Medical Assistance

2.1.1.2.1.3 Third Party Liability (Archive)

Third parties are people, entities, or programs that are, or may be, liable to pay all or part of the medical costs provided to Medical Assistance (MA) enrollees. A third party may be liable to pay all or part of the medical costs provided to MA enrollees because MA is always the payer of last resort, with limited exception, such as Indian Health Services. This means enrollees with Third Party Liability (TPL) will have medical costs paid by those sources before MA pays claims.

A third party payer includes, but is not limited to:

• Other health care coverage, such as employer sponsored insurance, Medicare, military insurance, COBRA, group or individual health insurance

• Medical support from absent parents

• Other sources such as automobile insurance, court judgments or settlements, workers’ compensation, and fundraisers to pay for medical expenses

Other Health Care Coverage

Applicants and enrollees must cooperate with identifying sources of existing health coverage and assign rights to other health care coverage. Those who fail to cooperate with Third Party Liability (TPL) requirements may be denied coverage or have their MA coverage ended. See the Minnesota Health Care Programs (MHCP) Cooperation policy for more information.

People must cooperate with TPL requirements by:

• Providing information to assist the Minnesota Department of Human Services (DHS) or an enrollee’s managed care plan to pursue any third party liable for payment, and applying for other benefits that may help pay for their medical costs. This includes:

  • Cooperation with completing Medical Service Questionnaires (MSQs) when the person has received a service that potentially indicates a third party may be responsible

  • Giving complete information about third party policies

• Enrolling, when eligible, in other health care coverage that is determined to be cost effective

• Assigning rights to DHS for medical support and payment for medical care from any third party

Enrollees are not required to cooperate with TPL when they are Safe at Home (SAH) Address Confidentiality program participants and the policyholder is their probable assailant.

MA applicants and enrollees who are enrolled in individual health care coverage are required to maintain enrollment as a condition of MA eligibility if the coverage is cost effective and premiums are paid by the county, tribal or state servicing agency.

Enrollees who are eligible for group health care coverage are required to enroll as a condition of MA eligibility if the coverage:

• is cost effective and premiums are paid by the county, tribal or state servicing agency, or

• there is no cost to the client.

Enrollees must maintain or enroll in group health care coverage during an open enrollment period, if one is offered.

Not all people who are eligible for other health coverage are able to enroll or otherwise cooperate on their own behalf. MA eligibility continues for people who do not enroll in, cooperate with or assign rights to other health coverage if they cannot do so on their own behalf.

See the MA Cost Effective Insurance policy for more information.

Medical Support

Medical support may include cash payments or health insurance coverage that a parent who does not live with their children must provide or are court-ordered to provide to meet the medical needs of their children. Parents and relative caretakers who are referred for medical support must cooperate with the county, tribal or state servicing agency as a condition of their own eligibility, unless they show good cause for non-cooperation. See the MA Medical Support policy for more information.

Other Third Party Liability

In some situations, automobile insurance, homeowner insurance, court judgments or settlements, workers’ compensation and other third parties may pay health care costs. See the MA Other Third Party Liability policy for more information.

Legal Citations

Code of Federal Regulations, title 42, sections 433.135 to 433.154

Federal Register, Vol.60, No.131 (July 10, 1995), page 35498

Minnesota Statues, section 256B.042

Published:  June 1, 2016

Archived:  August 1, 2016