Personal injury, casualty recoveries, and special needs trusts

Provide notification of injury or claim

An Apple Health (Medicaid) client or their legal representative is required to notify HCA when they file a claim against a third party, start an action at law, negotiate a settlement, or accept an offer from the liable third party. RCW 41.05A.080(1)(a); WAC 182-501-0100(6)(a).

An attorney who represents an Apple Health client who has been injured by a third party must contact HCA thirty (30) days before disbursing settlement funds. RCW 41.05A.080(1)(b). The attorney must keep the full amount necessary to satisfy HCA’s lien in their trust account or the court’s registry until the lien has been satisfied. RCW 41.05A.080(2).

For attorneys and insurance companies, it is important to contact HCA both at the beginning of the case and again before disbursing settlement funds to the Apple Health client. Sometimes it takes a while for providers to bill HCA. Even if HCA does not have a subrogated interest at the beginning of a case, claims may have been processed and paid by the time the case is ready to settle. HCA’s lien includes all injury-related medical services that have been provided through the date of settlement.

Information to include in notification of injury or claim

If you are an Apple Health client, you may have received a treatment questionnaire following your accident or injury. It is important you fill out the form and return it to HCA. HCA Casualty Unit will contact the insurance company listed on the form and/or your attorney if you have one.

If you represent an Apple Health client, provide notification of a new case by sending HCA a letter of representation. We will need a HIPAA compliant medical authorization naming the Health Care Authority to provide you with a claims ledger.

What information do I include?

To expedite your request, include the following information regarding the injured client, in your letter of representation. This information helps us determine if we have a subrogated interest.

• Full name
• Social security number or ProviderOne number (9-digit number end with WA)
• Date and type of accident
• Type of injury(ies) sustained and whether treatment has concluded (provide date of last treatment)
• Name of attorney handling the case
• Contact information for insurance company and claims adjustor, including the following:
  • Claim number
  • Policy number
  • Whether PIP/MedPay is available

Where do I send my notification?

Send your notification to one of the following:

• Email (preferred): HCA Casualty Unit (PDF documents preferred)
  • Fax: 360-753-3077
  • Mail to:
    The Health Care Authority
    PO Box 45561
    Olympia, WA 98504-5561

What happens when an Apple Health member's claim or lawsuit has resolved?

Contact us once a claim or lawsuit has been resolved, and before any settlement funds are released to the Apple Health client. We will need the following documentation to calculate HCA's proportionate share of fees and costs under RCW 41.05A.070(4)(c):

• Signed copy of the settlement or release;
• Signed copy of attorney's fee agreement with the client or, if fees were not charged according to the agreement, confirmation of the actual fee charged; and
• An itemized statement of attorney costs.

We request these documents in all cases so we can determine the final amount due to HCA.
Once we receive the information, we will calculate the final amount to pay and send payment instructions.

What if the attorney changes?

Notify us if the Apple Health client's legal representative changes.

Multiple Medicaid liens

When a person signs up for Apple Health (Medicaid), they are either fee-for-service or enrolled with a managed care organization (MCO). HCA pays for some services not covered by MCOs on a fee-for-service basis; this means there may be more than one lien. If there are two liens, payment must be made to HCA and the MCO separately.

When you contact us, we will let you know which MCOs, if any, your client was enrolled in. You must contact the MCOs directly regarding their subrogated interest.

View the Apple Health managed care page for more information about how managed care works.

Managed care organizations' (MCOs) subrogation contact

Current carriers

The following five MCOs are currently contracted with Apple Health (Medicaid):.

• Community Health Plan of Washington
  C/O Claritev
  535 E Diehl Road Suite 100
  Naperville, IL 60563

  Toll Free: 1-866-223-9974
  Fax: 1-866-926-0046
  Website: Claritev

• Coordinated Care
  C/O The Rawlings Company
  1 Eden Parkway
  La Grange, KY 40031

  Direct: 1-888-285-1276
  Fax: 1-502-440-1100

  Email: Centene Referrals

• Molina Healthcare of Washington, Inc.
  C/O Optum
  PO Box 32100
  Louisville, KY 40232-2100

  Toll Free: 1-800-395-5568
  Fax: 877-200-0207

• UnitedHealthcare Community Plan of Washington
  C/O Optum
  MN102-0300
  11000 Optum Circle
  Eden Prairie, MN 55344

