Third Party Liability
Purpose: This category applies to all individuals receiving medical assistance benefits. Federal law requires that Apple Health be the payer of last resort for the cost of medical care.
- Other Insurance: If an individual has other insurance, or indicates there is a pending lawsuit or casualty settlement, send TPL information to Health Care Authority's COB unit using tickler type: TPLI to @TPL pool, Site 102 in DMS. The tickler must include the following information:
- How the information was reported
- Where the information is located with the date
- What kind of TPL information was reported
Example: Report via document Subject: MAP in ECR 9/15/09Details: Individual reported new insurance
Example: Report via Phone or Interview Subject: See ACES narrative 9/20/09Details: Individual reports end of insurance
The HCA 14-194, Medical Coverage Information form can also be used to report insurance and casualty information, but does NOT need to be completed to report the presence of Medicare.
- Completion of HCA 14-194
- Ensure that the individual's name and ACES client ID number is prefilled on the form before sending it to the individual for completion.
- Write "For Information Only" on top of the HCA 14-194 and send to DMS when the only medical resource is:
- Accident case with potential liability (auto, medical malpractice, homeowners);
- Labor and Industries coverage of an injury;
- Crime Victim and Victim Assistance involvement; or
- Products liability potential coverage.
- No referral to COB/TPL is necessary when the only medical resource is:
- Coordinated Children Services;
- Indian Health
- Veterans coverage (other than active duty military coverage or Champus);
- Life Insurance
- Automobile Insurance (unless related to a current injury);
- Homeowner's or Rental Insurance (unless related to a current injury);
- Medicare (use TPL procedures in ACES for Medicare only); or
- Enrollment in a HMO/HIO under an Agency Medicaid contract.
Note: Coordination of Benefits (COB) automatically receives a copy of the HCA 14-194 form through the DMS System in a "to do" box when the individual completes and returns this form.
- Payment of Private Health Insurance: The Health Care Authority offers a Premium payment program for people who have been determined eligible for Apple Health, and have private health insurance (including individual policies, COBRA policies, and employer-sponsored plans). The Premium Payment Program handles applications for reimbursement of cost effective private health insurance premiums except for Medicare + Choice (managed care). All applicants for the premium payment program must first have been approved for free Apple Health coverage.
Note: An applicant diagnosed with HIV or AIDS is not eligible for Apple Health may be eligible for assistance through the Department of Health (DOH). The DOH HIV Client Services Program funds a contract to assist persons who have HIV and/or AIDS with ongoing medical insurance premiums, or to acquire insurance. For more information about this program contact the Early Intervention Program (EIP) at DOH at 1-877-376-9316 or visit the EHIP website.