during the three-month period before your 65th birthday. In order not to lose benefits, you must enroll in Medicare during this period even if you will not be receiving a Social Security check.

If you are over 65 or eligible for Medicare due to disability and did not join Medicare, contact your Social Security Office to find out when you may join. If you do not join Medicare Part B when you first become eligible, there is a 10% premium penalty for each year you were eligible but did not enroll. In addition, under certain circumstances there may be up to a 15-month delay before your Medicare Part B coverage can begin upon re-enrollment.

If you or your spouse are ineligible for Medicare Part A although over age 65 (reasons for ineligibility include non-citizenship or non-eligibility for Social Security benefits for Part A), contact:

N.Y.C. Health Benefits Program

40 Rector Street - 3rd Floor

Coverage for those not eligible for Medicare Part A can be provided under certain health plans. Under this Non-Medicare eligible coverage, you continue to receive the same hospital benefits as persons not yet age 65.

If you are living outside the USA or its territories, Medicare benefits are not available. Under this Non-Medicare eligible coverage, you continue to receive the same hospital and/or medical benefits as persons not yet age 65. If you do not join and/or do not continue to pay for Medicare Part B however, you will be subject to penalties if you return to the USA and attempt to enroll. Please provide full identifying information, including name, date of birth, address, agency from which retired, pension number, health plan and certificate numbers, health code, Social Security Number and Medicare claim number (if any). Also give the reason for ineligibility for Medicare Part A and/or Part B.

If you are eligible for Medicare Part B as a retiree but neglect to file    with the Social Security Office during their enrollment period (January through March) or prior to your 65th birthday, you will receive supplemental medical coverage only, and only through GHI/EBCBS Senior Care.

B.  Medicare Eligibility Notification

You must notify the Health Benefits Program in writing immediately upon receipt of your or your dependent’s Medicare card. Include the following information: a copy of the Medicare card and birth dates for yourself and spouse, retirement date, pension number and pension system, name of health plan, and name of union welfare fund.

C.  Medicare Part B Reimbursement

Once the Health Benefits Program is notified that you are covered by Medicare, deductions from your pension check will be adjusted, if applicable, and you will automatically receive the annual Medicare Part B premium reimbursement (See C. Medicare Premium Reimbursement). The Health Benefits Program will then notify your health plan that you are enrolled in Medicare so that your benefits can be adjusted. If you are

Medicare-eligible and are enrolling in an HMO you must complete an additional application form, which is available directly from the plan. If your plan does not provide coverage for Medicare enrollees, you will have the opportunity to transfer to another plan that does.

The City currently reimburses retirees for the monthly premium for Medicare Part B, as well for their eligible dependents on Medicare.  Medicare Part B reimbursement checks are generally issued once a year, in the year following your Medicare Part B eligibility. 

Periodically, the Medicare Part B premium is increased by the Social Security Administration. At the time of each increase, legislation must be approved by the City Council authorizing the City to reimburse you at a new rate.

If you are receiving a Social Security check, the premium for Medicare Part B will be deducted from that check monthly. If you are not receiving a Social Security check, you will be billed on a quarterly basis by the Social Security Administration. You must be receiving a City pension check and be enrolled as the contract holder for City health benefits in order to receive reimbursement for Part B premiums. For most retirees, the refund is issued automatically by the Health Benefits Program, 40 Rector Street, 3rd Floor, New York, NY 10006, telephone (212) 513-0470.

Special Provisions for Medicare-Eligible Employees

A.  Special Provisions

Federal law requires the City of New York to offer employees over 65 the same coverage under the same conditions as offered to employees under 65. The same stipulation applies also to dependents over 65 and those covered by Medicare through the Special Provisions of the Social Security Act for the Disabled.* In such cases, enrollment in the City health plan is automatic (unless waived) and Medicare becomes secondary coverage.

If you are a Medicare-eligible employee and want Medicare to be your primary coverage, you must complete the waiver section of the Health Benefits Application and return it to your agency payroll or personnel office. If you do so, you will not be eligible for the City’s group health plan.

Employees and their dependents covered by Medicare have identical benefits to those provided to employees and their dependents under age 65. Because of the cost of these benefits, the City does not reimburse employees or dependents for their Medicare Part B premiums if the City health plan is primary. (However, where Medicare has been elected as primary coverage, reimbursement of Medicare Part B premiums will be made.)

Medicare Part B premium reimbursement will be available at retirement when Medicare becomes the primary plan.

*The rules are somewhat different for persons eligible for Medicare due to end-stage renal disease. Consult your Medicare Handbook or agency health benefits representative for further information.

B.  Retirement

At retirement, employees who have chosen Medicare as their primary plan or whose dependents have not been covered on their plan because their spouse/domestic partner elected Medicare as the primary plan may re-enroll in the City health benefits program. This is done by completing a Health Benefits Application and submitting it to their agency health benefits, payroll or personnel office.

Also at retirement, Medicare-eligible employees for whom the City Health Benefits Program had provided primary coverage are permitted to change health plans effective on the same date as their retiree health coverage.

C.  Medicare Enrollment

Medicare Medical Insurance (Part B) is voluntary with a monthly premium that is subject to change. If you and/or your dependents choose City health coverage as primary, Medicare will be supplementary to any City health plan.

There are no penalties for late enrollment in Medicare Part B if employees choose the Health Benefits Program as primary coverage and cancel or delay enrollment in Medicare Part B coverage until retirement or termination of employment (when Medicare enrollment is permitted for a limited period of time). Medicare Hospital Insurance (Part A) should be maintained. For most persons, Part A coverage is free.

Download the Health Benefits Application Form (PDF)

Category: Insurance

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