Turning 65 on the Essential Plan or a NY State of Health plan
If your coverage comes through NY State of Health, turning 65 means moving to Medicare, and the handover is not automatic in the way people expect. Here is what ends, when, and what you have to do yourself.
The Essential Plan is for New Yorkers aged 19 to 64, so it ends when you turn 65: NY State of Health sends a notice and refers you to your county's social services office, which checks whether you qualify for Medicaid another way. A Qualified Health Plan bought through NY State of Health doesn't end on its own, but once you're eligible for premium-free Part A you can no longer get the premium tax credit, so you'd pay full price or pay the credit back at tax time. Either way, the step that matters is signing up for Medicare in your Initial Enrollment Period, the seven months around your 65th birthday, so there is no gap and no late penalty.
Which NY State of Health coverage do you have?
NY State of Health is New York's own marketplace. What happens at 65 depends on which of its three programs you're in, so check your latest notice or your account before anything else:
- Essential Plan: $0 premium, no deductible. NY State of Health lists it for residents aged 19 to 64, so it ends at 65.
- A Qualified Health Plan, often with a premium tax credit. It doesn't end at 65 on its own; you end it.
- Medicaid through NY State of Health. At 65 the case moves to your county's department of social services.
On the Essential Plan
The state's instructions to county social services departments describe the handover. Each month NY State of Health identifies Essential Plan and Medicaid members who are 65 or turning 65 within about 45 days, sends them a notice that they are no longer eligible through NY State of Health because of their age, and refers them to the county. Coverage generally ends at the end of the month after the month you're referred. The county then looks at whether you qualify for Medicaid under the rules for people 65 and older.
The notice is not a Medicare application. Social Security handles that, and the timing is yours to manage: apply in the three months before the month you turn 65 and Medicare starts on the first of your birthday month, so it is in place before the Essential Plan ends. That instruction dates from 2016; the dates on your own notice are the ones that count.
On a Qualified Health Plan
A Marketplace plan keeps running after Medicare starts, and that's the trap. Once you're eligible for premium-free Part A, you can't get the premium tax credit or the cost-sharing savings any more; the plan would cost its full price. If the credit keeps being applied because nobody told NY State of Health, you'll have to pay it back when you file your federal taxes.
So the order is: sign up for Medicare, choose how you'll fill its gaps (a Medigap policy with a Part D plan, or a Medicare Advantage plan), then report your Medicare start date to NY State of Health so the Marketplace plan ends when Medicare begins. If anyone else in your household stays on the plan, make sure their coverage is confirmed when you update the account.
On Medicaid through NY State of Health
At 65 your case moves to the county, which reviews eligibility under the rules for people 65 and older. New York requires Medicaid members who are turning 65, or who are already 65, to apply for Medicare when Medicaid can pay their Medicare premiums, and you may be asked for your Social Security award letter or online confirmation as proof. With both programs, Medicare pays first and Medicaid second, and you may qualify for a plan built for people with both (a D-SNP).
Don't miss your Initial Enrollment Period
Your first chance to sign up for Medicare runs for seven months: the three months before the month you turn 65, that month, and the three months after. NY State of Health coverage is not coverage from a current employer, so it doesn't give you the later sign-up window that people still working have. If you miss your Initial Enrollment Period, you may have to wait to sign up and pay late-enrollment penalties that last. The full timeline and the steps are in the turning-65 checklist.
Help with the costs
If you were on the Essential Plan, your income was within its limits, and Medicare's premiums and deductibles can be a real change. Before you choose a plan, check the Medicare Savings Program (it can pay the Part B premium, and New York has no asset test), Extra Help for Part D, and EPIC for prescriptions. They change which plan makes sense.
Three months before your 65th birthday month
- Apply for Medicare with Social Security (online at ssa.gov/medicare or 1-800-772-1213).
- Check whether you qualify for the Medicare Savings Program, Extra Help or EPIC.
- Compare Medigap with Part D against Medicare Advantage for your doctors and prescriptions.
- Watch for the NY State of Health notice; on a Qualified Health Plan, report your Medicare start date so the plan ends when Medicare begins.
Free help
NY State of Health answers questions about your current coverage at 1-855-355-5777. HIICAP, New York's free Medicare counselling program, is at 1-800-701-0501. I help with the Medicare side from anywhere in New York by phone or video, how that works, and there is no fee for Medicare plan help.
I'm also a certified NY State of Health broker, so I can help with both sides of the move: updating your NY State of Health account and ending the plan when Medicare starts, and choosing and enrolling in Medicare coverage. NY State of Health lists certified brokers among the free ways to get enrollment help.
- Essential Plan information (NY State of Health)
- GIS 16 MA/004: Referrals from NY State of Health to local departments of social services for individuals who turn 65 (NYS Department of Health, effective January 1, 2016)
- You must apply for Medicare (NYS Department of Health, Medicaid)
- Changing from Marketplace to Medicare (HealthCare.gov)
- Medicare and the Marketplace (HealthCare.gov)
We do not offer every plan available in your area. Currently we represent 11 organizations which offer 63 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Insurers' legal names and home offices: carriers page.
Common questions
Short answers to what people ask before they call.
Does the Essential Plan continue after I turn 65?
No. NY State of Health lists the Essential Plan for people aged 19 to 64. Under the state's instructions to counties, NY State of Health identifies members who are turning 65, sends a notice that they are no longer eligible through NY State of Health, and refers them to the county department of social services; coverage generally ends at the end of the month after that referral. Sign up for Medicare in your Initial Enrollment Period so it starts when the Essential Plan stops.
Can I keep my NY State of Health Qualified Health Plan when Medicare starts?
You can, but it rarely makes sense. Once you're eligible for premium-free Medicare Part A, you can't get the premium tax credit or cost-sharing savings on a Marketplace plan, so you would pay full price. If you keep receiving the tax credit, you'll have to pay it back when you file your federal taxes. Report your Medicare start date to NY State of Health so the plan ends when Medicare begins.
I have Medicaid through NY State of Health. What happens at 65?
NY State of Health refers you to your county's department of social services, which reviews whether you still qualify for Medicaid under the rules for people 65 and older. New York requires Medicaid members who are turning 65, or are 65 and older, to apply for Medicare when Medicaid can pay their Medicare premiums, and you may be asked for proof that you applied. With both, Medicare pays first and Medicaid second.
My income is low. Will Medicare cost me more than the Essential Plan did?
It can, which is why the cost-help programs matter. The Medicare Savings Program can pay the Part B premium, Extra Help lowers Part D costs, and EPIC helps with prescriptions; New York's Medicare Savings Program has no asset test. Check them before you choose a plan.
Turning 65 on a NY State of Health plan?
Send me your birthday month and the plan you have now. As a certified NY State of Health broker and Medicare agent, I can handle both sides: the Medicare dates, what ends when, and help with the costs. No fee.