Third Party Liability

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?