IMA POLICY MANUAL
PART V: PROGRAM REQUIREMENTS AND SANCTIONS
CHAPTER 3: THIRD PARTY REQUIREMENTS
This chapter applies only to MA. As a condition of MA eligibility, each individual who is legally able must assign to the Department rights to third party resources, unless s/he has good cause for not cooperating.
| Third Party Liability Requirements |
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MA: 42 USC 1396k; 42 CFR
433.145-.148, 435.610 |
THIRD PARTY LIABILITY FOR PAYMENT OF MEDICAL EXPENSES 3.3
A third party resource is a person (such as a non-custodial parent), entitlement, or program that is liable for payment of all or part of an individual's medical expenses. In most instances, the third party is an insurance company. A third party resource may exist in the following situations:
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an individual has private health insurance;
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there is a court decree, such as a judgement of divorce or a child support order which includes a provision regarding medical support;
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an individual has an employment-related or school-related illness or injury;
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an individual is injured in a motor vehicle accident and car insurance is liable to cover part or all of the accident-related expenses;
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an individual is age 65 or over or disabled and is covered by Medicare (Note: these individuals may have private health insurance in addition to Medicare);
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an individual is a member of a union and receives health insurance through the union or employer;
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retired persons may have health insurance through their former employer;
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military personnel and their dependents may have medical coverage through Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) or Civilian Health and Medical Program of the Veterans' Administration (CHAMPVA); or
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an individual has an injury-related accident/incident such as medical malpractice, slip and fall, faulty products, etc. and insurance or a court settlement is covering health care costs related to the accident.
The Third Party Liability Unit is responsible for making recoveries from liable third parties. Good cause for not assigning the Department rights to third party resources from a non-custodial parent are detailed in Section 2.6: Good Cause for Non-Cooperation in this Part.
Existing Health Coverage 3.4.1
Verification of information about existing health coverage is mandatory. The preferred source of verification is a document or statement from the insurance company or organization indicating the family members who are covered and their account or claim numbers.
Assignment of Rights to Third Party Payments 3.4.2
Verification of the assignment of rights to third party payments is mandatory. The only acceptable source of verification is the signature of the applicant/recipient or his/her authorized representative on the application or recertification form.
