Objective

To assess the extent of implementation of the two recommendations included in our initial audit report, New York State Health Insurance Program: Empire Plan Members With Dual Family Coverage (Report 2019-S-23).

About the Program

The New York State Health Insurance Program (NYSHIP), administered by the Department of Civil Service (Civil Service), covers over 1.2 million active and retired State and participating organizations’ employees and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP, providing coverage to about 1.1 million members.  

NYSHIP offers several coverage options, including Individual and Family coverage. The State does not permit two Family coverages for its employees; if a member and their spouse/domestic partner are both eligible to enroll in NYSHIP, only one may elect Family coverage (the other may either elect lower-cost Individual coverage or waive coverage). Participating organizations (such as local government entities and public authorities), however, may allow for dual Family coverage, whereby each employee has Family coverage.

We issued our initial audit report on January 7, 2021. The audit objective was to determine whether participating organizations and members were paying excessively for dual Empire Plan Family coverage. The audit covered the period January 1, 2014 through September 30, 2019. The audit concluded there were 696 employees and retirees of participating organizations who had dual Family coverage at a total cost to the members and participating organizations of $39,777,772 for the second Family coverage. The audit found that participating organizations may be unaware that an employee has dual Family coverage because they do not have information to determine if a member is a dependent on another NYSHIP policy with the State or a different participating organization.

Key Findings

While Civil Service officials addressed the issues identified in the initial audit, officials cited Health Insurance Portability and Accountability Act (HIPAA) as a limitation to more effective information sharing with participating organizations regarding dual Family coverage. However, in the initial audit, we communicated HIPAA exceptions that allow for certain information sharing and we encourage officials to reconsider those exceptions. Of the report’s two recommendations, both were implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in the follow-up report.