Department of Civil Service

New York State Health Insurance Program: Coordination of Medicare Coverage for Spouses and Dependents

The Department of Civil Service administers health insurance programs for State and local government employees and their spouses and dependents. The primary such program is the Empire Plan, which provides services costing more than $1.6 billion a year.

Medicare is a federal health insurance program for disabled people and people aged 65 or older. When Empire Plan enrollees, including covered spouses and dependents, become eligible for Medicare, their medical expenses should generally be paid by Medicare. 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 $739,000 of these claims should have been paid by Medicare. We also identified about $28,000 in claims that could have been paid by Medicare, but were not, because of errors in records maintained by the Department of Civil Service. We recommend that these payments be recovered from the appropriate parties. We also recommend that improvements be made in the Empire Plan's procedures for identifying covered spouses and dependents who are eligible for Medicare.

For a complete copy of Report 96-S-62 click here.
For a copy of the associated follow-up report click here.
For a copy of the 90-day response click here.