Beginning April 1, 2022, City of New York is automatically enrolling Medicare-eligible retirees, along with their eligible dependents, into a premium-free plan: the NYC Medicare Advantage Plus Plan.

Important information for those who choose not to be enrolled in the NYC Medicare Advantage Plus Plan

If you choose to opt out of the NYC Medicare Advantage Plus Plan, you are acknowledging that you agree to pay an additional plan premium to remain in your current retiree health plan for 2022, the specifics of which are available on the Health Benefits Program website at https://www1.nyc.gov/site/olr/health/summaryofplans/health-ratechart.page.

You have a new opportunity to choose between the NYC Medicare Advantage Plus Plan and your current plan from April 1, 2022 until June 30, 2022. If you are enrolled in the NYC Medicare Advantage Plus Plan on April 1, 2022, you can give it a try for up to three months, and if you want to return to your old plan, you will be able to do so during that time period. On the other hand, if you previously opted out of the NYC Medicare Advantage Plus Plan (on or before March 31, 2022) to stay in your current plan, and subsequently would like to enroll in the NYC Medicare Advantage Plus plan, you may do so from April 1, 2022 until June 30, 2022.

You also acknowledge that:

• You can only opt out of the NYC Medicare Advantage Plus in order to remain in your current retiree health plan for 2022.

To opt out of the NYC Medicare Advantage Plus Plan and remain in your current retiree health plan for 2022, please complete and sign the form on the next page no later than March 31, 2022. If you do not submit the form on-line, you can also return the opt-out form from your pre-enrollment guide via mail, fax or email but it must be postmarked no later than March 31, 2022. Each Medicare-eligible participant (i.e. retiree, spouse or dependent) must complete a separate opt-out form.

DO NOT complete this opt-out form if you would like to be enrolled in the NYC Medicare Advantage Plus Plan. No action is required by you. You will automatically be enrolled in the NYC Medicare Advantage Plus Plan effective April 1, 2022.

By your signature on the next page, you acknowledge that you do not wish to participate in the NYC Medicare Advantage Plus Plan and hereby elect to continue participation in your current plan option for 2022.

If you wish to cease your City of New York retiree health coverage altogether, complete the NYC Health Benefits Application/Change Form available on the Health Benefits Program website at: https://www1.nyc.gov/site/olr/health/retiree/health-retiree-forms-and-downloads.page. Please be advised, you will NOT be eligible for the reimbursement by the City of the Medicare Part B premium if your cease City of New York retiree health coverage. You may, however, re-enroll in City retiree health benefits during the next Transfer Period.

NYC Medicare Advantage Plus Plan Opt-Out Form

Complete this form if you wish to Opt Out of the NYC Medicare Advantage Plus Plan.

This section should be completed by the person opting out of the NYC Medicare Advantage Plus Plan:

 

Complete this section with the City Retiree’s information:

 

By providing my name below as an electronic signature, I elect to continue participation in my current retiree health plan, and acknowledge that I will pay an additional plan premium per month to remain in my current retiree health plan, the specifics for which are available on the Health Benefits Program website at https://www1.nyc.gov/site/olr/health/summaryofplans/health-ratechart.page.

Signature of Participant Opting Out

Date: 01/23/2022

Please re-type your name in the spaces below to confirm your signature.

Date: 01/23/2022