1805.045.00 Third Party Liability (TPL) – DSS Manuals

IM-64 June 29, 2021 ; IM-80 June 11, 2020

Per RSMo 208.215 , MO HealthNet is the payer of last resort. MO HealthNet is not obligated to pay for a participant’s medical expenses until other resources, such as private or employer-sponsored health insurance, have been considered. This concept is referred to as Third Party Liability (TPL). Health insurers and other payers are referred to as Third Party Resources (TPRs).

The purpose of TPL is to offset or recover costs to Missouri. In order to do this, TPRs must be properly reported and documented on behalf of participants. When a participant indicates a TPR, gather all necessary information regarding the policy. Review the participant’s MTPR screen to check for existing health insurance. If the reported health insurance is not present, complete a TPL-1 form to capture necessary details about the policy.

Information required on a TPL-1 includes, but may not be limited to:

insurance company name and address

employer name and address

policyholder name

policy number

social security number of the policyholder

Complete a TPL-1 for each insurance policy. Report the following types of health insurance on the TPL-1:

employer-sponsored insurance

self-insured labor unions and welfare funds

commercial health insurance policies (policies not provided/administered by a government program)

Medicare supplements

hospital indemnity policies

nursing care or long-term care policies

TRICARE

Veterans Administration

accident insurance that covers medical care necessary due to an accident

critical care/cancer policies Policies can include medical benefits and income payments

vision, dental, and pharmacy policies

healthcare sharing ministries such as Christian Healthcare Ministries.

Note: Though all of these plans do provide some health benefits, not all of the plans meet the federal minimum essential coverage requirement.

Do not report the following types of health insurance on a TPL-1 form:

Medicare

MO HealthNet or managed care plans

income replacement or disability policies these can be individual or group policies

life and burial insurance

school accident insurance

automobile insurance

Additional information on completing the TPL-1 form can be found in the TPL-1 Instructions .

A TPL form can be used to report changes to an existing TPR such as a policy end-date or additional policy members. Review the MTPR screen to determine if changes are needed.

Issues due to outdated TPR information can be reported using the process found in the Adding/Updating Private Insurance Information Using the TPL-1 Form user guide. Forward TPL-1 forms to the TPL Unit using the process outlined in the guide and maintain a copy in the electronic record.

Do not deny or close coverage because a participant failed to provide complete information regarding a TPR.

EXAMPLE: Andrea files an application on which she claims health insurance. She is eligible for MO HealthNet for Pregnant Women (MPW), but did not provide the details of her health insurance. Her case is approved and a request for information is sent to gather the insurance information, but she fails to respond. A staff member completes a TPL-1 with information known about Andrea and forwards it to the TPL Unit.

Uninsured status is an eligibility factor for certain types of coverage, such as Children’s Health Insurance Programs (CHIP). To determine eligibility for one of these coverage types, insured status cannot be questionable.

EXAMPLE: Amy files an application and attests to income in the Uninsured Women’s Health Services (UWHS) level. She claims no insurance; however, she supplies paystubs that reflect a health insurance deduction. Her insured status is questionable and she must be contacted to resolve the issue before she can be determined eligible for UWHS.

If a participant indicates a reluctance to provide TPR information due to a fear of domestic violence or abuse, include this information on the TPL-1 form. The TPL Unit will determine if good cause exists and if payment should be sought from the TPR.

NOTE: Heath insurance (including vision, dental, etc.) membership and premiums can affect other types of assistance. Document insurance policies and the cost, if applicable, in the appropriate area of the electronic eligibility system(s) to ensure correct eligibility for other programs.