505 THIRD PARTY LIABILITY ( TPL ) AND RECOVERY
A Medicaid recipient may have a third party that is available or required to provide direct services or payment of their medical care. A Medicaid recipient is required to assign to the state their right to their medical care and cooperate in obtaining or identifying any health resource available. Assignment is automatic upon application. The assignment ends when Medicaid ends. Adult applicants and recipients may be denied or terminated from Medicaid for failure to assign rights or cooperate, as specified in this section.
By law, the state is required to maximize all third party health care sources to the fullest extent possible before Medicaid will pay for services. Medicaid is the payer of last resort, except for the U.S. Public Health Service (Alaska Area Native Health Service (AANHS) or Indian Health Service ( IHS ). Persons eligible for Medicaid and AANHS have the option to choose between AANHS facilities and private health care providers for all medical services covered under Alaska Medicaid.
The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). The regular State of Alaska FMAP is 50% but certain groups receive a higher reimbursement so it is important to make sure individuals receive Medicaid in the correct category, with the correct Medicaid subtype. Alaska can receive a FMAP of 100% for individuals who are eligible for IHS so it is required that IHS eligibility be coded in the eligibility system(s) so that the State of Alaska can be fully reimbursed for these Medicaid expenditures.
Note:
When a client is IHS eligible,
the information must be populated
in ARIES under IHS Details and/or in EIS on the MERI
screen.
Medicare is also a third party resource. Applicants and recipients who appear to be Medicare eligible must pursue Medicare enrollment to become or remain eligible for Medicaid. See Subsection 505-C for information about exceptions for children. See Section 506-A for information about Medicare eligibility. See Section 506-B for information about Medicare enrollment.
The Division of Health Care Services ( DHCS ) edits medical claims submitted for payment which indicate that services have been delivered related to an accident or injury. Their TPL Unit develops this information and acts as a clearinghouse for all reports of Third Party Resources (TPR) or Third Party Liability ( TPL ), making referrals to the appropriate office or agency.
Indemnity Policy: Insurance which provides payment directly to the policyholder under certain conditions. Indemnity policies are a potential third party resource, which are subject to the assignment of rights provisions if the benefits payable are designated for medical care or can be used for that purpose. There are many variations in this type of policy. The caseworker must examine each policy to determine the type of benefit it provides and the purposes for which it can be used. If not a third party resource, the proceeds from this type of policy are usually considered income.
Medical Support: Payment of the costs of medical care ordered by a court or administrative process established under state law.
Private Insurer: A commercial insurance company offering health or casualty insurance to individuals or groups.
505 B. WHAT IS A THIRD PARTY RESOURCE ( TPR )
A third party resource is an entity, individual, or program that is, or may be, liable to pay all or part of a recipient's health care. Third parties include, but are not limited to:
Private or group health insurance, including Medicare;
Pre-paid Medical plans;
Employment-related health insurance;
Indemnity policies;
Medical support from an absent parent;
Self-insured and self-funded medical plans, or trusts;
Auto or homeowner liability insurance;
Tenant or landlord insurance;
Court judgments or settlements from a liability insurer, malpractice, wrongful injury, or civil assault lawsuit;
Workers’ compensation;
First party probate-estate recoveries;
Note:
Since Long Term Care insurance is not a valid type on the Medical Resource
Information (MERI) Screen,
when a Medicaid eligible individual has a Long Term Care Insurance policy,
caseworkers must email the policy information to the TPL
unit at DMATPL@Alaska.gov.
If the Long Term Care payments are going directly to the client, they are
counted as unearned income and used to determine COCA.
If the client is determined eligible for Medicaid, the caseworker
must case note the information and send an email to the TPL unit.
If the payments are going directly to the facility, the caseworker only
needs to case note the information and send an email to the TPL unit as Long Term Care payments
made directly to the facility do not count as income to the client.
