NYC Health Benefits Program

Important Notice

The Health Benefits Retiree client service walk-in center is closed. Due to the closure of the office, if you mailed or faxed forms or correspondence March 11, 2020 or after, we cannot access or process that form. Please resubmit your documents as follows:

1) Forms/documents can submitted electronically using the following link:

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.

Also, please do not send forms or documents via express mail.  The office is closed and the package cannot be accepted.

2) Inquiries and questions can be emailed to - do not send forms through email (see #1 above)

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

4) 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

Fall 2020 Retiree Transfer Period Notice and Form - Please do not complete this form if you are not making any changes to your health plan/coverage.

Health Benefits Summary Plan Description (SPD)

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 - July 2020

Young Adult Option Through Age 29 (NYS Law Chapter 240) - July 2020

Domestic Partner Enrollment Information


Medicare Part B Reimbursement

Medicare Part B Reimbursement Q&A

Medicare Part B Reimbursement Program Application

2019 Medicare Part B Reimbursement Differential Request Form

2018 Medicare Part B Reimbursement Differential Request Form

2017 Medicare Part B Reimbursement Differential Request Form


IRMAA Medicare Part B Reimbursement

IRMAA Medicare Part B Reimbursement Application (for 2019, 2018 & 2017) - Reimbursement for 2019 will be issued in October 2020

IRMAA Medicare Part B Reimbursement Application (2016) - This form must be submitted by December 31, 2020


Creditable Coverage Notice (Employees Age 65 or Over)

Form 1054 (For Use By Authorized Personnel Only)

Health Insurance Marketplace (Exchange) Notice