Medicare and NYSHIP

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.

Eligibility

There are a few ways you can become Medicare-eligible:

• When you turn 65, you will become Medicare-eligible on the first of your birth month
  • If your birthday falls on the first of the month, you will become Medicare-eligible the first of the month before your birth month
• After receiving Social Security Disability Insurance (SSDI) benefits for 24 months, you will become Medicare-eligible the first of the following month
• After receiving any SSDI benefits for amyotrophic lateral sclerosis (ALS), you will become Medicare-eligible the first of the following month
• After completing a three-month Medicare waiting period after a diagnosis of end-stage renal disease (ESRD), you will become Medicare-eligible the first of the following month (this waiting period is sometimes waived)

Work requirements may apply. Eligibility rules differ for non–U.S. citizens. 

If you have NYSHIP through COBRA, that coverage ends when you become Medicare-eligible.

Being eligible for Medicare does not automatically make Medicare your primary coverage. Learn about becoming Medicare-primary in the Who Pays First? section.

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.

Who Pays First?

In many situations, NYSHIP will remain primary for you and your dependents until you retire. 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.

Becoming Medicare-Primary

Become Medicare-primary means that Medicare coverage will pay for care first, while your NYSHIP coverage becomes secondary.

In most cases, it will depend on your employment status:

• Before you retire, NYSHIP is the main coverage for you and your dependents. This applies even if they are eligible for Medicare.
  • The only exceptions are if someone has ESRD or ALS or if a domestic partner dependent is over 65. In these situations, Medicare will become the primary coverage for these specific individuals (and not the whole family).
• When you retire, anyone on your NYSHIP plan who is eligible for Medicare will have Medicare as their primary coverage. This change takes effect on the first day of the month after active benefits end (usually 28 days after retirement). 
• After you retire, anyone on your NYSHIP plan who becomes eligible for Medicare will be covered by Medicare that same day (except those in an ESRD coordination period).

Once someone becomes Medicare-primary, 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.

How To Apply

Medicare enrollment happens automatically if you have received 24 months of SSDI. It also starts if you're receiving Social Security benefits four months before turning 65.

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