Department of Civil Service

New York State Health Insurance Program: Coordination of Medicare Coverage for Exhausted Benefits (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. In our prior audit report 96-S-56, we examined the hospitalization claims paid over a 45- month period by the Empire Plan and determined that $642,684 in claims had already been paid by Medicare. When Empire Plan enrollees become eligible for Medicare, their medical expenses should generally be paid by Medicare, unless their Medicare benefits are exhausted (as, for example, during a long hospital stay). In the duplicate payments we identified, enrollees' medical expenses were paid both before and after their Medicare benefits had been exhausted. We recommended that the duplicate payments be recovered and action be taken to prevent such duplicate payments in the future. In our follow-up review, we found that these recommendations have been fully implemented.

For a complete copy of Report 98-F-16 click here.