Medical Assistance - Third Party Liability (TPL)
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Medical Assistance - Third Party Liability (TPL)


Revised April 22, 2013



Purpose: This category applies to all clients receiving medical assistance benefits. The department re-captures approximately $355 million in tax funds every year through the TPL program (not including Medicare). Federal law requires that Medicaid be the payor of last resort for the cost of medical care.

WAC 182-503-0540Assignment of rights and cooperation.

WAC 182-503-0540

WAC 182-503-0540

Effective October 1, 2013

WAC 182-503-0540 Assignment of rights and cooperation.



(1) When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:

(a) A court order;

(b) An administrative agency order; or

(c) Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 388-501-0100).

(2) When you sign the application you assign the rights described in subsection (1) of this section to the state for:

(a) Yourself; and

(b) Any eligible person for whom you can legally make such assignment.

(3) You must cooperate with us (the agency) in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end.

(4) Your WAH coverage will not end due solely to the noncooperation of any third party.

(5) You will have to pay for your health care services if you:

(a) Received and kept the third-party payment for those services; or

(b) Refused to give to the provider of care your legal signature on insurance forms.

(6) The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

In most instances, where another party (a third party) has been identified as responsible for payment of medical care costs, Medical Assistance is not to pay the health care claims until after the third party has paid. Where Medical Assistance has paid a claim for health care costs, Medical Assistance is entitled to all uncollected third party benefits. Because it is a statutory assignment of medical coverage, it cannot be withheld or modified.

The limit of the Medicaid recoupment from the settlement, judgment or awards of monies is from the proceeds allocated to past medical expenses. The method of determining what portion of a settlement represents past medical expenses is left to the state, the parties, and/or the court. Refer all such questions or challenges to Health Care Authority, the Coordination of Benefits (COB) section at 1-800-562-3022.

Assignment of rights is effective for all periods of eligibility certification, including any retroactive period of eligibility.


WORKER RESPONSIBILITIES

Other insurance

If a client has other insurance or indicates there is a pending lawsuit or casualty settlement, send TPL information to Health Care Authority's COB unit using tickler type:  TPLI with an assignment to @TPL pool at Site 102 in DMS.  The tickler must include the following information:  

  • How the information was reported
  • Where the information is located with the date
  • What kind of TPL information was reported

EXAMPLE

Report via Document

Subject: MAP in ECR 9/15/09

Details: Client reported new insurance


EXAMPLE

Report via Phone or Interview

Subject: See ACES narrative 9/20/09

Details: Client reports end of insurance


DSHS 14-194, Medical Coverage Information form can also be used.

Do not use the DSHS 14-194 for Medicare.  Input Medicare information on the TPL screen in ACES.


Completion of DSHS 14-194(x)

  1. Ensure that the client's name and ACES client ID number is pre-filled on the form before sending it to the client for completion.  

NOTE:

Coordination of Benefits (COB) automatically receives a copy of the DSHS 14-194(X) form through the DMS System in a “to do” box when the client completes and returns this form.


2.  Write "For Information Only" on top of the 14-194(X) and send to DMS when the only medical resource is:

a.  Accident case with potential liability (auto, medical malpractice, homeowners);

b.  Labor and Industries coverage of an injury;

c.  Crime Victim and Victim Assistance involvement; or

d.  Products liability potential coverage.

3.  No referral to COB/TPL is necessary when the only medical resource is:

a.  Coordinated Children Services;

b.  Indian Health

c.  Veterans coverage (other than active duty military coverage or Champus);

d.  Life Insurance

e.  Automobile Insurance (unless related to a current injury);

f.  Homeowner's or Rental Insurance (unless related to a current injury);

g.  Medicare (use TPL procedures in ACES for Medicare only); or

h.  Enrollment in a HMO/HIO under a department Medicaid contract.


TPL Non-Cooperation


  1. Changes:  Review all TPL documents in DMS to determine if any action is needed.
  2. Non-cooperation:   The Health Care Authority (HCA) sends notification to financial services when the recipient has not cooperated in identifying or using a medical resource that has been determined to be available to the recipient.  Termination of medical coverage for non-cooperation is the last resort (notice should cite WAC 388-505-0540).
  3. Reinstatement:   HCA sends notification to financial services when the recipient has decided to cooperate after the recipient's medical coverage was terminated.  The financial worker reinstates the recipient's medical coverage when COB determines that the client is cooperating.  The reinstatement is effective back to when the client lost coverage if it is within the same certification period.  If the reinstatement is outside the certification period, the client must reapply.

