General eligibility requirements that apply to all Apple Health programs

Third Party Liability

Revised Date: 
December 5, 2016

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.

WAC 182-503-0540 Assignment of rights and cooperation.

Effective January 27, 2019.

  1. When you become eligible for any of the agency's health care programs, you assign certain rights to the state of Washington. You assign all rights to any type of coverage or payment for health care that comes from:
    1. A court order;
    2. An administrative agency order; or
    3. Any third-party benefits or payment obligations for medical care which are the result of subrogation or contract (see WAC 182-501-0100).
  2. When you sign the application you assign the rights described in subsection (1) of this section to the state for:
    1. Yourself; and
    2. Any eligible person for whom you can legally make such assignment.
  3. You must cooperate with us in identifying, using or collecting third-party benefits. If you do not cooperate, your health care coverage may end unless you can show good reason not to cooperate with us. Examples of good reason include, but are not limited to:
    1. Your reasonable belief that cooperating with us would result in serious physical or emotional harm to you, a child in your care, or a child related to you; and
    2. Your being incapacitated without the ability to cooperate with us.
  4. Your WAH coverage will not end due solely to the noncooperation of any third party.
  5. You will have to pay for your health care services if you:
    1. Received and kept the third-party payment for those services; or
    2. Refused to give to the provider of care your legal signature on insurance forms.
  6. The state is limited to the recovery of its own costs for health care costs paid on behalf of a recipient of health care coverage. The legal term which describes the method by which the state acquires the rights of a person for whom the state has paid costs is called subrogation.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

When another party (a third party) has been identified as responsible for payment of a health care expense, Apple Health does not pay the health care claim until after the third party has paid. When Apple Health has paid a claim for a health care expense prior to third party payment, the Health Care Authority or Managed Care Organization is entitled to collect third party benefits.

The limit of the recoupment from the settlement, judgment or awards of monies is the amount of the health care expense paid by the Health Care Authority or Managed Care Organization. The method of determining what portion of a settlement represents past medical expenses is left to the state, the parties, and/or the court. Refer all such questions or challenges to Health Care Authority at 1-800-562-3022.

Assignment of rights is effective for all periods of eligibility certification, including any retroactive period of eligibility.

Worker Responsibilities

  1. 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:
    1. How the information was reported
    2. Where the information is located with the date
    3. 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.
       

  2. Completion of HCA 14-194
    1. Ensure that the individual's name and ACES client ID number is prefilled on the form before sending it to the individual for completion.
    2. Write "For Information Only" on top of the HCA 14-194 and send to DMS when the only medical resource is:
      1. Accident case with potential liability (auto, medical malpractice, homeowners);
      2. Labor and Industries coverage of an injury;
      3. Crime Victim and Victim Assistance involvement; or
      4. Products liability potential coverage.
    3. No referral to COB/TPL is necessary when the only medical resource is:
      1. Coordinated Children Services;
      2. Indian Health
      3. Veterans coverage (other than active duty military coverage or Champus);
      4. Life Insurance
      5. Automobile Insurance (unless related to a current injury);
      6. Homeowner's or Rental Insurance (unless related to a current injury);
      7. Medicare (use TPL procedures in ACES for Medicare only); or
      8. 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.

  3. 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.
    1. How to Apply
      1. Download an Application for HCA Premium Payment Program, HCA 13-705.
      2. Mail the completed HCA 13-705 to:
        Premium Payment Program
        P O Box 45518
        Olympia WA 98599-5518

        or send by fax to: 877-893-3810

        Questions? Contact a Premium Payment Program specialist at 800-562-3022, ext. 15473

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.