TN 10 (06-96)

SI 01730.045 Third Party Liability for Medicaid Eligibility

Citations:

Social Security Act, Sections 1634(a), 1902(a)(25)

A. Introduction

Collection of third party liability information applies only in section 1634 States. The section 1634 States are listed in SI 01715.020.

AOR by an individual requires that the individual cooperate with the State in identifying and providing information to assist the State in pursuing any third party who may be liable to pay for care and services and in obtaining medical support and payments (e.g., appear as a witness at a court or other proceeding).

The collection of third party liability (TPL)information seeks to effectuate an individual's AOR by identifying health insurance resources available to the individual. This collection of information does not extend to Medicare or Medicaid coverage, but does include identifying other sources, such as the existence of any Medigap policies.

SSA provides TPL information to the State Medicaid agency in allowed SSI claims and when changes are detected in posteligibility situations.

B. Policy — TPL sources

1. Definition of Third Party

Third Party — A third party is any source, including health insurance, which is legally liable to pay medical bills before money from the Medicaid program, a welfare program or needs-based program (such as SSI) is spent.

2. Examples of Third Party

Examples of third parties include, but are not limited to:

  • Employer, private purchase and union membership based health insurance, sheltered workshops, continuation of health insurance coverage under statute (“COBRA continuation”) and coverage available from an employer under the Employee Retirement Income Security Act (ERISA)

  • Medical support derived from noncustodial parents

  • Armed Forces and the Public Health Service

  • Pending lawsuits or no-fault clauses or State laws covering accidents, product liability, and Workers' Compensation

  • Employee conversion/extension rights

  • Fraternal and benefit societies and churches and church groups

  • Insurance purchased or endowed as part of a college fee

  • Membership in a health maintenance organization (except for those with a contract under Medicare/Medicaid)

  • See SI 01730.050E., Exhibit 5, “Types of Insurance”

C. Procedure — when to get TPL information

Skip TPL data collection if the claimant has refused assignment of rights in a State that is not an automatic assignment State.

1. Pointers

There are various ways of detecting the existence of third party coverage during the interview. Depending on the claimant/recipient's circumstances, questions such as “Do you have a Medigap policy through a pension plan?” or “Do you have medical coverage through your spouse's employer?” or “How have you been paying for medical care?” may prove useful.

2. Initial Claims

a. Paper Applications

In applications for aged and simultaneously developed claims and at the PERC for a deferred claim, get answers to all application items. If item 59(b) of the SSA-8000-BK is completed with a “Yes,” complete an SSA-8019-U2. If the applicant does not have TPL information at the time of the interview, ask the applicant to call back later with the information and complete the SSA-8019-U2. Never delay adjudication of the SSI claim to get an SSA-8019-U2 completed. If necessary, complete the SSA-8019-U2 after adjudication and forward to the State agency.

Do not mail a copy of the SSA-8019-U2 to the State agency until after the claim is allowed. Retain a copy in the claims folder.

If the individual refuses to provide TPL information, annotate the “Remarks” section of the SSA-8000-BK with the reason for refusal and that the applicant understands that the refusal may affect Medicaid eligibility.

b. MSSICS Claims

The “HEALTH EXPENSES (Y/N)” question in BMEN will only appear at the PERC for a deferred claim and during the full path (i.e., aged and simultaneously developed claims). Answer the question with a “Y” in a section 1634 State, only when the individual appears eligible.

The question about insurance other than Medicare/Medicaid appears in BHLT. This question may be answered with a “Y,” “N,” or “?”

  • Enter a “Y” if the applicant alleges third party insurance other than Medicare/Medicaid.

  • Enter an “N” if the applicant alleges no third party insurance.

  • Enter a “?” if the applicant does not know or is not sure about the third party insurance.

    NOTE: The insurance question in BHLT is a mandatory field; the “?” will require resolution by the time the claim is adjudicated. See SI 01730.045D.2. on completing BTPL when information is not available at adjudication. Never delay adjudication of the SSI claim to complete BTPL data.

3. Initial Claims Refusals

a. MSSICS Claims

If the claimant refuses to provide TPL information and does not appear to need a representative payee, inform the individual that the refusal will probably result in Medicaid ineligibility, unless the State determines that there is good cause for refusal. Refer the claimant to the State Medicaid office for further information and a good cause determination. Inform the individual that if the applicant does not contact the Medicaid agency, the claimant will be notified by the State agency of the eligibility determination.

If it appears the refusing claimant will have a payee (or an applicant who is not the claimant refuses to provide TPL information), tickle the case to contact the payee (or claimant who is not the applicant) about TPL information after the interview. Put a “?” in the appropriate BHLT question until you contact the payee. If the payee (or claimant who is not the applicant) also refuses to provide TPL information, enter an “N” in the BHLT question and the reason (see MS INTRANETSSI 019.020 Health Expenses & Third Party Liability).