NOTE:

Once financial staff is notified of cooperation with TPL, medical is reinstated back to the month they lost coverage if otherwise eligible and within the original certification period.  If retroactive reinstatement is outside of the original certification period, the client would need to reapply for any time frame outside the original certification.


Possible effects on cash and food assistance:

  1. A client may receive a cash settlement related to health insurance, lawsuit or casualty settlement. Assignment of rights requires that the client surrender the lump sum to the department to be applied against medical expenses. This is best for the client since it does not impact their calculation of income/resources and it does not impact their ongoing eligibility. However, the client may fail to surrender the payment or the settlement amount may not be available when it is discovered by the FSS or the unit in Olympia that handles TPL. In such a case, benefit overpayments may have been made due to the client's "non-cooperation" with TPL (i.e., they actually used the assigned funds as income-unearned).

    1. Rather than terminating eligibility for non-cooperation, consider treating the unavailable settlement payment as a lump-sum payment type of unearned income (if the client's program rules allow it). Caution - do not treat such a case as both non-cooperation and a lump-sum payment. If the funds have been treated as income or they must be treated as income because they are no longer available for surrender to the department, do not terminate the case for non-cooperation.


NOTE:

If you receive a statement of non-cooperation from the Health Care Authority and the funds have already been treated as income, advise Health Care Authority that the funds are no longer available for their consideration and that non-cooperation would constitute duplicate treatment.


  1. There is no set period of ineligibility for non-cooperation with TPL. If the client reapplies for assistance, the actual income and resources for the application period are considered without special regard to the prior non-cooperation.  Direct the client to contact the COB Casualty Unit at 1-800-562-3022.


Ongoing insurance premiums / access to insurance:

  1. A client may have access to ongoing medical insurance which requires the payment of a premium by the client. The department may be willing to pick up those ongoing premium payments if it is cost effective to do so.

  2. If an applicant who has been diagnosed with HIV or AIDS is not eligible for department medical programs, there is another resource available.  The Department of Health HIV Client Services Program funds a contract to assist persons who have HIV and/or AIDS with ongoing medical insurance premiums, or to acquire insurance.  For more information about this program contact the Early Intervention Program (EIP) at DOH at 1-877-376-9216, or go to www.doh.wa.gov/cfh/hiv_aids/client_svcs or www.ehip.org.


Payment of Private Health Insurance

DSHS offers a premium payment program for people who have Medicaid and private health insurance, which includes individual policies, COBRA policies, and employer-sponsored plans.  Coordination of Benefits handles applications for private health insurance except for Medicare + Choice (managed care).

How to Apply

If coverage is employer-based, a client should call Employer Sponsored Insurance Program's toll-free line at 1-800-562-3022 and follow the instructions to reach a case manager.  All others, follow the guidelines below. 

Any applicant who declares other medical coverage on the application must complete a DSHS 14-194 Medical Coverage Information.  Once approved for Medicaid, a client may ask for assistance in paying insurance premiums.  Requests will be reviewed for cost effectiveness.

 

Making a referral for a Premium Payment

  1. Download an Application for DSHS Premium Payment Program, DSHS 13-705, at http://asd.dshs.wa.gov/FormsMan/FormPicker.aspx.

  2. Send all mail requests to Coordination of Benefits, P.O. Box 45518, Olympia, WA 98599-5518.

Contact Coordination of Benefits (COB) premium specialists:

 

Premium Payment Unit

9/21/2012

Phone: (800) 562-3022 ext 15473

Fax: (877) 893-3810

Supervisor:

Norma Leavitt

Ext 51364

norma.leavitt@hca.wa.gov

Lead Worker:

Lorena Delgado

Ext 51572

lorena.delgado@hca.wa.gov

 

  1. A client or worker can call COB toll free at (800) 562-3022 to report insurance information or request premium assistance.
  2. The premium payment fax number is (877) 893-3810. 
  3. The Premium Payment Program number is (800) 562-3022, ext 15473.

ACES PROCEDURES

See Medicare - TPL screen coding
Modification Date: April 22, 2013