Department of Civil Service

New York State Health Insurance Program: Coordination of Workers' Compensation Hospitalization Coverage

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. In certain circumstances, the people covered by the Empire Plan may also be covered by other health insurers. In such circumstances, any claims covered by the other insurers should be paid by these insurers rather than by the Empire Plan. For example, as required by State law, employees in New York receive hospitalization coverage from their employers for work-related injuries or illnesses. Therefore, work-related hospitalization claims should not be paid by the Empire Plan. We found that the procedures used by the Empire Plan to identify work-related hospitalization claims are generally adequate. When such claims are identified, and payment has already been made by the Empire Plan, the payment is recovered from the appropriate insurer by a contractor of the Empire Plan. However, we noted that about $565,000 in recovered payments were not promptly returned to the State by the contractor.

For a complete copy of 95-S-124 click here.
For a copy of the associated follow-up report click here.
For a copy of the 90-day response click here.