Department of Civil Service

New York State Health Insurance Program: Coordination of Medicare Coverage for Spouses and Dependents (Follow-Up Review)

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 about $1.6 billion a year. When Empire Plan enrollees, including covered spouses and dependents, become eligible for Medicare, their medical expenses should generally be paid by Medicare. In our prior audit report 96-S-62, we examined the hospitalization and major medical claims paid during 1995 by the Empire Plan on behalf of covered spouses and dependents who were eligible for Medicare and estimated that about $767,000 of these claims should have been paid by Medicare. We recommended that these payments be recovered from the appropriate parties and improvements be made in the procedures for identifying covered spouses and dependents who were eligible for Medicare. In our follow-up review, we found that only a small portion of the overpayments have been recovered and further improvements are needed in the procedures for identifying spouses and dependents who are eligible for Medicare.

For a complete copy of Report 98-F-56 click here.
For a copy of the 90-day response click here.