*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: June 1, 2012 |
|
|
Archived: June 1, 2016 (Previous Changes) |
This chapter provides detailed policy on how third party liability (TPL) affects payment of covered services and program eligibility.
Benefit Recovery Section (BRS).
Cooperation with Third Party Liability.
Assigning Rights to Third Party Liability.
MinnesotaCare Insurance Barriers.
What is Not Third Party Liability.
Third parties are individuals, entities, or programs that are, or may be, liable to pay all or part of the medical costs provided to Minnesota Health Care Programs (MHCP) enrollees. Third parties include, but are not limited to:
See the following sections for specific policy information by program regarding other health care coverage:
n Other Health Care Coverage - MA.
n Types of Other Insurance Coverage for MinnesotaCare.
l Medical support from absent parents.
l Other sources of TPL, such as automobile insurance, court judgments or settlements, and workers’ compensation.
Note: The Health Care Programs Manual distinguishes between types of TPL because applicable policies and procedures differ depending on the type of TPL.
Minnesota Health Care Programs (MHCP) is the payer of last resort. This means clients with TPL will have medical costs paid by those sources first before MHCP pays claims. Clients who fail to cooperate with TPL requirements may be denied coverage or disenrolled from MHCP.
Clients must cooperate with TPL requirements by:
l providing information to assist DHS or an enrollee’s MCHP managed care plan to pursue any third party liable for payment, and applying for other benefits that may help pay for their medical costs.
l enrolling in other health care coverage that is determined to be cost effective.
l assigning rights to DHS for medical support and payment for medical care from any third party.
Benefit Recovery Section (BRS)
The Benefit Recovery Section (BRS) of DHS assists in the coordination of benefits between the Minnesota Health Care Programs and liable third parties.
When BRS receives information regarding third party liability (TPL), BRS:
l Updates the Third Party Liability (TPL) Subsystem of MMIS and/or
l Contacts workers via a worker message.
Cooperation with Third Party Liability
Clients must cooperate with county and tribal agencies, a client's MHCP managed care plan, MinnesotaCare Operations, and the state Benefit Recovery Section (BRS) by:
l identifying potential sources of TPL.
l providing information on TPL that is or may be available to them or their dependents. This includes cooperating with establishing paternity for the purpose of determining medical support obligations for children.
Example:
Heather, age 24 and a full-time student, applies for MHCP for herself. She thinks she may be covered on her father's group insurance plan.
Action:
Heather must provide as much information as she can about the insurance.
l enrolling in or maintaining other health care coverage when required.
l cooperating with and following the rules of the other health care coverage provider by responding to requests from providers and using the highest level of benefits available to them.
Note: MHCP will not pay for care that could be paid by a client’s other health care coverage if the client does not cooperate in obtaining benefits from the other coverage. MHCP will only pay for services not covered by the other health care coverage.
Deny or close MHCP for adults who refuse to cooperate with TPL requirements based on program provisions.
Note: Children and adults unable cooperate with TPL on their own behalf remain eligible if the adult responsible for providing TPL information refuses to cooperate.
Example:
Marla, a 22-year old mother, applies for MA for herself and her 3-year old daughter, Lily. Lily has other health care coverage through her non-custodial parent. Marla fails to submit information about Lily’s other health care coverage.
Action:
Deny MA for Marla because she failed to cooperate with TPL requirements. Approve MA for Lily if she meets all other MA eligibility criteria because she is a child under 21 and cannot be penalized for non-cooperation with TPL.
Information about TPL is available to clients in Your Notice about Third-Party Liability (DHS-2810). DHS sends this notice to clients annually to inform them of their reporting responsibilities.
Assigning Rights to Third Party Liability
Clients must assign their rights to third party liability to DHS as a condition of eligibility. By accepting assistance through a MHCP, clients assign to DHS all rights they may have to medical support or payment for medical expenses from a liable third party for themselves or their dependents.
l Clients assign their rights by signing the:
n Combined Application Form (CAF) (DHS-5223).
n Health Care Programs Application (HCAPP) (DHS-3417).
n ApplyMN Application.
n Minnesota Health Care Programs Renewal Form (DHS-3418).
n Minnesota Health Care Programs Application for Payment of Long-Term Care Services (DHS-3531).
n Renewal for People Receiving Long-Term Care Services (DHS-2128).
l Parents who have children with other health care coverage must assign their children’s rights to coverage to DHS as a condition of eligibility.
l Adults who refuse to assign their rights or the rights of other household members for whom they are legally able to assign rights are not eligible for MinnesotaCare or MA.
Note: Children and adults who are unable to cooperate with TPL on their own behalf remain eligible if the person responsible for providing TPL information refuses to cooperate.
MinnesotaCare Insurance Barriers
Insurance barriers were established for MinnesotaCare eligibility to prevent individuals with access to other health care coverage from enrolling in MinnesotaCare. Enrollment in or access to health insurance may affect eligibility for MinnesotaCare. MinnesotaCare has specific eligibility rules for people who:
l are enrolled in or are eligible to enroll in other health care coverage.
l have had other health care coverage in the past.
l have access to a third party payer that is not considered to be health insurance.
What Is Not Third Party Liability
The following government health programs are not considered third party liability:
l Head Start.
l Comprehensive Health Services Projects.
l Migrant Health Projects.
l Appalachian Regional Commission (ARC).
l Health and Child Development Projects.
l Health Under-Served Rural Areas (HURA).
l Indian Health Services.
l Crime Victims’ Compensation Fund.
Third Party Liability requirements do not apply to these programs.