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 182-503-0540 Assignment of rights and cooperation.
When a person becomes eligible for any medical assistance program, they make assignment of some of their rights to the state of Washington. This assignment includes all rights to any type of coverage for medical care which results from:
A court order;
An administrative agency order; or
Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 388-87-020). (Ed Note: The correct reference is WAC 388-501-0100.
Subrogation is a legal term which describes the method by which the state acquires the rights of a client for whom or to whom the state has paid benefits. The subrogation rights of the state are limited to the recovery of its own costs.
The person who signs the application makes the assignment of rights to the state. Assignment is made on their own behalf and on behalf of any eligible person for whom they can legally make such assignment.
A person must cooperate with the department in the identification, use or collection of third-party benefits. Failure to cooperate will result in a termination of eligibility for the responsible person. Other obligations for cooperation are located in chapters 388-14 (Ed. Note: This correct reference is chapter 388-14A WAC.) and 388-422 WAC. The following clients are exempt from termination of eligibility for noncooperation:
A pregnant woman, and
Minor children, and
A person who has been determined to have "good cause" for noncooperation (see WAC 388-422-0015). (Ed. Note: The reference is incorrect. The correct reference is WAC 388-422-0020.).
A person will not lose eligibility for medical assistance programs due solely to the noncooperation of any third party.
A person will be responsible for the costs of otherwise covered medical services if:
the person received and kept the third party payment for those services, or;
the person refused to provide to the provider of care their legal signature on insurance forms.
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)
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
Changes: Review all TPL documents in DMS to determine if any action is needed.
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).
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:
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).
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.
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:
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.
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.
