D-7300, Potential Sources of Third-Party Coverage

Revision 18-1; Effective March 1, 2018

TPRs include:

  • health insurance;
  • group health plans;
  • government health insurance;
  • liability or casualty insurance and court settlements; and
  • long-term care insurance policies.

A TPR is any individual, entity or program, including health insurance, that is or may be legally liable to pay all or part of the costs for medical assistance before money from the Medicaid program is spent.


D–7310 Examples of Third-Party Resources

Revision 18-1; Effective March 1, 2018

Examples of TPRs include, but are not limited to, the following:

  • health insurance;
  • self-insured plans;
  • group health plans;
  • service benefit plans;
  • employer, private purchase; and
    • union membership-based health insurance;
    • sheltered workshops;
    • continuation of health insurance coverage under statute (COBRA continuation);
    • and coverage available from an employer under the Employee Retirement Income Security Act (ERISA);
  • medical support derived from noncustodial parents;
  • armed forces and the public health service;
  • pending lawsuits or no-fault clauses or state laws covering accidents, product liability and workers' compensation;
  • employee conversion/extension rights;
  • fraternal and benefit societies and churches and church groups;
  • Insurance purchased or endowed as part of a college fee;
  • membership in a health maintenance organization (except for those with a contract under Medicare/Medicaid);
  • pharmacy other insurance;
  • worker's compensation;
  • government health insurance;
  • liability or casualty insurance and court settlements;
  • insurance (including automobile, homeowners and medical malpractice);
  • indemnity plans (if review of the plan determines that the policy provides for payment of health care items or services, including policies that pay a cash benefit to the policyholder if the payment is conditional upon the occurrence of a medical event);
  • long-term care insurance policies;
  • any other parties that are, by statute, contract, or agreement legally responsible for paying a claim for a health care item or service; and
  • Medicare.

Liability or casualty insurance and court settlements — Accidental injuries may result in third parties being liable for medical expenses. The usual sources of payment for medical expenses in these situations are automobile insurance; homeowners insurance; owners', landlords' and tenants' insurance; workers' compensation and lawsuit settlements.

Individual or group health insurance — Health insurance policies include individual or group contracts and commercial hospital, medical and surgical policies. A recipient may have medical insurance coverage from current employment, residual coverage from previous employment or private insurance paid for by the recipient or a relative. A recipient's relative may have personal or group insurance that covers the recipient's medical expenses.

TRICARE, formerly known as CHAMPUS, is a health insurance plan available to dependent children and spouses of active, retired and deceased military services personnel.

Parts A and B of Medicare provide a TPR for Medicaid recipients entitled to Medicare.