5065            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 Division of Health Care Services (DHCS) edits medical claims submitted for payment that indicates services have been delivered that are related to an accident or injury.   DHCS TPL Unit develops this information and acts as a clearinghouse for all reports of Third Party Resources (TPR) or Third Party Liability (TPL), making appropriate referrals to Child Support Services Division (CSSD), Public Consulting Group, or the Department of Law.

 

5065 A.       DEFINITIONS

 

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.

 

5065 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 recipients health care.  Third parties include, but are not limited to:

 

  1. Private or group health insurance, including Medicare;
     

  2. Pre-paid Medical plans;
     

  3. Employment-related health insurance;
     

  4. Indemnity policies;
     

  5. Medical support from a noncustodial (absent) parent;
     

  6. Self-insured and self-funded medical plans, or trusts;
     

  7. Auto or homeowner liability insurance;
     

  8. Tenant or landlord insurance;
     

  9. Court judgments or settlements from a liability insurer, malpractice, wrongful injury, or civil assault lawsuit;
     

  10. Workers compensation;
     

  11. First party probate-estate recoveries; and
     

  12. Other federal programs, with the exception of AANHS or IHS programs.

 

5065 C.       APPLICANT / RECIPIENT RESPONSIBILITY

 

An applicant or recipient must:

 

  1. Provide all available information about any third party resources and must inform their caseworker of any changes;
     

  2. 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;
     

  3. Cooperate in establishing paternity and obtaining medical support and payments;
     

  4. Cooperate, in the absence of good cause, in providing information to assist the state in pursuing any liable third party; and
     

  5. Except for poverty level pregnant women, cooperate in establishing paternity (CSSD) and obtaining medical support.

 

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.

 

5065 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 a noncustodial 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:

 

 

  1. Work History:  A look at work history may indicate eligibility for cash and medical benefits described above.  Previous military service, or a noncustodial parent on active duty or retired from the military, suggests the potential for VA or TRICARE Standard coverage.
     

  2. Monthly Expense:  A look at work expenses may show that the applicant pays health insurance premiums.
     

  3. 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.
     

  4. Change In Marital Status:  Marriage or divorce of a recipient may indicate the possibility of health insurance coverage for a member of the household.
     

5065 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, code the applicant out and pend the case for information of the resource and send the client notice M350 - Request Medical Insurance Information. Continue to determine eligibility for all other household members and authorize benefits as appropriate.  Benefits may be authorized for the adult as soon as the missing information is received.

 

If the client refuses to provide third party or insurance information available to them after they have received adequate notice, they remain ineligible for Medicaid.  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 DKC.

 

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 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 noncustodial 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 a noncustodial parent) and send an email with this information to the DHCS TPL unit at DMA_TPL@health.state.ak.us.  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, that individuals Medicaid eligibility ends.

 

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 (noncustodial 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 DMA_TPL@health.state.ak.us.  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.

 

5065 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, 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 their parents have any health insurance coverage, and email the TPL unit at DMA_TPL@health.state.ak.us 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.

 

5065 G.       TRICARE

 

TRICARE Standard is the governments 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.

 

5065 H.       MILITARY FACILITIES

 

Military beneficiaries whose address fall within the listed zip codes below must receive medical care in the noted facility or TRICARE Standard will not pay the service unless there is specific authorization of nonavailability from the base health benefits advisor.

 

FACILITY

CATCHMENT AREA (ZIP CODE)

Elmendorf Air Force Base

99501, 99502, 99503, 99504, 99505, 99506, 99507, 99508, 99509, 99510, 99511, 99512, 99513, 99514, 99515, 99516, 99517, 99518, 99519, 99520, 99521, 99522, 99523, 99524, 99540, 99547, 99567, 99577, 99587, 99599, 99605, 99645, 99652, 99654, 99683, 99687, 99694, 99695.

Bassett AH

99701, 99702, 99703, 99705, 99706, 99707, 99708, 99709, 99710, 99711, 99712, 99714, 99716, 99725, 99775

BRH Adak

96505, 96506, 98777, 98791

Juneau and Sitka

The military has a contract with SEARHC Southeast Alaska Regional Health Consortium in these areas to provide outpatient services.

 

5065 I.          INDIAN HEALTH SERVICE FACILITIES

 

  1. Alaska Native Medical Center and Anchorage Service Unit;
     

  2. Barrow Service Unit;
     

  3. Kotzebue Service Unit;
     

  4. PHS Alaska Native Health Center, Ketchikan;
     

  5. Annette Island Service Unit, Metlakatla; and
     

  6. Yukon-Kuskokwim Delta, Bethel.

 

Clinics (contract services for IHS) include:

 

  1. SEARHC, Juneau (includes Mt. Edgecumbe Hospital and Sitka Alcoholism Therapy Unit);
     

  2. Tanana Chiefs, Fairbanks (Chief Andrew Isaac Health Center);
     

  3. Bristol Bay Health Corporation, Dillingham (Kanakanak Hospital); and
     

  4. Norton Sound Health Corporation, Nome.

 

5065 J.       RESOURCE CODES

 

The DHCS 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 DMA_TPL@health.state.ak.us.

 

5065 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@health.state.ak.us 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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MC #30 (3/05)