The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
PA16-09
PAEX16-09
TO: Health Benefits Administrators of Participating Agencies
FROM: Employee Benefits Division
SUBJECT: 2016 Dependent Eligibility Verification Audit Appeals and Reinstatement Processes
DATE: May 25, 2016
Health Management Systems, Inc. (HMS) has completed the NYSHIP Dependent Eligibility Verification Audit (DEVA) for Participating Agency enrollees and their covered dependents. Enrollees were required to provide proof of eligibility for their covered dependents by April 15, 2016 and were notified of a grace period which extended their reporting deadline to May 4, 2016.
Termination of Dependents
Unverified dependents were removed from NYSHIP coverage on May 23, 2016 and most terminations were effective January 1, 2016, as indicated in our previous DEVA memo. Note: Medicare primary dependents will be removed from NYSHIP coverage effective July 1, 2016, in accordance with CMS termination guidelines.
Agencies can review their transaction listings to identify enrollees who had dependents removed from their NYSHIP coverage as a result of the DEVA. Additionally, agencies will be able to run a new NYBEAS report which will list the dependents who were removed from NYSHIP coverage as a result of the DEVA. Refer to the section titled New NYBEAS Report: DEVA Terminations for more information.
Enrollee Communications
Enrollees received notice from HMS advising them whether or not their dependents were verified and indicated which dependents were deemed to be ineligible. Enrollees will also receive a termination of coverage letter for each dependent removed due to DEVA. Note: Medicare primary dependents have a July 1, 2016, termination date. It is important, to assure continuous coverage, that reinstatement is accomplished before July 1, 2016.
Samples of these letters are enclosed for your convenience.
90-Day Reinstatement Period
Enrollees requesting reinstatement must contact HMS by August 5, 2016, and provide HMS with the required eligibility documentation. If the enrollee is unsure what documents are needed or has additional questions, they should be referred to HMS at 1-855-893-8477.
The dependents of enrollees who provide appropriate documentation during this Reinstatement Period will be re-added to the enrollee’s policy effective the date of removal, thus ensuring continuous coverage.
Dependent reinstatements will be processed daily from May 22 through August 5, based upon information received from HMS.
NYBEAS Processing Limitations During Appeal and Reinstatement Period
During the 90-Day Reinstatement Period, HBAs will not be able to re-add dependents that were removed as a result of the DEVA. HBAs who attempt to do so will receive the following error message:
Transaction Denied – Dependent Deleted During DEVA
This transaction is not allowed, as the dependent was deleted as a result of the Dependent Eligibility Verification Audit (DEVA). Advise enrollee to immediately contact HMS, NYSHIP’s DEVA vendor, at 1-855-893-8477 for instructions regarding dependent reinstatements.
NYBEAS Processing After the Reinstatement Period
After the 90-Day Reinstatement Period has passed, HBAs will again be able to re-add DEVA removed dependents. HBAs must continue to obtain the appropriate documentation and proofs as outlined in Policy Memo 139 and will be asked to attest that the documentation was received. Dependents added after the reinstatement period will be added on a current basis and will be subject to NYSHIP late enrollment rules.
New NYBEAS Report: DEVA Terminations
Agencies will be able to run a report which lists the dependents that HMS determined to be ineligible for NYSHIP coverage and whose coverage was terminated. The report will identify the enrollee, the dependent whose coverage was terminated, the effective date of the termination of coverage, and the enrollee’s address.
As dependents are reinstated during the 90-Day Reinstatement Period, this report will be updated to reflect this information. In other words, if a dependent was reinstated to coverage, they will no longer appear on this report.
This report will be called BEA_DEVA_DEP_TERM. For instructions on how to run the DEVA Termination report (BEA_DEVA_DEP_TERM) refer to HBA Memo PA15-14 dated September 14, 2015.
An updated Run Control ID and HBA Report List and a sample of the output of this report is attached.
Agency Billing Statements Affected by DEVA Project
Agencies will receive a credit on the billing statement dated June 3, 2016, for enrollees who experienced a change from family to individual coverage retroactive to January 1, 2016, as a result of the DEVA project.
Any charges for subsequent reinstatements will be reflected in appropriate NYBEAS bill.