EmblemHealth Settlement Over NYC Retiree Co-Pays: $53 Million Fund

At issue are $15 co-pays charged under the medical GHI Senior Care health plan that EmblemHealth administers for the City of New York. Retired city workers and a retiree organization filed suit claiming these co-pays were improperly introduced starting January 1, 2022, in violation of the contract between the City and Emblem. According to the lawsuit, the plan's Certificate of Insurance never mentioned co-pays and instead stated that Medicare would cover 80% of a covered service's cost, with Emblem covering the remaining 20%.

EmblemHealth and the City deny any wrongdoing and dispute all claims; no court has ruled on the merits. Rather than continue litigating, both sides agreed to settle to avoid further cost, risk, and delay.

The $53 million settlement is only proposed so far and still requires court approval. A Final Approval Hearing is set for March 24, 2027, and no payments will go out until after approval is finalized and any appeals are resolved.

You may qualify if you're a Medicare-eligible retired New York City employee, or a Medicare-eligible dependent, who was enrolled in the Emblem-administered GHI Senior Care plan anytime between January 1, 2022 and January 31, 2023. While everyone in that group counts as a Class Member, only those whose records show they were potentially charged at least one co-pay will receive a customized Claim Form, and only those individuals can actually claim money back.

To participate, you must complete and submit your customized Claim Form by the deadline, either online or by mail. Getting the form doesn't mean payment is automatic: you'll need to confirm which of the listed co-pays you actually paid and sign the affirmation at the bottom, since a signature is required for reimbursement. Depending on your situation, you may also need supporting documents, proof of payment (such as a receipt, cancelled check, bank or credit card statement, or a signed provider letter) if you're seeking full reimbursement, and proof of a legal name change or authority to act on someone else's behalf if applicable. If your form or documents are incomplete, the Claims Administrator may send a 'cure letter' asking you to fix or add information.

To file online, you'll need to log into the settlement portal using the unique Claimant ID printed on your Claim Form along with your Senior Care Member ID from your insurance card. Check the Notice and customized Claim Form mailed or emailed to you for these details, if you can't locate them, reach out to the Claims Administrator.