New York City Office of Labor Relations
Health Benefits Program
nyc.gov/olr
Notification of Your Medicare Part B Enrollment Application
Complete this application to notify the Health Benefits Program that you have enrolled in Medicare Part B. Attach a copy
of your Medicare card to this application. Once you submit this application, you will be enrolled in the Medicare Part
B Reimbursement Program and will not have to resubmit an application every year.
Medicare Part B Reimbursement Program: The City of New York Health Benefits Program reimburses Medicare-eligible
retirees and their Medicare-eligible dependents for any Medicare Part B premiums (excluding any penalties) paid during
the calendar year, as long as the following conditions are met:
1. The Medicare-eligible retiree is receiving a pension from a City of New York pension system, and
2. The Medicare-eligible retiree and/or Medicare-eligible dependent(s) is covered under a City of New York health
plan, and
3. The health plan has the Medicare-eligible retiree and/or Medicare-eligible dependent(s) in Medicare status, and
4. The retiree is currently paying Medicare Part B premiums and is not receiving Medicare Part B reimbursement(s)
from any other source including Medicaid.
Reimbursement will be issued to you in the same ma
nner in which you receive your pension payments; if you receive
direct deposit of your pension payments, your reimbursement will also be made via direct deposit.
Reimbursement will occur in the spring of the year, following the close of the year in which you paid Medicare Part B
premiums. For example, any Medicare Part B premiums you paid in 2019, would be reimbursed to you in Spring 2020.
Section I: Retiree Information: YOU MUST PROVIDE A COPY OF YOUR MEDICARE CARD
Name (Last, First, MI): __________________________________________________ Social Security Number: _________________
Retirement Date: _______________________ Pension System:_________________________ Pension No.:____________________
Health Plan Name: ____________________________________________ Union/Welfare Fund:_____________________________
Date of Birth: ________________________________ Address: _______________________________________________________
Phone Number:_______________________________ _______________________________________________________
City
State Zip
Section II: Eligible Dependent Information: YOU MUST PROVIDE A COPY OF YOUR DEPENDENT’S MEDICARE CARD
1) Name (Last, First, MI):_________________________________________________ Social Security Number: ________________
Date of Birth: ________________________________ Address: _______________________________________________________
Phone Number:_______________________________ _______________________________________________________
City
State
Zip
2) Name (
Last, First, MI):_________________________________________________ Social Security Number: ________________
Date of Birth: ________________________________ Address: _______________________________________________________
Phone Number: _______________________________ _______________________________________________________
City State
Zip
Please submit this form, along with a copy of applicable
Medicare Card(s) electronically (do not mail)
to: https://nycemployeebenefits.leapfile.net
Please note: Queens Borough Public Library retirees, Brooklyn Public Library retirees, and City University of New York retirees should contact their agency’s benefits office directly.
Retired NYCTA civilians, with the exception of NYCTA Police Officers, must contact the Transit Authority.
Furthermore, the Medicare Part B/IRMMA reimbursement by the City of the Medicare Part B premiums actually paid to Medicare by retirees, pursuant to Section 12-126 of the
New York City Administrative Code, are excludable from the gross income of the retiree under Section 106 of the Internal Revenue Code.
