An official State of Texas website.
Revision 09-4; Effective December 1, 2009
Texas requires, as conditions of Medicaid eligibility, that a person must:
- cooperate in providing any third-party resource (TPR) information to HHSC; and
- agree to the assignment of rights (AOR) of any TPR benefits to HHSC.
Medicaid is usually the payer of last resort. A TPR is a source of payment for medical expenses other than the person, HHSC or Medicaid. A TPR must be applied toward the person's medical and health expenses.
Under state law, an applicant or recipient of Medicaid automatically gives HHSC his/her right to financial recovery from personal health insurance, other recovery sources or personal injuries, to the extent HHSC has paid for medical services. This allows HHSC to recover the costs of medical services paid by the Medicaid program. Any applicant or recipient who knowingly withholds information regarding any sources of payment for medical services violates state law.
Fraud Referrals — Medicaid recipients must report any TPR within 60 days of learning about the coverage or liability. An applicant or recipient who knowingly withholds information regarding any sources of payment for medical services violates state law.
Refer the person for fraud, if the person:
- fails to report any TPR coverage or liability within 60 days; or
- does not reimburse HHSC when a third-party payment for medical services is received and the expenditure is $100 or more.
Denial — Deny the person if the person refuses to:
- cooperate in providing TPR information; or
- agree to the AOR of TPR benefits to HHSC.
See Appendix XVI, Documentation and Verification Guide.