IM-64 June 29, 2021; IM-80 June 11, 2020
Per RSMO 208.215, MO HealthNet is the payer of last resort. MO HealthNet is not obligated to pay for a participant’s medical expenses until other resources, such as private or employer-sponsored health insurance, have been considered. This concept is referred to as Third Party Liability (TPL). Health insurers and other payers are referred to as Third Party Resources (TPRs).
The purpose of TPL is to offset or recover costs to Missouri. In order to do this, TPRs must be properly reported and documented on behalf of participants. When a participant indicates a TPR, gather all necessary information regarding the policy. Review the participant’s MTPR screen to check for existing health insurance. If the reported health insurance is not present, complete a TPL-1 form to capture necessary details about the policy.
Information required on a TPL-1 includes, but may not be limited to:
- insurance company name and address
- employer name and address
- policyholder name
- policy number
- social security number of the policyholder
Complete a TPL-1 for each insurance policy. Report the following types of health insurance on the TPL-1:
- employer sponsored insurance
- self-insured labor unions and welfare funds
- commercial health insurance policies (policies not provided/administered by a government program)
- Medicare supplements
- hospital indemnity policies
- nursing care or long term care policies
- Veterans Administration
- accident insurance that covers medical care necessary due to an accident
- critical care/cancer policies
- Policies can include medical benefits and income payments
- vision, dental, and pharmacy policies
- healthcare sharing ministries such as Christian Healthcare Ministries.
Note: Though all of these plans do provide some health benefits, not all of the plans meet the federal minimum essential coverage requirement.
Do not report the following types of health insurance on a TPL-1 form:
- MO HealthNet or managed care plans
- income replacement or disability policies
- these can be individual or group policies
- life and burial insurance
- school accident insurance
- automobile insurance
Additional information on completing the TPL-1 form can be found in the TPL-1 Instructions.
A TPL form can be used to report changes to an existing TPR such as a policy end-date or additional policy members. Review the MTPR screen to determine if changes are needed.
Issues due to outdated TPR information can be reported using the process found in the Adding/Updating Private Insurance Information Guide.
Forward TPL-1 forms to the TPL Unit using the process outlined in the Adding/Updating Private Insurance Information Guide and maintain a copy in the electronic record.
Do not deny or close coverage because a participant failed to provide complete information regarding a TPR.
EXAMPLE: Andrea files an application on which she claims health insurance. She is eligible for MO HealthNet for Pregnant Women (MPW), but did not provide the details of her health insurance. Her case is approved and a request for information is sent to gather the insurance information, but she fails to respond. A staff member completes a TPL-1 with information known about Andrea and forwards it to the TPL Unit.
Uninsured status is an eligibility factor for certain types of coverage, such as Children’s Health Insurance Programs (CHIP). To determine eligibility for one of these coverage types, insured status cannot be questionable.
EXAMPLE: Amy files an application and attests to income in the Uninsured Women’s Health Services (UWHS) level. She claims no insurance; however, she supplies paystubs that reflect a health insurance deduction. Her insured status is questionable and she must be contacted to resolve the issue before she can be determined eligible for UWHS.
If a participant indicates a reluctance to provide TPR information due to a fear of domestic violence or abuse, include this information on the TPL-1 form. The TPL Unit will determine if good cause exists and if payment should be sought from the TPR.
NOTE: Heath insurance (including vision, dental, etc.) membership and premiums can affect other types of assistance. Document insurance policies and the cost, if applicable, in the appropriate area of the electronic eligibility system(s) to ensure correct eligibility for other programs.