505 C. APPLICANT / RECIPIENT RESPONSIBILITY
An applicant or recipient must:
Provide all available information about any third party resources and must inform their caseworker of any changes;
Assign his/her rights (and the rights of any other eligible individuals on whose behalf he/she has legal authority under state law to assign such rights) to medical support and to payment for medical care from any third party;
Cooperate in establishing paternity and obtaining medical support and payments;
Cooperate, in the absence of good cause, in providing information to assist the state in pursuing any liable third party;
Except for poverty level pregnant women, cooperate in establishing paternity (CSSD Child Support Services Division) and obtaining medical support; and
6. Provide verification of TPR/TPL termination.
Note:
A pregnant woman must cooperate in identifying and providing information
in pursuing third parties
( TPR ) who may
be liable to pay for medical care and services, unless good cause is established.
Cooperation with third party recovery is required from all applicants and recipients of Medicaid. However, a child is never penalized for the non-cooperation of a parent or other person who may be applying for them.
505 D. INDICATORS OF A POTENTIAL THIRD PARTY RESOURCE
During the intake process, the following indicators may represent potential third party resources:
1. Age
An applicant over age 65 is usually eligible for Medicare coverage. A student may have insurance available through the school they attend. A minor child may also be covered through an absent parent.
2. Death
An application on behalf of a deceased person should be examined for last illness coverage through any life insurance policies.
3. Income
Certain income sources are indicators of possible health insurance coverage:
Railroad Retirement Benefits and Social Security Retirement or Disability indicates eligibility for Medicare.
Long Shore and Harbor Workers Compensation (LHWC) and Workers' Compensation (WC) - employees who suffer work-related accidents or injuries must file for benefits to compensate for incurred medical expenses and lost income. Payment for medical expenses may be a lump sum award.
Black Lung Benefits payable under the Coal Mine Workers' Compensation Program are awarded on a diagnosis of pneumoconiosis. Payments are made monthly and medical expenses are paid as incurred.
Child Support Payment from an absent parent strongly indicates potential medical support for a child. An absent parent may be required by court order to provide health insurance coverage for the child as well as cash payments. If the absent parent is employed, with health insurance available through that employment, CSSD is required by federal law to obtain a court order for health insurance coverage for the child.
Earned Income indicates that health insurance may be available through employment. This may be the case with individuals receiving Transitional Medicaid coverage.
4. Work History
A look at work history may indicate eligibility for cash and medical benefits described above. Previous military service, or an absent parent on active duty or retired from the military, suggests the potential for VA Department of Veterans Affairs or TRICARE Standard coverage.
5. Monthly Expense
A look at work expenses may show that the applicant pays health insurance premiums.
6. Disability Information
If a disability is indicated in the application or brought up in the interview, look for a casualty or accident involving a legally responsible third party. Chronic renal disease applicants are probably eligible for Medicare. Medicare coverage for a disabled individual is not available until the individual is entitled to receive a social security disability benefit for more than 24 months.
An Application for Social Security Disability is an application for Medicare as well.
7. Change In Marital Status
Marriage or divorce of a recipient may indicate the possibility of health insurance coverage for a member of the household.
505 E. CASEWORKER ACTIONS RELATED TO TPL / TPR
1. Application, Case Review, Report Of Change
During application, case reviews, or reports of change, the caseworker must take the following actions in these specific situations when a TPR is known to exist:
If the applicant meets all other eligibility criteria but does not have specific TPR information available at the time of application, authorize the Medicaid and then pend the case for information about the resource.
If the client refuses to provide third party or insurance information available to them after they have received adequate notice, then they are ineligible for Medicaid. You must close the Medicaid case for the client who is refusing to provide third party insurance information. If the non-cooperating person later agrees to cooperate, his or her eligibility may begin in the month cooperation begins.
If a minor child is involved in the application or case review, continue to process the application for the child, either removing the non-cooperating parent from the need standard while including their income and resources, or determine eligibility for the child under MAGI.
2. Definite Third Party Resources
If the applicant or recipient names a definite third party resource, enter any known specific information on the MERI screen. The information requested on that screen includes:
The carrier code indicating the insurance company;
Type of insurance;
Policy number;
Group number; and
The start and end dates.
The Division of Health Care Services ( DHCS ) TPL unit may also update the MERI screen.
