Revision 20-4; Effective December 1, 2020

There are two methods of Third-Party Recovery (TPR):

  • cost avoidance, in which available third-party benefits are applied before Medicaid payment is made. This is the method of Third-Party Recovery required by the Centers for Medicare and Medicaid Services (CMS); and
  • post-payment recovery, where Medicaid pays the medical costs before seeking reimbursement. This method is typically used when Medicaid is unaware of the TPR at the time of billing or the TPR is not eligible for use at the time of billing (e.g., a trust or annuity).

HHSC uses the cost avoidance method of TPR for Medicaid payments to nursing facilities (NF), hospice providers, and non-state intermediate care facilities for persons with intellectual disabilities (ICF/IID). The cost avoidance method requires providers to bill the recipient’s long-term care insurance (if applicable) before billing Medicaid. This ensures that Medicaid is the payer of last resort.

A Medicaid recipient must reimburse HHSC as soon as they receive a third-party payment for medical services already paid by Medicaid.

A provider who receives a third-party payment for medical services already paid by Medicaid must process an adjustment claim and report the third-party payment amount on the claim. The Medicaid paid claim is reduced by the amount of the other insurance payment reported on the adjustment claim.

Providers can contact Texas Medicaid and Healthcare Partnership (TMHP) for assistance with adjustment claims at 800-626-4117, option 3.

Providers may contact TMHP at 800-626-4117, option 6 to report other insurance coverage for a Medicaid recipient.

D–7410 Cost Avoidance

Revision 18-1; Effective March 1, 2018

Inform the person to:

  • use health insurance as a resource;
  • tell medical providers that the person has insurance coverage; and
  • show providers any insurance identification card the person may have.
If the person, the employer or other sources indicate that ...then complete ...
Medicaid-eligible household members have private health insurance coverage,

information about the private health insurance on:

  • the TPR screen in TIERS. This screen will interface with the TMHP TPR Unit.
  • report any changes in insurance coverage for existing recipients via the TPR screen in TIERS.
health insurance coverage is available for Medicaid-eligible household members, but the members are not enrolled in the health insurance plan,

information about the available health insurance on:

  • the TPR screen in TIERS. This screen will interface with the TMHP TPR Unit. The TMHP TPR Unit will use the information to initiate an inquiry about Health Insurance Premium Payment (HIPP) program eligibility.

To contact the TPR Unit with questions or problems concerning TPR:

HIPP Program Notes: Individuals approved for the HIPP Program receive reimbursement for the employee’s portion of an employer-sponsored health insurance premium payment. For eligibility and co-payment calculations, HIPP reimbursement checks are not considered income.  For co-payment calculations, the reimbursed health insurance premium payment is not considered an incurred medical expense.

TMHP will take action to deny all benefits to a recipient who voluntarily drops his or her health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness.

A recipient cannot appeal decisions made by TMHP. To obtain assistance in resolving problems or issues concerning HIPP, contact the TPR HIPP Unit at 800-440-0493.

For more information about the HIPP program, see HHS' HIPP website: https://hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program.

Recipients may also call 800-440-0493 for more information.

D–7420 Post-Payment Recovery

Revision 25-1; Effective March 1, 2025

Sources for post-payment recovery include liability or casualty insurance and court settlements resulting from accidental injuries. If a person reports an injury that requires medical treatment that liability or casualty insurance may provide payment for, ask the person to provide the date of the accident.

Report potential subrogation funds available from trusts, annuities and court settlements to the Texas Medicaid and Healthcare Partnership (TMHP) Third Party Liability (TPL) Tort department by emailing Form H1210, Subrogation for Trusts, Annuities and Court Settlements, to Tort Subrogation.

When the TPL Unit at TMHP becomes aware of accidental injuries, it seeks cost recovery from people who receive a health insurance or settlement payment for medical services already paid by Medicaid.

When a person reimburses HHSC for medical expenses, the reimbursement should be in the form of a personal check, cashier's check or money order.

Follow these steps when a reimbursement is received:

StepProcedure
1Give the person Form H4100, Money Receipt.
2Enter the types and dates of the medical services in the For section of Form H4100.
3If unsure about which medical services are involved, attach a memorandum giving as much information as possible about the reimbursement.
4Attach a copy of any other document identifying the nature of the payment, such as a statement from the insurance company.
5Send the reimbursement, a copy of Form H4100 and any other information to HHSC Accounts Receivable, P.O. Box 149055, Mail Code 1470, Austin, TX 78714-9055.

State office verifies the actual claims paid by Medicaid and refunds any overpayment.