Your Medicare Options With NYSHIP
Becoming eligible for Medicare is a significant milestone, but it can also be overwhelming: Four Medicare parts. Medicare Advantage plans sending offers in the mail. And your NYSHIP coverage—what happens to that?
To make things even trickier: As a NYSHIP retiree, you’re required to have Medicare when you’re eligible. However, some Medicare plans will cancel your NYSHIP coverage. And, to top it off, some NYSHIP plans are also Medicare plans!
It can get a bit confusing—so, in this article, we’re going to clear a few things up.
NYSHIP vs. Medicare
A good starting point for all this is to understand the basic difference between NYSHIP and Medicare.
NYSHIP is a health insurance program for New York State workers, retirees and their dependents. Some local governments and quasi-governmental employers participate as well.
It’s your choice to have NYSHIP coverage through either The Empire Plan or a NYSHIP HMO.* These plans have different premiums, deductibles and coverages. The Empire Plan also offers non-network coverage, while NYSHIP HMOs do not.
* Participating Agencies can only have The Empire Plan.
Medicare is a federal health insurance program for people age 65 and over as well as those with certain medical conditions. Medicare offers two options for medical and hospital coverage:
- Part A and Part B (sometimes referred to as “original” Medicare). Your Medicare benefits are administered by the federal government. You have access to a nationwide provider network.
- Medicare Advantage (Part C). Your Medicare benefits are administered by an approved private health insurer. You must usually stay in your provider’s network.
These plans are all required to be “actuarially equivalent,” but they all have different premiums, deductibles and coverages.
Part D coverage under Medicare is for prescription drugs. This coverage can be either through a separate Part D plan or bundled with a Medicare Advantage plan. Original Medicare doesn’t include drug coverage.
NYSHIP Options
As a NYSHIP enrollee, you don’t choose your Medicare option independently of your NYSHIP plan. In fact, the NYSHIP option you choose is exactly what determines your Medicare coverage.
- If you have The Empire Plan, you can have Medicare Part A and B. When you sign up for these parts, NYSHIP automatically enrolls you in Empire Plan Medicare Rx, a Part D drug plan currently administered by SilverScript. You must remain enrolled in Empire Plan Medicare Rx to keep overall Empire Plan coverage.
- If you have a NYSHIP HMO, you can have its Medicare Advantage plan. You need to sign up for Part A and B first, after which your NYSHIP HMO will move you to its Medicare Advantage plan. All NYSHIP HMO Medicare Advantage plans include Part D drug coverage.
When You Must Enroll in Medicare
When you’re Medicare-primary, NYSHIP requires you to sign up for Medicare.
You and your NYSHIP dependents are typically Medicare-primary when you’re retired or otherwise not working and when each of you is Medicare-eligible.
If you don’t enroll in Medicare when Medicare-primary:
- Your overall health benefits may be reduced.
- Your NYSHIP coverage may be terminated.
If you’re Medicare-eligible but not Medicare-primary (i.e., still working), you don’t have to sign up for Medicare yet—but be sure Medicare coverage is in effect before you retire.
Exceptions apply for end-stage renal disease (ESRD) patients and domestic partners.
Enrolling in Medicare
You can enroll in Medicare online, by calling the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778) or by visiting your local Social Security Administration office.
To keep your NYSHIP coverage, sign up for Medicare Part A and Part B when eligible. If you have a NYSHIP HMO, it'll then move you to its Medicare Advantage plan. If you have The Empire Plan, you’ll be all set.
Medicare Plans That Terminate NYSHIP
Here’s what you need to be careful about: If you sign up for a non-NYSHIP Part C or Part D plan, your NYSHIP coverage will be terminated—no matter your NYSHIP plan option.
In rare exceptions, you or your covered dependent can have an outside Part D plan with The Empire Plan only:
- If you’re receiving assistance from Medicare’s Extra Help program for Part D coverage
- If you or your dependent are confined in a skilled nursing facility (since many skilled nursing facilities only accept specific Part D plans)
- If you or your dependent are disabled and enrolled in an approved Medicare Special Needs Plan
Call the Employee Benefits Division (EBD) at 518-457-5754 or 1-800-833-4344 for more information. You must submit supporting documentation to qualify.
—
For more information, see Medicare and NYSHIP. A more comprehensive Medicare and NYSHIP publication is also available.
