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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 - PowerPoint PPT Presentation
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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?