Tiaa-Cref Medicare-Eligible Retirees Application For Medicare Part B Premium Reimbursement Form Page 2
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1
2INSTRUCTIONS
Application for Members of TIAA-CREF Pension System
For Reimbursement of Medicare Medical Insurance (Part B) Premiums
A. ELIGIBILITY
During those months for which a refund is requested, the retiree must have been:
1. Receiving a Lifetime Income Annuity from TIAA-CREF to satisfy standard health care premium deductions
(Interest Only, Minimum Distribution and Transfer Pay Out Annuity are not considered settlement options
used to satisfy your health care premium deductions); and
2. Enrolled in and paying premiums for a New York City Health Benefits Plan as the contract holder (premiums
must be deducted from your monthly TIAA-CREF pension check); and
3. Enrolled in and paying premiums for Medicare Medical Insurance (Part B).
B. SPOUSE/DOMESTIC PARTNER OR DISABLED CHILDREN OF RETIREE
If a spouse/domestic partner or a disabled dependent is enrolled in Medicare Medical Insurance (Part B) and is
covered under an eligible retiree’s New York City health plan, Medicare premiums may be reimbursed to the retiree.
An application for reimbursement must be completed when adding a spouse/domestic partner and/or disabled child.
C. HEALTH INSURANCE COVERAGE FOR DISABLED DEPENDENT CHILDREN
Unmarried children age 26 and older who cannot support themselves because of a disability, including mental illness,
developmental disability, mental retardation or physical handicap are eligible for coverage if the disability occurred
before the age at which the dependent coverage would otherwise terminate. You must provide medical evidence of
the disability.
D. SURVIVORS OF RETIREES
Unless a survivor is retired from The City University or a New York City agency, and is eligible for and enrolls in the
New York City Health Insurance Program as the contract holder, he/she is not eligible for reimbursement for any
month beyond the period of the deceased retiree’s eligibility. As a reminder, health insurance benefits for survivors of
retirees ceases with the death of the retiree, however, survivor dependents may be eligible for continuation of
coverage under COBRA. Also, refer to the PSC-CUNY Welfare Fund website
for
information on continuation of coverage under COBRA for supplemental benefits.
E. GENERAL INFORMATION
The City of New York Office of Labor Relations (OLR) – Health Benefits Program processes Medicare Part
B reimbursements annually, usually in August, for the previous year at the standard monthly rate. The first
payment year will be the year after your retirement date, provided you are Medicare-eligible; or the year
after you become Medicare-eligible. You do not need to apply annually for this benefit.
IRMAA – If you and eligible dependents pay more than the standard monthly rate, you must apply annually
directly through OLR to obtain full reimbursement of Medicare Part B premiums. Claims must be submitted
to OLR following receipt of the standard monthly premium reimbursement. Forms and information regarding
IRMAA can be found at:
Your Medicare Reimbursement check will be mailed to the address that appears on your application. Please
notify this office of your change in address by completing a Change of Address form. Forms can be obtained
by contacting University Benefits Office at 646.313.3281. You do not need to apply for reimbursement each
year, however, periodically we will mail out a recertification form requesting you review and update your
personal information.
Medicare does not pay for hospital or other medical expenses outside the U.S. If you plan to travel abroad,
consider obtaining additional insurance. Currently, the Health Benefits Program does not process
reimbursement for retirees residing outside the US territory.
The University Benefits Office should be notified of any changes due to death of the retiree, spouse/domestic
partner or dependent, changes in marital status or any other change which may impact payment of
reimbursement for premiums of Medicare Part B.
A beneficiary is a person, other than yourself, who has been designated by you, to be the administrator or
executor of your estate. This beneficiary will be notified of any final Medicare Part B Premium
reimbursement upon your death. However, if your spouse/domestic partner is covered as a dependent under
your New York City health plan, final payments will be paid to your spouse/domestic partner. To obtain any
final payments your beneficiary or surviving spouse/domestic partner must complete and submit a notarized
Affidavit, along with a copy of the death certificate and a copy of the will or court document indicating who is
the sole beneficiary, the executor/executrix or the administrator/administratix of your Estate.
When writing to this office about your Medicare Part B reimbursement, please include: Name, last four digits
of Social Security Number, Medicare Number for yourself and your eligible dependent(s), Retirement System
and number, date of retirement, date of birth for yourself and dependent(s), college from which you retired,
home telephone number and the calendar year about which you are inquiring.
The City University of New York – University Employee Benefits Office
th
395 Hudson Street, 5
Floor, New York, NY 10014
formsmedicare part B applic instruct / Rev6/13
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