health-retiree-forms-and-downloads

Office of Labor Relations


EmployeeNon-Med RetireeRetireePlans & Rates

Health Benefits Videos
Forms and Downloads
Responsibilities & Health Benefits Assistance
Choosing a Health Plan
Enrollment
Changes in Status
Effective Dates of Coverage
Health Plan Premiums
Medicare Part B & IRMAA
Coverage for Medicare-Eligible Retirees
Termination and Reinstatement
COBRA
Special Continuation of Coverage
Disability Benefits
Contact the Health Benefits Program

Health Benefits Videos

Forms and Downloads

Responsibilities & Health Benefits Assistance

Choosing a Health Plan

Enrollment

Changes in Status

Effective Dates of Coverage

Health Plan Premiums

Medicare Part B & IRMAA

Coverage for Medicare-Eligible Retirees

Termination and Reinstatement

COBRA

Special Continuation of Coverage

Disability Benefits

Contact the Health Benefits Program


NYC Health Benefits Program

Important Notice

The Health Benefits Retiree client service walk-in center is closed. Please resubmit your documents as follows:

1) Forms/documents can be submitted electronically using the following link: https://nycemployeebenefits.leapfile.net

For detailed instructions on how to submit your form/document securely through LeapFile and to view a short video, click here.

Please do not submit your form/document more than once. This will only delay processing.

You will immediately receive notification stating "Success! Your file has been received" upon completion of your document upload. You will not receive a separate email confirmation.

Please allow 30-45 days from the day you submit your document(s) for them to be processed. Coverage will be retroactive to the effective date of retirement.

2) Forms and documents can be mailed to:

NYC Office of Labor Relations
Health Benefits Program
22 Cortlandt Street, 12th Floor
New York, NY 10007

3) Inquiries and questions can be emailed to healthbenefits@olr.nyc.gov - do not send forms through email (see #1 and #2 above)

4) For questions regarding the PICA prescription drug benefit program please call 1-800-467-2006.

5) If you are a HIP-HMO member turning 65 or on Medicare due to a disability, please contact HIP at (800) 447-9169 to enroll over the phone. Please identify yourself as a City of New York retiree or dependent of a retiree. For all other members enrolled in a HMO plan, please contact your health plan at the customer service numbers on the back of your ID card.

Please check our website periodically for updates.

Health Benefits Forms & Downloads

Health Benefits Summary Plan Description (SPD)

Retiree Health Benefits Application/Change Form (Not for use by NYCAPS Agencies)

Health Plan Rate Chart for Retirees

Retiree Change of Address Form

COBRA Form, Notice of Rights and COBRA Rates

Young Adult Option Through Age 29 (NYS Law Chapter 240)

Dependent Eligibility Required Documentation (DEVA)

Dependent Eligibility Required Documentation (DEVA) FAQs

Domestic Partner Enrollment Information

Medicare Part B Reimbursement

Medicare Part B Reimbursement Q&A

Medicare Part B Reimbursement Program Application

2023 Medicare Part B Reimbursement - The reimbursement for the standard Medicare Part B was $1,978.80. Any premiums paid above the standard amount should be submitted using the IRMAA 2023 Application.

2022 Medicare Part B Reimbursement - The reimbursement for the standard Medicare Part B was $2,041.20. Any premiums paid above the standard amount should be submitted using the IRMAA 2022 Application.

2021 Medicare Part B Reimbursement - The reimbursement for the standard Medicare Part B was $1,782.00. Any premiums paid above the standard amount should be submitted using the IRMAA 2021 Application.

IRMAA Medicare Part B Reimbursement

Important - Please do not submit your application more than once. Submitting your application multiple times or ways will only delay the processing time. You will receive a confirmation letter in the mail 4-6 weeks from the date you submit your application.

The 2023 IRMAA reimbursement payment was issued in October 2024. Applications for the 2024 IRMAA reimbursement payment will be available in May 2025.

IRMAA Medicare Part B Reimbursement Application (for 2023, 2022, 2021)

IRMAA Medicare Part B Reimbursement Application (for 2022, 2021, 2020)

Creditable Coverage Notice (Employees Age 65 or Over)

Form 1054 (For Use By Authorized Personnel Only)

Health Insurance Marketplace (Exchange) Notice