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 will remain in your current retiree health plan, 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 also acknowledge that:

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

To opt out of the NYC Medicare Advantage Plus Plan and remain in your current retiree health plan, please complete and sign the form below. 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. 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.

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.

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, 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: 07/05/2022

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

Date: 07/05/2022