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Effective: October 1, 2008 |
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15.15ar2 - Non-Health Care Coverage Third Party Liability (TPL) (Archive) |
Archived: June 1, 2011 |
In some situations people may have access to third party liability other than health care coverage for all or part of their medical expenses related to an accident or injury.
The Benefit Recovery Section (BRS) of DHS assists in the coordination of TPL benefits and MA or GAMC.
Non-Health Care Coverage Third Party Liability.
Cooperation with Third Party Liability.
MinnesotaCare and Non-Health Care Coverage TPL.
MA and GAMC and Non-Health Care Coverage TPL.
Non-Health Care Coverage Third Party Liability (TPL)
Examples of TPL that are not health care coverage include, but are not limited to the following:
l Workers' Compensation may be liable for the cost of medical care and subsistence related to on-the-job injuries.
l Auto insurance policies may cover medical costs related to auto accidents or injuries involving a motor vehicle.
l Homeowners or business liability policies may cover medical costs related to accidents on the home or business owner's property.
l Tort claims and lawsuits may result in court-ordered awards for recovery of medical expenses caused by another party's negligence or malpractice including but not limited to:
n Product liability.
n Medical malpractice.
n Pedestrian injuries.
Cooperation with Third Party Liability
For information about requirements to cooperate with pursuing medical support and TPL, see Who Must Cooperate.
For information about good cause for not cooperating in pursuing medical support and TPL, see Good Cause for Non-Cooperation.
Notify the Benefit Recovery Section (BRS) in the following situations:
l An applicant or enrollee currently has access to third party liability payments.
Note: BRS will coordinate payments for which the third party is liable with payments made by the health care programs.
l An applicant or enrollee has a claim, settlement, or lawsuit pending within the last six years that could result in payment of medical expenses.
Note: BRS may be able to file a claim or intervention to allow DHS to be reimbursed for medical care and subsistence paid by DHS while the claim, settlement or lawsuit was pending.
Do not require a Health Insurance Information Form (HIIF) (DHS-1922B) for current or potential TPL payments reported on an application that are not health care coverage.
Notify BRS by sending a SIR webmail message to HCOBRS-Health@CO.DHS.state.mn.us. Include the information from Step 3, below.
When necessary, mail or fax information to BRS at:
DHS Benefit Recovery.
P.O. Box 64994.
St. Paul, MN 55164-0994.
(651) 431-7431 (FAX).
Please specify the source of TPL, such as health care or tort claim, when sending information to BRS.
MinnesotaCare and Non-Health Care Coverage TPL
Do not consider actual or potential non-health care coverage TPL payments to be other health care coverage for purposes of MinnesotaCare insurance barriers. Non-health care coverage TPL is not an insurance barrier to MinnesotaCare eligibility. However, to be eligible for MinnesotaCare a client must cooperate with TPL benefit recovery.
l Close or deny individuals who refuse to cooperate on their own behalf.
l People who later cooperate are not barred from MinnesotaCare for past non-cooperation with TPL Benefit Recovery.
l Do not deny or close children and adults who are unable cooperate with TPL on their own behalf if the person responsible for providing TPL information refuses to cooperate.
Follow these steps if someone indicates at application, renewal or between renewals that a household member has been injured on the job or in an accident:
1. Contact the client to determine if there are current or potential TPL payments.
2. Send the Accident/Injury Follow-Up Request for Information (DHS-4870) to the client if the application does not contain enough information.
Note: Do not pend an application or renewal for receipt of this information.
3. Notify BRS by sending a MAXIS e-mail using e-mail code BRSS. Include the following in the e-mail:
l The enrollee’s name and Person Master Index (PMI) number.
l The date of injury.
l The type of potential TPL (auto insurance, workers’ compensation, homeowner’s insurance, etc.).
l Whether a claim or settlement is pending.
l The name and address of the parties involved including the name of any of the following, as applicable:
n Attorney.
n Insurance Company.
n Liable party.
4. An MMIS worker message is automatically generated if a MinnesotaCare enrollee does not return an MSQ. Deny or close with a 10-day notice if the applicant or enrollee has not responded.
l Do not deny or close benefits for children under age 18.
l Clients closed for non-cooperation with the MSQ or BRS who later cooperate with BRS are eligible as of the first of the month of cooperation.
MA and GAMC and Non-Health Care Coverage TPL
Do not consider actual or potential non-health care coverage TPL payments to be other health care coverage or a barrier to MA or GAMC eligibility.
Follow these steps if a client reports accidents or injuries with possible TPL at application, renewal or between renewals:
1. Contact the client to determine if there are current or potential TPL payments.
Note: Do not pend an application or renewal for receipt of this information.
2. Enter the information on the MAXIS STAT/ACCI screen if any of the following situations are met:
l The applicant or enrollee is pursuing legal action on an old or recent injury.
l Insurance is currently paying for medical costs related to the injury.
l Potential insurance payments are available for costs associated with the injury.
l The client has an active or pending Workers' Compensation claim.
Note: BRS will generate a Work Injury Report if they receive notice of possible Workers' Compensation eligibility through an interface with the Department of Labor and Industry.
3. MAXIS will interface the information to MMIS.
l MMIS will generate and send a Medical Services Questionnaire (MSQ) (DHS-2237A) to the client to be returned to BRS.
l BRS will monitor the return of the MSQ. If the client does not respond to the first MSQ, BRS will generate a second notice and send it to the client.
4. A MAXIS DAIL message will be generated if the client does not return the second MSQ. Deny or close the applicant or enrollee with 10-day notice after receiving this DAIL message.
l Do not deny or close benefits for children under age 18.
l Clients closed for non-cooperation with the MSQ or BRS and who then cooperate with BRS are eligible as of the first of the month of cooperation.
Example:
Mark applies for GAMC. He reports he was injured in a fall at a grocery store two years ago. He has not received any payments as a result of this injury but has retained an attorney and plans to file suit.
Action:
1. Complete the STAT/ACCI screen in MAXIS.
2. MAXIS sends an interface with the information to MMIS which generates an MSQ to the client.
Mark does not return a completed MSQ. BRS generates a second MSQ and sends it to Mark.
Action:
BRS will update the RMSQ screen in MMIS when Mark returns a completed MSQ. No further action is needed.
Example:
Jean applies for MA. She reports she was injured in an auto accident two months ago. Her auto insurance carrier is covering the costs of ongoing medical treatment related to the accident.
Action:
1. Complete the STAT/ACCI screen.
2. MAXIS sends an interface with the information to MMIS which sends out the MSQ to Jean.
Jean must provide information on the auto insurance claim to BRS.
Example:
Jolene applies for MA for herself and her children. She reports that her son was treated at the emergency room for cuts and bruises sustained in a sledding accident two months ago. There are no insurance claims active or pending. Jolene does not plan to file a suit.
Action:
Do not complete the STAT/ACCI screen because there is not any potential TPL.
Example:
Bob applies for MA for himself and his family. He was injured on the job six months ago and has been unable to return to work. He receives weekly payments from Workers’ Compensation as well as coverage for medical costs related to the injury.
Action:
1. Complete the STAT/ACCI screen.
2. MAXIS sends an interface to MMIS which sends out the initial MSQ.
Bob must provide information about the injury and the Workers Compensation. Count the income he receives as unearned income.