NOTE: This information can be updated at any time before the claim is processed to pay. (See MS INTRANETSSI 019.020 Health Expenses & Third Party Liability and MS INTRANETSSI 019.002 Potential Eligibility for Other Benefit Leads Selection.)

b. Paper Claims

Annotate Remarks on the SSA-8000-BK (or, if at a PERC, an SSA-795) with the reason for refusal to provide TPL information and that the individual understands that the refusal may affect Medicaid eligibility. Refer the claimant to the State Medicaid office for further information and a good cause determination. Enter a PR-9 input of “R” in the PT field after adjudication and allowance.

If the applicant is not the claimant, and no representative payee is likely to be appointed, contact the claimant about the effects of TPL refusal on Medicaid unless the State determines there is good cause for refusal. Inform the individual that if the applicant does not contact the Medicaid agency, the claimant will be notified by the State agency of the eligibility determination.

4. Redeterminations

a. Earlier Refusal - AOR or TPL

  • Paper Environment

    Do not address TPL at all if the SSIRD shows an “A” (refusal to assign rights) or “R” (previously refused to provide TPL information) in the PT field.

  • MSSICS 4.4 and Later

    Do not address TPL if the record shows a previous refusal to assign rights or to provide TPL information.

b. No Health Insurance on Record

  • Paper Environment

    If the SSIRD shows no health insurance (“N” in the PT field, or the PT field is blank), ask if the recipient is now covered by health insurance other than Medicare/Medicaid. Complete an SSA-8019-U2 if the recipient now has health insurance coverage.

  • MSSICS 4.4 and Later

    If there is no health insurance on record, ask if the recipient is now covered by health insurance other than Medicare/Medicaid. If the answer is “Yes”, complete the BTPL screen(s). Be sure to code the coverage starting and ending dates appropriate for the coverage(s).

c. Health Insurance on Record

  • Paper Environment

    If the SSIRD shows health insurance (“Y” in the PT field), ask if the recipient is still covered by health insurance other than Medicare/Medicaid or if there is a third party responsible for medical expenses.

    If the answer is “Yes”, ask if the company, coverage or responsible party has changed. If there has been a change, complete an SSA-8019-U2 with ending dates for the old coverage and complete information on all current coverages. If there has not been a change, no further action is needed.

    If the answer is “No,” change the “Y” in the PT field to an “N” using a PR-9 transmission.

  • MSSICS 4.4 and Later

    If the record shows health insurance, ask the recipient (or payee, if appropriate) whether there still is health insurance coverage other than Medicare/Medicaid, or if there is a third party responsible for medical expenses.

    If the answer is “Yes”, ask if there has been a change. If there has been a change, note that in BTPL and complete the screen(s) for the ending dates of the old coverage(s) and the new information. If there has not been a change, no further action is needed.

    If the individual no longer has health insurance coverage, change the BHLT “Y” about third party insurance to an “N” .

5. Other PE Situations

a. Moves to a 1634 State

When an individual moves from a section 209(b) State or SSI State to a section 1634 State and the new servicing FO is contacted to change the address, complete the AOR process and collect TPL information as appropriate.

b. TSC Contact

Changes in health insurance reported to a teleservice center, e.g., when a change of address is reported, should be forwarded to the FO for completion of a paper SSA-8019-U2 and routed to the State agency.

c. Refuses TPL Later

NOTE: PE TPL refusals require notice suppression and a manual notice including paragraph 1146, NL 00804.110. See NL 00801.010C. for notice suppression references.

  • Paper Environment

    If the FO is contacted later by the recipient or representative payee with a refusal to give new or updated TPL information to the State agency, use a PR-9 input to change the PT of “Y” to a PT of “R”.

    If the FO is contacted by the State concerning a subsequent refusal to provide TPL information, obtain the request to post a refusal from the State agency in writing, then use a PR-9 input to change the PT of “Y” to a PT of “R” .

  • MSSICS 4.4 or Later

    Annotate refusals when appropriate on the BHLT screen.

    NOTE: A change which disadvantages the recipient should be accompanied by a signed, written request from the State (or county) Medicaid agency whenever possible.

d. State Completes a Section 1634 Agreement

If a State becomes a section 1634 State, absent regional direction to the contrary, complete the AOR process and collect TPL information at the first redetermination or PE contact after the effective date of the section 1634 Agreement.

D. Procedure — completing BTPL

In general, the SSA-8019-U2 (and BTPL, which is an electronic version of the SSA-8019-U2) is logically laid out for completion. Below are pointers to help you correctly complete the MSSICS screens and what to do when you cannot complete the screens before adjudication.

1. Pointers

a. Covered Services

Situation:

Before you get to the name of the policy holder, you are asked to complete a list of services that are covered.

Enter all services that are covered by all health insurance policies for the claimant.

EXAMPLE: If the claimant's parent has two health insurance policies which cover her, one which covers hospital, prescription, physician, outpatient, emergency and laboratory services, and another which covers dental services, make sure you complete two separate iterations of the BTPL screens (or two separate sections of a paper SSA-8019-U2 when appropriate).

b. Name and Address Fields

Situation:

Claimant data on BTPL are propagated from the application itself. All other name and address fields (i.e., for insurance companies, the attorney, other insurance company against which the claimant filed a claim) on BTPL are at present free format.

