Results of Dependent Eligibility Audit
During the past year, the Department of Civil Service (DCS) conducted an eligibility audit to verify that any enrollee’s dependents covered under the New York State Health Insurance Program (NYSHIP) meet the state’s definition of an eligible dependent. If they were found to be ineligible, either because the enrollee failed to submit the required documentation or submitted incomplete documentation, DCS terminated the dependent’s coverage. Enrollees received a letter from NYSHIP advising them that coverage had been terminated for their ineligible dependent(s) retroactively to February 1, 2009.
| Members who disagree with the ineligible status determination of their dependent(s) may still pursue an appeal through DCS. DCS has established a special call center for this purpose. The toll-free number for the DCS call center is 1-800-409-9059. Before DCS will reinstate coverage, the member will have to provide DCS with the documentation required to prove the dependent’s eligibility. |
During the eligibility audit, DCS notified enrollees that any claims paid for a dependent while the dependent was ineligible would be the enrollee’s responsibility to pay. In other words, if a dependent’s coverage was terminated retroactively to 2/1/09, and the dependent’s coverage has not been reinstated, then the enrollee’s health plan will be requesting a refund from the enrollee for any payments made for services performed on or after 2/1/09.
As of 4/14/10, 2,275 covered dependents of PEF-represented enrollees were deemed ineligible. Of these dependents, 1,437 were deemed ineligible because no documentation of eligibility was received, and the documentation for the other 838 dependents was incomplete.
These tables indicate the number of PEF claimants who received refund request letters from the Empire Plan and from GHI Dental.
Regarding the Vision program, an analysis was made of potential recoveries from dependents removed during the eligibility audit and for the Vision program. The cost of recovering exceeded the expected recoveries so no claims recoveries will be pursued under the Vision program.
It appears that a significant portion of the ineligible dependents did not actually have claims paid. Most likely, employees did not ask their Health Benefit Administrators (HBAs) to terminate the coverage of their dependent children between 19 and 25 years old even though they knew their children were no longer eligible. The employees either didn’t submit claims for these children, or the insurers rejected their claims because the employee did not submit full-time student or disabled dependent documentation. The state’s enrollment system automatically terminates coverage when a dependent child reaches age 25.