Department of Civil Service

New York State Health Insurance Program: Coordination of Medicare Coverage (Exhausted Benefits)

The Department of Civil Service administers health insurance programs for State and local government employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $1.6 billion a year. We examined the hospitalization claims paid over a 45-month period by the Empire Plan and determined that $642,684 in claims had already been paid by Medicare, a federal health insurance program for disabled people and people aged 65 or older. When Empire Plan enrollees become eligible for Medicare, their medical expenses should generally be paid by Medicare, unless their Medicare benefits are exhausted (as, for example, during a long hospital stay). In the duplicate payments we identified, enrollees' medical expenses were paid both before and after their Medicaid benefits had been exhausted. We recommend that the duplicate payments be recovered and action be taken to prevent such duplicate payments in the future.

For a complete copy of Report 96-S-56 click here.
For a copy of the associated follow-up report click here.
For a copy of the 90-day response click here.