Try to get the exact name of the company, Post Office box number when applicable, the street address, city, State and ZIP code. It is very important in PE MSSICS to enter the coverage ending dates when available and appropriate.

NOTE: The States have requested that address data be posted to BTPL in a fixed format, so that the State agencies can use those data to run computer interfaces against their records and records supplied by health insurance intermediaries/carriers. At some point, the BTPL fields will be modified for fixed format input, rather than free format.

2. Information Not Available at Adjudication

If you have entered a “?” in the BHLT question about third party insurance, e.g., the applicant alleges the claimant has third party insurance, but has not provided the information you need to complete BTPL, do not delay adjudication to complete TPL data. Instead:

  • Make sure there is a “Y” in the BHLT question about insurance other than Medicare/Medicaid,

  • Complete the services covered if you can, or check “Other”,

  • Complete “Name of Policy Holder” and “Relationship” if you can,

  • In “Name and Address of Insurance Co.”, as shown in MS INTRANETSSI 019.020 Health Expenses & Third Party Liability, enter “PAPER TO FOLLOW”, and

  • Contact the applicant (or claimant, or representative payee), complete a paper SSA-8019-U2, and route the completed form to the Medicaid State agency.

E. Procedure — completing the SSA-8019-U2

1. Applications

  1. In the block marked “Type of Case,” check the “Initial Application” block. Record the FO code and Medicaid identification number.

  2. Record the claimant's name, date of birth, and Social Security number (SSN).

  3. Record the claimant's complete address and telephone number.

  4. When questioning the applicant regarding the claimant's health insurance, be sure to inquire about insurance available through the spouse, parents, or other responsible persons. Do not document any Medicaid or Medicare information. Indicate the type of services covered. Use two separate sections of a paper SSA-8019-U2 to document more than one health insurance when appropriate.

    Document any health insurance information whether available through the claimant, spouse, parent, or responsible person. If the application is for an eligible couple, complete a separate health insurance information request form for each individual who indicates the availability of health insurance. Record any health insurance information provided and indicate whether it is available through the claimant or spouse.

    If the claimant is a minor child, record the availability of health insurance of the parents/stepparents or other responsible persons.

  5. If the claimant is covered by more than one policy, document health insurance information for all policies. Complete the name of the policy holder; i.e., the name of the claimant, spouse, mother/father, stepmother/stepfather, or other responsible person(s). Record the policy holder's SSN, relationship of the policy holder to the claimant, and date of birth of policy holder.

  6. Complete the name and address of the insurance company, policy number, beginning and ending dates of policy coverage, and group number and/or name of employer.

    NOTE: The group identification will usually be the name of an employer or union through which group insurance is available. Even incomplete information is helpful to the Medicaid agency.

    Therefore, if the individual does not have full information, obtain all that is available. For example, the name of the employer will provide a lead which State Medicaid workers can pursue.

  7. Ask if the claimant has, or is planning, a claim or legal action because of an injury or illness. If so, ask the nature of the claim, date injury or illness occurred, name and address of attorney, and name and address of person, corporation, or insurance company against which the claim is filed.

  8. In face-to-face situations, although a signature is desirable, the individual is not required to sign the SSA-8019-U2 to be eligible for Medicaid. Complete the SSA-8019-U2 by telephone when necessary; e.g., when the SSA-8000-BK is completed by telephone. For telephone contact situations, do not forward the SSA-8019-U2 for a signature; place a copy of the unsigned SSA-8019-U2 in file.

2. Redeterminations

  1. In the block marked “Type of Case,” check the “Redetermination” block. Record the FO code and Medicaid identification number.

  2. Record the recipient's full name, date of birth, and SSN.

  3. Record the recipient's complete address and telephone number.

  4. For each policy that has been added, dropped, or changed; e.g., the coverage within the policy has changed, enter the name of the policy holder, policy holder's SSN, relationship of policy holder to the recipient, and date of birth of policy holder.

  5. Complete the name and address of the insurance company, policy number, beginning and ending dates of policy, and group number and/or name of employer.

  6. If the recipient indicates that he/she has added, dropped, or changed a policy, indicate the addition, deletion, or change by writing “added,” “dropped,” or “changed” in the upper right-hand corner of the “Name and Address of Insurance Co.” block.

  7. Ask if the recipient, since the last redetermination, has, or is planning, a claim or legal action because of an illness or injury. If so, ask the nature of the claim, date injury or illness occurred, name and address of attorney, and name and address of person, corporation, or insurance company against which claim is filed.

  8. In face-to-face situations, the recipient or representative payee is not required to sign the SSA-8019-U2. For mailouts and telephone contact situations, do not obtain a signature.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501730045
SI 01730.045 - Third Party Liability for Medicaid Eligibility - 07/27/2016
Batch run: 07/27/2016
Rev:07/27/2016