Department of Civil Service

New York State Health Insurance Program: Payments for Ineligible Claimants

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 $1.6 billion a year. We examined selected claims paid by the Empire Plan for prescription drug coverage over a three-year period to determine whether any claims were paid on behalf of individuals who were not enrolled in the Plan at the time the services were provided. We identified a total of about $867,000 in such overpayments, most of which were made because of delays by employers in communicating changes in enrollment information to the Empire Plan's insurance carrier. We recommend that the overpayments be recovered by the insurance carrier and remitted to the State.

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