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Third Party Liability

Third Party Liability. Minnesota Department of Human Services Benefit Recovery Section MFWCAA Conference October 1, 2009. Benefit Recovery Section. Responsible to ensure that MHCP is payer of last resort; all other resources must be used to fullest extent

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Third Party Liability

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  1. Third Party Liability Minnesota Department of Human Services Benefit Recovery Section MFWCAA Conference October 1, 2009

  2. Benefit Recovery Section • Responsible to ensure that MHCP is payer of last resort; all other resources must be used to fullest extent • Partner with financial worker staff in many ways to gain information and fulfill responsibilities • Important that clients understand their responsibilities about TPL

  3. Units within BRS • Health Insurance Unit • Tort Liability Unit • MA Lien and Estate Recovery Unit • Medicare Revenue Enhancement (LTC) See Handout Pg. 1—BRS Contact List

  4. Health Insurance Unit Maintain the TPL Resource File in MMIS • Reviewing county added TPL records (including those interfaced from PRISM) • Incoming faxes from medical providers—updates • Reviewing Possible Insurance Cases for unknown TPL See Handout—Attachment A

  5. Health Insurance Unit • Bill health insurers for retro coverage --Processing TPL payments/denials • Review & Approve Cost Effective Health Insurance policies • File updates with data match results • Child support (daily) • Tricare (annually) • Other insurance carriers (new contract)

  6. Medicare & LTC Insurance are TPL • Regardless of where the payment of benefits is directed • LTC insurance must be coded as a policy in MMIS/TPL Resource • Providers of LTC services must bill and report receipt of payment on the claims submitted to MHCP

  7. TPL Cooperation RequirementsElements of Cooperation • Provide information to determine third party liability • Coverage in effect • Coverage available through employer/group • To assist in pursuing any liable third party • Complete forms to provide requested information

  8. Elements of Cooperation • Pay to the agency any funds received based on “assignment of rights” • Identify and assist in pursuing third party liability • Enroll in a health plan determined to be cost effective (and premiums necessary to enroll will be paid by MHCP)

  9. Waiver of Cooperation for Good Cause • Strict federal guidelines for meeting “Good Cause” for Non-Cooperation • Cooperation is “anticipated to result in reprisal against and cause physical or emotional harm to the individual or other person” • Enrollee has the right to appeal the decision

  10. Denial or Termination of Eligibility • Sanctions apply only to adult members of a case • Assume that both adults are able to cooperatesanctions apply to both parents • Sanctions are lifted to the first of the month in which cooperation was met

  11. Non-Cooperation—Enrolling in a Group HI Plan • Adults must enroll/re-enroll in the plan to be in cooperation • Adults remain ineligible for MA/GAMC until they are able to re-enroll in the plan • “Special Enrollment” periods may apply for persons who lose MA coverage and their children (60 day limit for requesting)

  12. Cost Effective Health Insurance • Implementing new CEHI criteria approved by CMS (State Plan Amendment) • Bulletin #09-19-01 Issued in June 2009 • Video training August 14, 2009 • FAQ Will be Updated for County Staff • DHS-2841 Series of Forms • HCPM Updates to be Issued (11/09)

  13. Determining Cost Effectiveness • CEHI Calculation Using DHS-2841A • Comparison to “Low Cap” Chart by Age • Use fillable e-Docs forms with internal calculations

  14. Medical Expense Review • Request completion of DHS-2841B for Medical Services/Expenses • Review EOMBs to determine if 2:1 ratio (benefits paid : premiums paid)

  15. Request Review by BRS • Fax to BRS All of the Following DHS-2841 DHS-2841A DHS-2841B Summary of policy benefits Copies of EOMBs

  16. CEHI Premium Reimbursement • Verify amount and due date(s) of premium • Verify payment of the premium (if not issued directly to the employer/insurer) • Retroactive reimbursement cannot exceed 12 months • Determine payable premium amount if not all members are MA/GAMC enrollees

  17. Not All Members are Eligible • Determine the pro-rated premium amount(s) for MHCP-eligible enrollees; reimburse the pro-rated amount • If an ineligible family member must enroll in the health plan to get coverage for MHCP-eligible enrollees, contact BRS for assistance with the review

  18. Court-Ordered Medical Support • Do not reimburse HI premiums when parent(s) is court-ordered to provide HI Exceptions*: The court-ordered parent is also on MA/GAMC or The court-ordered parent is unable to continue in their job and COBRA is available

  19. Medical Support Exception • Communicate with the Child Support Officer before proceeding • Determine if premium payment is cost effective • Pay premiums directly to the employer/insurer

  20. Payments Subject to PERM Audits • CEHI premiums are “claims” submitted to MMIS and subject to audit • Federal Financial Participation (FFP) is provided for these expenses • Increased editing of payment and review of any possible overpayments

  21. Tort Liability Unit • Pursues TPL Related to Accidents/Injuries --Grant money may be part of BRS Claim • “Leads” to Cases • Client has a duty to report • Attorney for client is looking for medical expenses paid as related to the injury • Medical Service Questionnaires are generated • Refer calls/correspondence to BRS

  22. Tort Liability • Types of Tort TPL • Workers’ Compensation (DOLI data match) • Auto no-fault/auto litigated (New DPS match) • Homeowners’ Insurance • Medical Malpractice • Product liability (rx drugs, devices, etc.) • Personal Liability • Class Action or Multiple Plaintiff Cases

  23. MSQ Revised in 2008 • Simplified form for better client understanding • Implemented “script” process with data integration • Clearer turnaround time requirements • Responses can be faxed • Fillable MSQ on edocs • Forthcoming reprint & add capabilities through Tort Unit • 2nd Notices Issued by DHS • New County Notice of Late MSQ Report available through InfoPac – roll out coming

  24. MA Lien & Estate Recovery • County agency staff send MA Lien Referral Worksheets and SNT/Pooled Trust Referrals to BRS • BRS staff file MA property liens when appropriate and monitor SNT/Pooled Trust clients • County Agency staff file estate claims upon the death of the last surviving spouse • BRS provides technical assistance to county collections staff

  25. DHS as Beneficiary Recoveries • Special Needs or Pooled Trusts New annual reporting requirements Review of expenditures (“sole benefit of the individual” • Annuities Recoveries more labor intensive Pay-outs typically made monthly as opposed to lump sum

  26. Medicare Revenue Enhancement (MREP) • Program to ensure that Medicare benefits are used first for LTC Services • LTC facilities required to submit documentation for review of potential cases • Technical assistance provided to LTC facilities re: Medicare, and other requirements

  27. Deficit Reduction Act (DRA) & LTC Partnerships • MN passed implementing language effective 07/01/06 based on DRA authority given to states • More people will be buying LTC insurance which may or may not be Partnership qualified • All LTC insurance has the effect of protecting assets (by virtue of providing the benefit)

  28. Goals • Effective communication with our customers (develop and maintain presence on public and county websites, etc.) • More efficient processes with better results • Continue to review & implement changes

  29. Questions?

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