Insurance carriers demand repayment of health benefits for ineligible dependents

By DEBORAH STAYMAN

Of the approximately 50,000 state

PS&T employees enrolled in the NYS Health Insurance Plan (NYSHIP), hundreds are receiving letters asking them to pay back medical benefits they received for dependents who were ineligible for coverage. As of April 14, a total of 2,275

PS&T dependents covered by the Empire Plan are deemed ineligible. And the timing couldn’t be

worse, as state employees are deprived of their raises and face threats of unpaid furloughs and lagged pay. Although the letters are going to just a

small percentage of members, some are being asked to repay sizeable sums. For instance, just 160 PS&T enrollees

are being dunned by Empire Blue Cross and Blue Shield (EBCBS) for hospitalization benefits paid for ineligible dependents. However, the total EBCBS is trying to recover from them is $428,571,

or an average of $2,679 per affected enrollee. Empire Plan medical benefits are provided by United Healthcare (UHC) and it’s seeking an average of $3,138 from the 627 PS&T enrollees it says received benefits for ineligible dependents. NYSHIP HMOs and GHP,

the dental insurer, also want the benefits for ineligible dependents repaid. They are all seeking

reimbursements for benefits going back to February 1, 2009. However, EyeMed has stated it will not

pursue reimbursement for vision benefits it paid for ineligible dependents. During the past year, the state

Department of Civil Service (DCS) conducted an eligibility audit to verify all NYSHIP enrollees’ covered dependents are, in fact, eligible for coverage. If no, or insufficient, proof was submitted by the enrollee, DCS terminated the dependent’s

coverage retroactive to February 1, 2009. The audit affected all enrollees with covered dependents, not just PS&T enrollees. If you are among those being asked to

reimburse the insurers for benefits to an ineligible dependent, the door is still open for you to appeal that ineligible status determination through DCS by calling 1-800-409-9059. However, before DCS will reinstate coverage, you must provide sufficient documentation to prove your dependent’s eligibility. Apparently, no claims were paid for

many of the ineligible dependents, either because no claims were submitted, or the claims were rejected by the insurers. NYSHIP’s enrollment system is designed to automatically end coverage when a dependent child reaches age 25. “While the audit process has been

challenging for some PEF members, the removal of truly ineligible dependents from coverage should help reduce the premiums for all enrollees,” said PEF President Ken Brynien.

Empire Plan enrollees may share in $350M legal settlement

If you are or were enrolled in the

Empire Plan, you might be eligible for part of a $350 million settlement of a class-action lawsuit over “reasonable and customary” charges for services and supplies. Empire Plan members who received

medical-surgical services from a non- participating provider between March 15, 1994, and November 18, 2009, may receive a notice in the mail concerning a class-action settlement between the American Medical Association (AMA) and United Healthcare (UHC). This nationwide settlement agreement resolves a class-action lawsuit filed on

MAKINGA POINT—PEF Executive Board MemberAlbertYasus speaks at the Region 8 Leadership Conference held in Saratoga SpringsApril 24.More than 100 people attended the event.Topics included implementation of workplace violence programs, hot issues in termination disciplines, understanding themerit systemand a panel discussion on leadership.

—Photo by FredMoody

www.pef.org The Communicator June 2010—Page 11

behalf of the AMA, health plan members, health care providers, and state medical societies regarding issues raised by the AMA concerning the reasonable and customary charges used by UHC to reimburse their health plan members for services performed by non-participating providers. You must file a claim form to receive

any share in the settlement. The deadline for submission of claim forms and any required supporting documentation is October 5, 2010. How much you might receive from the

settlement will depend, in part, on how many claims are received nationwide.

That also will affect how long it takes to pay the claims. You may file claims for services

received through the “final order and judgement date,” which will be established on or after September 13, 2010. All questions related to the settlement

or submission of forms should be directed to Berdon Claims Administration LLC. To view the notice and for more information regarding the settlement, please visit their website at www.berdonclaims.com.

– Lorraine Simpkins

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