Revision 15-4; Effective October 1, 2015

Medical Programs

A TPR is a source of payment for medical expenses other than the recipient or Medicaid. TPR include payments from private and public health insurance and from other liable third parties that can be applied toward the recipient's medical expenses. Title XIX (Medicaid) funds are to be used for the payment of medical services only after all available third-party resources have been used, except for medical services from the following:

  • Texas Department of Assistive and Rehabilitative Services;
  • Texas Commission for the Blind;
  • Texas Kidney Health Care Program;
  • Muscular Dystrophy Association;
  • Children with Special Health Care Needs;
  • Texas Band of Kickapoo Equity Health Program;
  • Maternal and Child Health (Title V);
  • State Legislative Impact Assistance Grant (SLIAG);
  • Crime Victims Compensation Program; and
  • adoption agencies or adoptive parents with medical obligations to the recipient.

Income maintenance insurance policies not related to actual medical expenses are not third-party resources unless the policy is assignable to a hospital or other medical provider.

When an applicant has health insurance, the advisor must instruct the individual to tell medical providers about the health insurance. The provider then bills the insurance company rather than or before billing Medicaid.

Individuals must cooperate:

  • in identifying and pursuing any third party who may be liable for medical support payments, including absent parents who pay cash medical support;
  • in reimbursing HHSC for medical expenses paid by Medicaid from:
    • court settlements, and
    • liability, casualty, or health insurance payments, and
  • with HHSC and its Health Insurance Premium Payment (HIPP) contractor by:
    • providing information about available health insurance coverage;
    • enrolling in their employer's health insurance program; and
    • providing proof of their premium payments.

Individuals who refuse to cooperate without good cause are denied.

The denied legal parent is included in the household composition.

 

A—861 Third-Party Resources (TPR) and Accidents

Revision 15-4; Effective October 1, 2015

Medical Programs

The advisor must instruct individuals to report any accident-related injuries requiring medical care or accident-related unsettled legal claims within 60 days.

 

A—861.1 Reporting the Accident to the Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

If a recipient reports an injury requiring medical treatment for which liability/casualty insurance (the individual's own or someone else's) may provide payment, the advisor must determine the details of the accident and any legal action involved and forward the information by memorandum to:

HHSC/OIG/TPR Unit
MC 1354
P.O. Box 85200
Austin,Texas78708-5200

Advisors must include in the report:

  • individual-identifying information;
  • the date and nature of the accident and resulting injuries;
  • information regarding the liable or potentially liable third party, including the liability insurance policy number and the name and address of the insurance adjuster, if available;
  • dates, types, and sources of medical services related to the injury; and
  • the status or plans for any legal action, including the name and address of any attorney involved, if available.

 

A—861.2 Responding to Third-Party Resources (TPR) Unit Noncooperation Notices

Revision 15-4; Effective October 1, 2015

Medical Programs

When the TPR Unit becomes aware of a possible accident through information included on a Medicaid claim form, the TPR Unit contacts the individual to obtain information about the accident.

 

A—861.3 Third-Party Resources (TPR) Reimbursements

Revision 15-4; Effective October 1, 2015

 

A—861.3.1 Client-Initiated Reimbursements

Revision 15-4; Effective October 1, 2015

Medical Programs

When a recipient reimburses HHSC for medical expenses from a court settlement or from a liability, casualty, or health insurance payment, the reimbursement should be by personal check, cashier's check, or money order payable to the Texas Department of Health and Human Services.

Advisor action:

  1. Give the individual Form H4100, Money Receipt.
  2. Send the reimbursement and a copy of Form H4100 to ARTS at P.O. Box 149044, Austin, Texas 78714.
  3. Enter the type(s) and date(s) of the medical service(s) in the "For" section of the form.
  4. If unsure what medical services were involved, complete a memorandum giving as much information as is known concerning the reimbursement.
  5. Attach a copy of any information identifying the nature of the payment, such as a statement from the insurance company, to Form H4100.

The actual claim paid by Medicaid is verified in state office, and the individual is reimbursed if the payment made is in excess of the Medicaid payment. The advisor is notified of the reimbursement. Advisors must consider the reimbursement as possible TANF and/or TP 08 income.

 

Related Policy

Lump-Sum Payments, A-1331
Reimbursements, A-1332

 

A—861.3.2 Reporting Non-Reimbursement to the Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

When an advisor becomes aware that a recipient received a reimbursement for medical expenses paid by Medicaid and failed to reimburse HHSC, the advisor reports the non-reimbursement to the TPR Unit. The advisor must include any available information about the accident and the payment in the report.

The TPR Unit investigates the claim and reports back. The advisor uses the guidelines in A-861.4, Responding to Third-Party Resources (TPR) Unit Recovery Requests, upon receipt of a memo from the TPR Unit confirming the non-reimbursement.

 

A—861.4 Responding to Third-Party Resources (TPR) Unit Recovery Requests

Revision 15-4; Effective October 1, 2015

Medical Programs

Advisors use the following chart in responding to TPR Unit recovery requests.

When the TPR Unit becomes aware that an individual received a private insurance payment and has not made any payments to the Medicaid provider, the TPR Unit sends a memo to the regional director. The memo includes the amount of:

  • Medicaid paid; and
  • the private insurance payment, if known.

The advisor must use the following procedures after receiving the memo:

Step

Action

1

Send Form H1020, Request for Information or Action, to the caretaker, requesting that the individual:

  • provide verification of the amount of the private insurance payment, and
  • contact the advisor about reimbursing HHSC.

If the individual does not respond, then go to Step 2.
If the individual does respond, then go to Step 3.

