Third Party Liability

Minnesota Department of Human ServicesBenefit Recovery Section

MFWCAA ConferenceOctober 1, 2009

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

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

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

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)

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

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

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)

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

Denial or Termination of Eligibility

Sanctions apply only to adult members of a case

Assume that both adults are able to cooperatesanctions apply to both parents

Sanctions are lifted to the first of the month in which cooperation was met

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)

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)

Determining Cost Effectiveness

CEHI Calculation Using DHS-2841A Comparison to “Low Cap” Chart by Age Use fillable e-Docs forms with internal

calculations

Medical Expense Review

Request completion of DHS-2841B for Medical Services/Expenses

Review EOMBs to determine if 2:1 ratio (benefits paid : premiums paid)

Request Review by BRS

Fax to BRS All of the Following

DHS-2841

DHS-2841A

DHS-2841B

Summary of policy benefits

Copies of EOMBs

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

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

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

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

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

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

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

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

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

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

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

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)

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

Questions?