Third Party Liability 510-03-12

 

Individuals applying for coverage under ACA Medicaid may have other insurance coverage.

There is no penalty for individuals who drop their Health Insurance coverage when they apply for ACA Medicaid, with the exception of those determined eligible under ACA Healthy Steps.

 

Cooperation - Third Party Liability 510-03-12-05

(New 7/1/2014 ML #3404)

View Archives

IM 5353

 

1. States are required to pursue known third parties that may be liable to pay for care or services. The Department and county agency are required to make reasonable efforts to obtain the necessary information needed to pursue third parties. This includes following up on any leads that indicate there may be a third party payer, and assisting applicants and recipients in obtaining necessary information.

2. As a condition of eligibility, legally able applicants or recipients and their spouses must cooperate with the Department and county agency in identifying and providing information to assist Medicaid in pursuing third parties who may be liable to pay for care or services, unless there is good cause not to cooperate.

This policy is not intended to place an unreasonable burden on applicants or recipients, or to shift the state's responsibility to pursue third parties. If Department and county staff have the ability to obtain the information, it cannot be shown that an applicant or recipient is not cooperating. If the necessary information cannot be obtained without the applicant or recipient’s cooperation, and the applicant or recipient has the ability to assist, this provision applies. As part of cooperation, the Department or agency may require an individual to:

1. Appear at a state or local office designated by the Department or county agency to provide verbal or written information or evidence relevant to the case;
2. Appear as a witness at a court or other proceeding;
3. Provide information, or attest to lack of information, under penalty of perjury;
4. Complete SFN 566, "Medicaid Questionnaire and Assignment," (which is available on eforms).
5. Pay to the agency any medical payments received that are covered by the assignment of benefits; and
6. Take any other reasonable steps to assist the state in securing third party payments and in identifying information to assist the state in pursuing any liable third party.

3. An exception to cooperation exists when the recipient is receiving Extended or Transitional Medicaid Benefits.

4. It is never a condition of a child’s eligibility that a parent or caretaker cooperates. A parent or caretaker who does not cooperate will not be eligible for Medicaid, but the children in the ACA Medicaid Household remain eligible. When a parent or legally responsible caretaker relative is not eligible because they are not cooperating, the earned and unearned income of that individual must still be considered in determining eligibility for the ACA Medicaid Household.

5. The determination of whether an applicant or recipient is cooperating is made by the county agency in conjunction with their Economic Assistance regional representative. The determination may be based on information received from the Third Party Liability unit. The applicant or recipient has the right to appeal the decision.

6. When an applicant initially applies for Medicaid, it can usually be assumed that there will be cooperation. If the recipient then fails to cooperate, without "good cause," eligibility for that recipient is terminated. For applications in which a recipient clearly states that he or she will not cooperate, and there is no "good cause," that recipient is ineligible for Medicaid. Once the individual begins cooperating, eligibility can be restored or established. Eligibility can begin retroactively if the individual cooperates for the period to be covered. If an individual who failed to cooperate, and eligibility was terminated, later reapplies for assistance, the individual will remain ineligible until the individual begins to cooperate.