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Effective: December 1, 2006 |
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15ar1 - Insurance and Third Party Liability (TPL) (Archive) |
Archived: October 1, 2008 |
Minnesota Health Care Programs (MHCP) via DHS is typically the payor of last resort. Clients with other health care coverage or who have another party liable for their medical expenses will have medical costs paid by those sources first before DHS pays claims.
There are specific rules for people to be eligible for any of the Minnesota Health Care Programs (MHCP), 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 payor that is not considered to be health insurance.
This chapter provides detailed policy on how other health care coverage or third party liability (TPL) affects program eligibility.
This section provides information on the role of the DHS Benefit Recovery Section, an introduction to other health care coverage and third party liability, assigning rights requirements and cooperation requirements with the policies found in this chapter.
The Benefit Recovery Section (BRS) of DHS assists in the coordination of benefits between the Minnesota Health Care Programs and:
l Other health care coverage.
l Liable third parties.
When BRS receives information regarding other health care coverage or third party liability (TPL), BRS:
l Contacts workers via a worker message.
l Updates the Third Party Liability (TPL) Subsystem of MMIS.
Other health care coverage may be:
l Privately held by:
n The client.
n A current, separated or divorced spouse.
n A parent, non-custodial parent or parent of a minor child living apart from the parents.
l Received through the employer of:
n The client.
n A current, separated or divorced spouse.
n A parent, non-custodial parent or parent of a minor child living apart from the parents.
Employers may purchase coverage from insurance companies or provide it through a self-insured plan.
Employers usually allow employees to sign up for health care coverage when they are first hired, and during open enrollment if available.
l Received available through military service, including:
n CHAMPVA.
n Free services at veterans’ clinics and hospitals.
l Potential or current COBRA.
For specific policy information by program regarding other health care coverage see the following sections:
l MinnesotaCare Insurance Barriers.
l MA and GAMC Types of Other Insurance Coverage.
Some employers offer a time each year when employees and dependents can join the employer's health benefit plan. This time is referred to as open enrollment.
Note: Not all employers offer an open enrollment period.
Clients with employers who have open enrollment maybe required to enroll in the other health care coverage to be eligible for or to maintain eligibility for MinnesotaCare, MA or GAMC.
Some employers offer a special enrollment period. During a special enrollment period an employee has an opportunity to enroll in a group health plan without having to wait for an open enrollment period.
A group health plan must provide individuals with an opportunity for special enrollment if they either:
l Declined coverage under the plan because they had alternative coverage but since have lost that alternative coverage.
Note: Special enrollment may be available to people who declined Employer Subsidized Insurance (ESI) when it was first offered because they had MinnesotaCare and whose MinnesotaCare coverage later ends.
l Have new dependents through marriage, birth or adoption.
Clients with a change in health care coverage or a change in dependents must request a special enrollment period from the employer following program provisions. An employer may request a Certificate of Creditable Coverage (COCC) to verify eligibility for special enrollment.
In some situations people may have coverage for all or part of their medical expenses related to an accident or injury through a third party payor. This is third party liability (TPL).
TPL is not considered other health care coverage but it may pay for certain medical expenses. Examples of TPL include:
l Worker’s Compensation.
l A lawsuit filed after a car accident.
l Homeowner’s insurance payments for an injury taking place on a person’s property.
For specific policy information and steps to follow when TPL is reported see Third Party Liability.
People who have other health coverage must assign their rights to coverage to DHS as a condition of eligibility.
l People assign their rights by signing the:
n Combined Application Form (CAF) (DHS-3469).
n Health Care Programs Application (HCAPP) (DHS-3417).
n Health Care Programs Renewal Form (DHS-3418).
l Parents who have children with other health 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, MA or GAMC.
l Do not sanction children whose parents refuse to assign their rights to insurance or other third party liability.
Information is available to clients in Your Notice about Third-Party Liability (DHS-2810). This notice is sent to clients annually and informs them of their reporting responsibilities.
People must cooperate with the county agency, MinnesotaCare Operations and the state Benefit Recovery Section (BRS):
l Identifying potential sources of other health coverage and third party liability (TPL).
l Providing information on other health coverage and third party liability which is or may be available to them or their dependents, regardless of whether the applicant or enrollee is the policy holder.
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 an insurance plan covers if the client does not follow the plan. It will pay for care that is not covered by the plan.
Deny or close MHCP if the client does not cooperate with all other health care coverage and TPL requirements based on program provisions.
The parent or caretaker of a newborn must provide information regarding potential health care coverage for the child upon the birth of the child.
l Request the information as soon as you receive the report of the birth.
l Document the contact information in case notes.
If you are not able to reach the parent or caretaker by phone, send both:
l Request for Information from parents (DHS-4599), which asks parents if their infant has or has access to other health care coverage.
l MHCP Health Insurance Information Form (HIIF) (DHS-1922b), which requests detailed health care coverage information.
Do not deny or close the child's eligibility if the parent or caretaker fails to respond.