Department of Civil Service

New York State Health Insurance Program: Medicare Limiting Charges

In the New York State Health Insurance Program, 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 $1.4 billion a year.

Medicare is a federal health insurance program for disabled people and people aged 65 or older. When Empire Plan enrollees become eligible for Medicare, most of their medical expenses should be paid by Medicare and a portion of these expenses may be paid by the Empire Plan in accordance with established fee schedules and other requirements. However, when we examined selected medical claims paid by the Empire Plan during a six-year period on behalf of people who were eligible for Medicare, we found that the payments often exceeded the maximum amounts permitted by the established fee schedules and other requirements. We estimate that, during the six years we examined, these overpayments totaled more than $4.7 million. We recommend that the overpayments be recovered from the insurance company that processed the claims for the Empire Plan. We also recommend that future payments for Medicare beneficiaries be made in accordance with the established fee schedules and other requirements.

For a complete copy of Report 96-S-79 click here.
For a copy of the 90-day response click here.