2910 Third-Party Resources

A third party is an individual, institution, corporation, public or private agency (other than the applicant/ recipient or KDHE-DHFC) who is or may be liable to pay all or part of the medical costs of a recipient that otherwise would be paid through the medical program.

Individuals eligible for medical assistance will be informed that they have the responsibility to utilize all available medical resources and to inform the agency of any third parties which may have a legal obligation to assume responsibility for payment of any or all medical expenses. (Examples are Medicare and other health insurance.) Refer to 2120 for the eligibility factor related to cooperation and 2912 regarding cooperation with HIPPS.

Third party liability can be considered a resource to the applicant/ recipient in the sense that it is or may be available to meet particular medical expenses, but is not considered against allowable non-exempt resource standards. No one may be denied Medicaid or MediKan because of an existing or potential third party resource or other medical resources. See KFMAM regarding CHIP eligibility. Payment for a particular covered service may be withheld pending a determination of failure to utilize other medical resources or an existing liable third party (e.g., Medicare extended care benefits for payment of adult care home costs). The MMIS fiscal agent will attempt to identify the needed TPL information in order to create an accurate record. If the fiscal agent is unable to locate the record using the information provided, it is the responsibility of the agency to obtain the information from the consumer. In addition, eligibility may be denied or terminated for failure to cooperate in identifying and pursuing third party resources in accordance with 2120 or in cooperation with the HIPPS process in accordance with 2912 .

The eligibility staff have the responsibility to:

Ascertain and document legal liabilities of third parties (e.g., private or group health insurance coverage, Medicare, VA, etc.) or of pending law suits which might establish such a liability. NOTE : Once verified, all existing health insurance coverage must be notated in the MMIS system. Failure to do so can result in claims being paid incorrectly or in error. However, certain third party coverages such as Indian Health Services, VA, and Kansas Health Insurance Association coverage are not to be included on the TPL file.

Inform the Medical Subrogation Unit in writing of failure of Medicaid and MediKan clients to utilize such third party liability or of pending law suits, insurance settlements, etc. which might establish such liability. This is not applicable to CHIP. The R-2, Medical Subrogation Referral – Injury form shall be used to notify the unit.

Request assistance from Medical Subrogation Unit in writing to help obtain third party resource information from non-cooperative sources such as birth mothers, adoption agencies, or adoptive parents when a Medicaid or MediKan client is adopted. This is not applicable to CHIP. The R-1, Medical Subrogation Referral -Adoption form shall be used for this purpose.