Adult Medicaid Manual MA-2400 THIRD PARTY RECOVERY

III. TYPES OF THIRD PARTY RESOURCES

A. Types of Private Insurers

1. Any commercial insurance company offering medical or casualty insurance to individuals or groups, including indemnity contracts.

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(III.A.)

2. Any profit or non-profit prepaid plan offering either medical service or full or partial payment for diagnosis or treatment of an injury, disease, or disability.

3. Any organization administering medical, casualty or indemnity insurance plans for professional associations, unions, fraternal groups, employer/employee benefit plans, and any similar organizations offering these payments or services, including self-insured and self-funded plans.

4. Examples:

a. Individual private medical policies, including Medicare supplemental policies sometimes called “Medi-Gap”.

b. Family medical and group medical policies.

c. Individual or group accident policies.

d. Prescription drug policies.

e. Vision policies.

f. Dental policies.

g. Long term care policies.

This list is not all inclusive.

5. EIS 3350 includes descriptions of most types of health insurance.

B. TRICARE and CHAMPVA

1. Determine whether a/r or a/r’s spouse, parent or stepparent is on active or retired military duty. Refer to questions in IV. to solicit this data.

2. If a/r indicates he has TRICARE or CHAMPVA, accept his statement.

3. If you have further questions on eligibility requirements, contact:

a. TRICARE by calling 1-888-363-5433 or by going to the web site at http://tricare.osd.mil, or

b. CHAMPVA by calling 1-888-733-8387 or by going to the web site at www.va.gov/hac, or

c. Your local military personnel office.

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(III.)

C. Medicare Part A and B (Title XVIII)

1. Medicare is a health insurance program for people 65 years of age and older, disabled people under 65 years of age as determined by the Social Security Administration and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

2. Most people do not pay a monthly premium for Part A benefits. Medicaid pays Part B medical coverage premiums when eligibility is approved. See MA-2410, Medicare Enrollment & Buy In.

3. The Health Insurance Claim (HIC) identification number for Social Security Medicare is identifiable by an alpha suffix.

4. Information regarding Medicare coverage is generated by system exchanges. Refer to II.B.7, above.

D. Railroad Retirement Act

1. Medicare is available to every retired employee of any American railroad company through the Railroad Retirement Act.

2. Medicare Part A coverage is free to the Railroad Retirement retiree. Medicaid pays the premiums for Part B coverage when eligibility is approved.

3. The HIC identification number for Railroad Retirement Medicare is identifiable by an alpha prefix.

4. Information regarding Medicare coverage is generated by system exchanges. Refer to II.B.7, above.

E. Tort Liability

1. Definition

a. “Tort liability” means failure to use reasonable care when such failure results in injury to another and for which a civil action can be brought.

b. Most policies of this kind have medical payment coverage which pay a limited amount toward medical expenses related to accidents even without fault being proved against the responsible party.

2. Types

a. Motor vehicle accidents of all kinds,

b. Accidents in commercial buildings or businesses,

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(III.E.2.)

c. Medical malpractice,

d. Accidents in or on private property not owned or occupied by the recipient,

e. Worker’s Compensation,

f. Criminal assaults.

3. Procedures

a. At application, redetermination, or change in situation, ask the a/r whether he has been involved in any type of accident.

b. Follow up on leads (e.g., statements by the a/r, articles in the local newspaper) regarding information that an a/r has been involved in an accident or an assault which may potentially be covered by a third party source.

c. Document the a/r’s statement in the case record.

d. Report information regarding accidents involving tort liability to Division of Medical Assistance, Third Party Recovery Section, on DMA-2043, Third Party Recovery “Accident” Information Report.

Do not enter information for tort liability accidents on the TA Screen/TU Screen.