Department of Civil Service

New York State Health Insurance Program: Coordination of Medicare Coverage

Medicare is 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. We reviewed the hospitalization and major medical claims paid over a four-year period by the Empire Plan to people aged 65 or older and determined that about $12 million of these claims should have been paid by Medicare. We recommended that these payments be recovered from Medicare. We also recommended that improvements be made in the Empire Plan's procedures for identifying enrollees who are eligible for Medicare. If these improvements are not made, we estimate that the Empire Plan will continue to pay about $5.3 million a year for claims that should be paid by Medicare. 95-S-23