Department of Civil Service

PA94-17

TO: Participating Agency Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: Medicare Secondary Payer Program- Data Match Project for the Years 1990 and 1991
DATE: November 21, 1994

In response to requests received at the PA Institutes, we are providing information on the Medicare Secondary Payer Data Match Project II for the tax years 1990 through 1991. This memorandum will give you sufficient information concerning the Empire Plan to complete certain sections of the Match Questionnaire or the Electronic Match Questionnaire (EMQ). Employers are urged to read the Instructions for Completing the Group Health Plan Report (included in the Data Match response packet) carefully before completing their report.

The Empire Plan is not a Multi-Employer Plan or a Multiple Employer Plan for purposes of Part I of the questionnaire. It is not a Multi-Employer Plan because it is not a "union" plan or health and welfare fund. It is not a Multiple Employer Plan because it is sponsored by only one employer, the State of New York.

In completing Part II of the questionnaire, use the following names and addresses for the Empire Plan:

Empire Plan, EBCIBS
New York State Service Center
P0 Box 11815
Albany, New York 12211-0815

Empire Plan, Met Life
CPO Box 1600
Kingston, New York 12401

Do not use the address of the Department of Civil Service as the address of the Empire Plan insurers.

The "Type of GHP" letter code for Blue Cross (EBC/BS) is "J"; the "Type of GHP" letter code for MetLife is "K."

Leave the GHP ID Number blank.

We are attaching PA 94-05 to this memorandum to assist you in handling recovery letters that you may receive as the Match enters the recovery stage next year.

Under legislation passed by Congress, Medicare is required to recover any claims payment it may have paid erroneously as primary insurer. An example of such a situation would be if Medicare paid as primary insurer for an active employee with health insurance benefits. The first phase of the recovery program was the information gathering phase in which employers were required to provide data on certain employee's service and health insurance coverage so that Medicare could identify recovery situations. The program is now in the recovery phase which seeks to actually recover the erroneously paid funds. According to law, the Medicare Secondary Payer (MSP) contractors seek to recover the funds first from an employer's insurer. If that effort fails, the MSP contractor seeks to recover the money directly from the employer. If you are receiving bills form an MSP contractor, it is because they have not been able to recover from an insurer.

The Employee Benefits Division of the New York State Department of Civil Service administers the Empire Plan which provides indemnity coverage to State government employees and retirees as well as employees and retirees of local governments that participate in the Empire Plan. However, we do not maintain employee data for local government participating agencies. When this Department receives a Medicare Recovery letter for an employee of a participating agency, we must return it to Medicare. We cannot determine whether or not the individual should receive Empire Plan primary benefits because this Department is not the employing agency. In these situations, therefore, we have no alternative but to advise Medicare to contact the employer to establish the order of benefit determination.

Recently, we have received numerous phone calls from localities requesting assistance with these Medicare Recovery letters. Therefore, we have developed the following guidelines to assist you with forwarding the claims to the appropriate destination. These instructions are for "Type of MSP Situations- Working Age and Disability" listed on the MSP Summary Data Sheet/Summary of Medicare Reimbursement.

1. Confirm the employment status of the individual on the date(s) of medical service. If the individual is the spouse of an employee, confirm the employment status of your employee on the date(s) of medical service.
2. 2Verify that the Central Enrollment File has the correct status of your employee on the date(s) of service and that coverage was in effect for the employee and/or dependent on the date(s) of service. If the employment status is incorrect on the Central Enrollment File for the date(s) of service, you must write to the Employee Benefits Division to correct the information.
3. If your employee or the spouse of your employee was eligible to receive benefits as an active employee and should have received Empire Plan Primary benefits on the date(s) of service, you must confirm this information in writing and forward the MSP Summary Data Sheet/Summary of Medicare Reimbursement and Claims Facsimiles to the appropriate Empire Plan insurance carriers and advise Medicare in writing of your action. The claim documentation submitted to the insurance carriers must be sufficient for them to process the charges in the same manner as a claim is usually processed.

Empire Blue Cross Blue Shield
New York State Service Center
P.O. Box 11815
Albany, New York 12211-0815
Attention Mr. Joseph Newell

Metropolitan Life Insurance Company
C.P.O. Box 1600
Kingston, New York 12401
Attention Ms. Sharon Holsapple

4. If your employee or the spouse of your employee was eligible for benefits as a retiree of your agency on the date(s) of service, you must provide this information to Medicare and return the claims to them advising that no further action is required by the Empire Plan insurance carriers.

Please call your processor at (518) 457-5766 pr (518) 457-5847 if you have any questions.