3. Possible Third Party Resource
If there is an indication of a possible third party resource, including insurance coverage, liable party for an accident or injury, or absent parent coverage, but not enough specific information necessary for entry on the MERI (insurance company, type of insurance, etc.), collect all data the client is able to provide (e.g., name, address, phone number of the insurance company, SSN of policy holder, employer of an absent parent) and send an email message with this information to the DHCS TPL unit at DMATPL@alaska.gov. The TPL unit will research the information.
4. Third Party Resource Is Available
If the client indicates that a third party resource is available to a member of the household for which the household member has not applied, notify the applicant or recipient that they must apply and send notice M006 - Application for Other Benefits. If the individual is a mandatory member of the household and refuses to apply for the available resource, remove the recipient from participation in Medicaid, but do not remove any children for whom the recipient can legally assign rights.
5. Third Party Resource is Available - Unable To Provide Information
If the client reports an accident or injury, mentions a Workers' Compensation claim, or reports receipt of any lump sum income which is, or appears to be, related to an accident, or indicates that there is a possibility of a third party resource (absent parent with employment), but the client does not have access to the information. Collect as much information as the client can provide and email the DHCS TPL unit at DMATPL@alaska.gov . Do not deny the case because the client is unable to provide all the information requested.
6. No Third Party Resources
The client indicates that they do not have any third party resource and there is none available to them or any member of their household for whom they are applying. No further action is needed regarding TPL .
505 F. COOPERATION WITH TPL / TPR AND INDIVIDUALS UNDER 21
In Alaska, individuals have legal authority to conduct their own business when they are 18, married, or legally emancipated. For these individuals, follow the procedures outlined in this manual section for cooperation as though the minor were an adult. If a minor applies for Medicaid, and is living independently in the community, the minor may sign the Medicaid application (assigning rights to medical support and indicating cooperation with TPL). Ask the minor under 18 if his or her parents have any health insurance coverage, and email the TPL unit at DMATPL@alaska.gov if any information is available. DHCS will follow-up on the TPL information. Do not require the minor to obtain the health insurance policy of the parent for verification unless the minor indicates a willingness to do so.
TRICARE Standard is the government’s health insurance program for members of the uniformed services, their families, survivors, and retired members. A TRICARE Standard eligible who resides within a forty-mile radius of a military health facility (see Catchment Area in H. below) must get certification of non-availability of medical services from the base health benefits advisor to receive non-emergent services from a facility other than the military treatment facility. If they do not obtain this statement, TRICARE Standard will not cover the expense.
505 I. INDIAN HEALTH SERVICE FACILITIES
Alaska Native Medical Center and Anchorage Service Unit;
Barrow Service Unit;
Kotzebue Service Unit;
PHS Alaska Native Health Center, Ketchikan;
Annette Island Service Unit, Metlakatla; and
Yukon-Kuskokwim Delta, Bethel.
Clinics (contract services for IHS ) include:
SEARHC, Juneau (includes Mt. Edgecumbe Hospital and Sitka Alcoholism Therapy Unit);
Tanana Chiefs, Fairbanks (Chief Andrew Isaac Health Center);
Bristol Bay Health Corporation, Dillingham (Kanakanak Hospital); and
Norton Sound Health Corporation, Nome.
The DHCS Division of Health Care Services TPL unit updates the carrier codes on a monthly basis for each insurance carrier registered by the DHCS . A complete listing of these carriers and codes can be obtained at DMATPL@alaska.gov .
505 K. WAIVERS FOR COOPERATION WITH TPL REQUIREMENTS
It is a condition of Medicaid eligibility that every applicant or recipient provide third party resource information and cooperate in identifying the resource. Inform clients that a good cause waiver of cooperation is available if physical or emotional harm may occur, either to himself or herself or to another person for whom the individual may assign rights, if cooperation is required of them.
If the client claims that cooperation in identification and pursuit of a third party resource is reasonably anticipated to result in physical or emotional harm, (excluding situations related to CSSD ) the client must provide evidence to substantiate the claim.
Issue benefits to an otherwise eligible recipient pending resolution of whether a waiver should be granted, if the applicant or recipient meets all other eligibility factors and has submitted the evidence to determine good cause.
Email dpapolicy@alaska.gov that a good cause waiver determination is needed and send the documents supporting the claim. The Program Officer will notify the caseworker and the DHCS TPL unit of approval or disapproval of the good cause claim.
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