2

Send Form TF0001, Notice of Case Action, to initiate action to disqualify the legal parent from the certified and/or budget group. Process a referral for intentional program violation if the Medicaid payment was $100 or more. To report waste, abuse or fraud to the OIG/TPR Unit, use the online reporting form https://oig.hhsc.state.tx.us/wafrep/ or call toll-free 1-800-436-6184.

3

Collect the lesser of the:

  • Medicaid payment, or
  • private insurance payment.

Note: If the private insurance payment is greater than the Medicaid payment, count the difference as lump-sum payments for TANF, SNAP and Medical Programs. Refer to A-1200, Resources, and A-1300, Income, for policy on how to count the payments.

If the individual does not make a full payment, then go back to Step 2.

If the individual makes full payment, then go to Step 4.

4

When the individual makes a payment:

  • ensure the payment is made by personal check, cashier's check or money order payable to the Texas Department of Health and Human Services;
  • give the individual Form H4100, Money Receipt. Annotate the form with "TPR/TMHP Insurance Recovery”; and
  • send a copy of Form H4100 with the payment to Fiscal Division, State Office, E-411.

 

A—861.5 Remitting Cash Medical Support Payments to the Third-Party Resources (TPR) Unit

Revision 15-4; Effective October 1, 2015

Medical Programs

After certification, Medicaid recipients must remit to the TPR Unit any cash medical support payments received for a certified child. The advisor gives the individual sufficient copies of Form H1710, Payment Identification, and TPR self-addressed envelopes, if payments are being made or might be made. The advisor instructs the individual upon receipt of a cash medical support payment from an absent parent after certification of the requirement to:

  • write on the check or money order "Deposit Only - State Treasury" and to not endorse the check or money order;
  • include Form H1710 with the check or money order; and
  • send it to the HHSC/OIG/TPR Unit, MC 1354, P.O. Box 85200, Austin, TX 78708-5200.

If the individual turns in cash medical support payments to the local office, the advisor must:

  • forward the payment(s) to the HHSC/OIG/TPR Unit; and
  • give the individual a copy of Form H4100, Money Receipt.

Upon becoming aware that an individual did not remit a cash medical support payment, advisors must follow policy in B-700, Claims, and process a claim for the month(s) of unreported income, if required.

Related Policy

TANF, A-1124
Medical Support Payments, A-1326.2.3

 

A—862 Third-Party Resources (TPR) Reporting System

Revision 15-4; Effective October 1, 2015

Medical Programs

The application asks applicants and individuals whether any household members have health insurance. Form H1028, Employment Verification, asks employers to verify if health insurance is available, and whether the employee is enrolled. When an individual reports a new job or a change in employers, the advisor determines whether there is any new or potential private health insurance coverage for certified household members during the eligibility interview or application processing.

If information from the individual, the employer or other source indicates ...

then report ...

Medicaid-eligible household members have private health insurance coverage,

information about the private health insurance in the Third Party Resources logical unit of work of the case the individual is a member of 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 in the Third Party Resources logical unit of work of the case the individual is a member of in TIERS.

The TPR Unit will use the information to initiate an inquiry about HIPP Program eligibility.

To contact the TPR Unit about TPR questions or problems:

  • advisors may call 1-800-846-7307.
  • clients may call the Client Medicaid Hotline at 1-800-252-8263.

 

A—863 Health Insurance Premium Payment (HIPP) Program

Revision 17-1; Effective January 1, 2017

Medical Programs

The Health Insurance Premium Payment (HIPP) program is a Medicaid benefit that helps families pay for employer-sponsored health insurance.

To qualify for HIPP, an employee must either be Medicaid eligible or have a family member that is Medicaid eligible. The HIPP program may pay for individuals and their family members who receive, or have access to, employer-sponsored health insurance benefits when it is determined that the cost of insurance premiums is less than the cost of projected Medicaid expenditures.

Note: An employee and their Medicaid-eligible family member must be enrolled in the employer-sponsored health insurance in order to receive HIPP reimbursements.

Medicaid-eligible HIPP enrollees do not have to pay out-of-pocket deductibles, co-payments, or co-insurance for health care services that Medicaid covers when seeing a provider that accepts Medicaid. Instead, Medicaid reimburses providers for these expenses.

HIPP enrollees who are not Medicaid eligible must pay deductibles, co-payments, and co-insurance required under the employer's group health insurance policy.

Report individuals who are potentially eligible for HIPP on Form H1039, Medical Insurance Input. Send Form H1039  to HHSC's Third Party Resource (TPR) Unit, Mail Code 1354.

HHSC's TPR Unit refers Form H1039 to the current state Medicaid contractor, Texas Medicaid and Healthcare Partnership (TMHP). If TMHP determines it is cost-effective for Medicaid to pay the recipient's employer-sponsored health insurance premiums, then TMHP sends:

  • a letter to the recipient and requests verification of the employer-sponsored insurance plan and premium payments; and
  • a premium reimbursement to the recipient upon receipt of complete documentation and proof of the premium payment.

Note: Do not consider an incurred medical deduction for the reimbursed premium for individuals participating in HIPP.

TMHP will terminate HIPP enrollment if the individual is no longer enrolled in health insurance coverage or fails to provide TMHP with the information needed to determine cost effectiveness or proof of premium payments.

For more information about the HIPP program, see HHSC's website: http://hhs.texas.gov/services/financial/insurance/health-insurance-premium-payment-hipp, or contact the Medicaid HIPP program at MCD_HIPP_Program@hhsc.state.tx.us.

Individuals may call 800-440-0493 for more information.

Related Policy

Reimbursements, A-1332