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9.1 Third Party Liability 9.1.1 Third Party Liability Introduction TPL refers to the obligation a third party (not Wisconsin Medicaid program or the Medicaid member), has to pay the bills for a Medicaid member’s medical services. Medicaid is the payer of last resort for the cost of medical care. This means that if a Medicaid member also has coverage under a private health insurance plan, that plan is to be billed first for any medical services. Medicaid then pays any amount remaining after the private insurer has paid what they owe, up to the Medicaid reimbursement rate. Another common example of TPL is when someone receives an insurance settlement resulting from an accident. If Medicaid paid for any medical services resulting from that accident, the Medicaid program is to be reimbursed the cost of those medical services from the proceeds of the insurance settlement. Third party payers include health insurers, court ordered medical support, and any other third party that has a legal obligation to pay for medical services. 9.1.2 Third Party Liability Cooperation All Medicaid members must assign to the State of Wisconsin their rights to payments for medical services from third-party payers. A member complies with this requirement by signing the application form. The assignment includes all unpaid medical support and all ongoing medical support obligations for as long as Medicaid is received. In addition, Medicaid members must cooperate in identifying and providing information to assist the State in pursuing third parties who may be liable to pay for care and services, unless the individual establishes good cause for not cooperating. If a member fails to cooperate with TPL requirements, they could be sanctioned. 9.1.3 Third Party Liability Cooperation Requirements The Medicaid member must cooperate in providing TPL information unless they are exempt or there is good cause for refusing to cooperate. TPL information could include the name and address of an insurance company, insurance policy number, and the name and address of the policy owner. If an adult refuses, without good cause, to provide health insurance information for themselves, or anyone for whom they are legally responsible and is receiving Medicaid, the adult is ineligible until they cooperate. The following individuals are not sanctioned for non-cooperation: 1. Minors, including minor caretakers. 2. A parent or caretaker relative requesting child support services for a child receiving SSI . 3. Pregnant BadgerCare Plus members are not sanctioned during the pregnancy or the 12-month postpartum period if the TPL source is from the absent parent. 9.1.4 Third Party Liability Good Cause Claim When good cause is claimed (see SECTION 8.3 CLAIMING GOOD CAUSE), the IM agency must review the circumstances and decide on whether it is an appropriate claim of good cause. The appropriate entry on the Medical Coverage page in CWW regarding the good cause determination must be made, and the reason for the decision must be documented in case comments. TPL good cause reasons are the same as those for Medical Support.