  Toll free:1-800-655-4021
  Fax: 1-800-842-8810
  Email: Optum subrogation referrals
  Website: Optum subrogation referral portal (attorney portal to check online or set up a case)

• Wellpoint Washington (previously Amerigroup)
  C/O Elevance Health
  PO Box 659940
  San Antonio, TX 78265

  Toll Free: 1-844-410-6891
  Fax: 1-844-634-2520

Previous carriers

• Group Health
• Regence Blue Shield
• Asuris Northwest Health
• Columbia United Providers, Inc. (CUP) (CUP closed it's business and transferred its assets to Molina Healthcare of Washington, Inc., effective 01/01/2016. Please contact Molina or its subrogation agent for further information.)

Special needs trust monitoring and reimbursement

If an Apple Health client has a disability and is under age 65, they may be eligible to establish a special needs trust (SNT). When a client receives a personal injury settlement or award, we need to know whether they will place any of the funds in an SNT. We will need a copy of the trust and contact information for the trustee so we can monitor the trust.

Which SNTs does the HCA Casualty Unit monitor?

HCA Casualty Unit monitors first-party special needs trusts funded by a personal injury recovery. The Department of Social and Health Services monitors special needs trusts funded any other way.

What if the trustee changes?

Provide contact information for the new trustee if the trustee changes.

What if the SNT terminates?

A trustee is required to tell HCA when an SNT terminates. HCA will let you know the Medicaid reimbursement owed from the trust.

Mass tort/class action litigation

Send request to HCA Casualty Unit.

Frequently asked questions (FAQ)

Our client's card says Apple Health or ProviderOne on it. Is that your agency?

Yes. All clients enrolled in Apple Health will have a blue ProviderOne ID card. It has a nine-digit number that starts with a 1 or 2 and ends with WA.

When a Washington resident needs state Medicaid—known in Washington as Washington State Apple Health (Medicaid), or Apple Health—they apply for coverage through the Health Care Authority (HCA). In an effort to make health coverage more affordable and accessible to all eligible clients that live in Washington, the HCA contracts with MCOs.

HCA pays the client's monthly premium and any carve-outs not covered by their managed care plan. In those cases, the managed care plan becomes the primary payer and we become secondary for any noncovered services. ALL Medicaid clients will have a blue ProviderOne ID card in addition to the card provided by their managed care plan. It has a nine-digit number that starts with a 1 or a 2 and all of our ID numbers end with WA. If a client has a managed care plan, they will have an additional insurance card with an ID number for that managed care organization (MCO). The MCO card will also have the Apple Health logo on it.

Contact us if a client has either of these cards. When you contact us, will let you know which MCOs, if any, your client was enrolled in. You must contact the MCOs directly regarding their subrogated interest.

You can view samples of the cards Apple Health clients receive in the First Timer's Guide to Washington Apple Health (Medicaid).

Where do I find Apple Health Plan documents?

The Medicaid (Title XIX) State Plan is the officially recognized statement describing the nature and scope of Washington State's Medicaid Program. When Medicaid program policies or operations change or new information is added, the state sends state plan amendments (SPAs) to the Centers for Medicare & Medicaid Services for review and approval.

There are also state laws applicable to HCA, including but not limited to, Chapter 41.05 RCW, Chapter 41.05A RCW, Title 182 WAC, Title 74 RCW.

Can I pay HCA's and the MCO's subrogation balance all in one check?

No. If there are two liens, separate checks must be sent to HCA and the MCO at their respective addresses. HCA does not accept checks on behalf of the MCOs.

My client is on Medicare, do I still need to contact HCA?

Yes. It is possible for a person to be enrolled in both Medicare and Medicaid. These clients are "dually eligible" by virtue of their age or disability and low incomes. The client's primary payer for medical services is Medicare. You must contact Medicare for their conditional payment amount. Payment to Medicare does not satisfy HCA's lien.

Does ERISA apply to the Health Care Authority?

No. ERISA does not apply to publicly subsidized health plans such as Apple Health (Medicaid).

My client has received a blue Treatment Questionnaire (TQ) regarding a visit with their provider. Does the client need to complete this form and send it to HCA?

Yes. When a client becomes eligible for any of HCA's health care programs, they assign to the state any right they may have to receive payment from any liable third party for medical expenses, assistance, or residential care. WAC 182-503-0540. The client must cooperate with HCA in identifying, using, or collecting third-party benefits.