The recipient must give information about any third-party resources that may be available to pay medical expenses. This includes medical resources available from legally responsible relatives (LRR). 55 Pa. Code § 178.3(1) 55 Pa. Code § 178.3(3)
DPW is the payer of last resort for all medical expenses. The CAO will review third-party resources at each application and renewal and record them in the case file. Third-party resources include, but are not limited to, the following:
Private health insurance plans.
Health insurance plans (including dental, prescription, vision, and major medical) offered by an employer (See Section 338.22, Health Insurance Premium Payment (HIPP) Program).
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
Workers compensation (if an accident occurs at work).
Patient pay.
Reminder: With the exception of patient pay liability (900P0), only insurance policies are considered third-party resources. When a court order names an LRR who must pay for medical bills not covered by insurance or other sources, the LRR cannot be listed as a third-party resource. These cases must go through the Domestic Relations Office.
NOTE: Car insurance is not considered a third-party resource. Caseworkers will fill out the PA 176K/176KM and 173-S forms in cases involving accidents or lawsuits. (See Supplemental Handbook Chapter 915, Reimbursement.)
The CAO will enter information about medical resources into CIS. (See the “Using TPL” OIM manual.)
NOTE: If the client has HMO coverage through an out-of-state provider and there are no providers in that plan in Pennsylvania, the CAO will not enter the HMO in the TPL file. A local provider can be used if the HMO has a national network.
Exception: For medical coverage under the Health Insurance Premium Payment (HIPP) program, HIPP program staff will enter medical resource information into CIS and the TPL. (See Section 338.22.)
The Bureau of Financial Operations, Third Party Liability Unit completes automated matches with Blue Cross, Blue Shield, Medicare, and Workers Compensation files to find third-party resources that are not in the CIS TPL.
The Bureau of Information Systems (BIS) will enter any new information from the match into the master file.
NOTE: A Blue Cross/Blue Shield match may show that a individual has a job that has not been reported.
The HIPP program pays MA recipients’ premiums for group health insurance offered by their employers when cost effective.
The CAO will refer recipients with access to employer group health insurance to the HIPP program if they are not excluded from HIPP referral. (See Section 338.223, Referral Process.)
The CAO will not refer the following people to the HIPP program:
Recipients over age 65.
Recipients with Medicare.
Recipients in monthly spend-down cases.
Recipients in presumptive eligibility cases.
Recipients getting only Supplemental Nutritional Assistance Program (SNAP).
Recipients in the following categories or with the following program status codes will not be referred to the HIPP program:
Categories: A, PA, PJ, PM, TA, TJ, and SNAP-only cases.
Program status codes: 00, 17, 21, 65, 66, 67, 80, and 86.
The CAO reviews all new applications (such as PA 600, PA 600-CH, or PA 600 WD or COMPASS) and renewals (such as PA 600R, PA 600-CH, or PA 600 WD or COMPASS) to see whether an applicant or recipient has health insurance through a past or current job. These questions have been added to CIS:
Current Employment: Could anyone in your family get health insurance at their job?
Employment Ended in the Past 30 Days: Did you, or someone in the family, lose a job within the past 30 days where you had health insurance?
Anyone Have a Serious Illness: Is there someone in your family who is pregnant or seriously ill?
The recipient must answer these questions. The CAO will make sure they are correct after discussing the HIPP program with the recipient. The answer to the first question must be “yes” if anyone in the family has a job and:
Could buy coverage for the employee or the family.
Has free coverage for the employee and could buy coverage for other family members.
Is paying for coverage but is planning to stop paying for it.
For applications, clerical staff complete data entry for the questions using the applicant’s answers along with work history information. The income maintenance caseworker (IMCW) will make any needed corrections using information from the interview process. The IMCW’s complete data entry for renewals and case record actions.
When the answer to the first or second question is “yes,” CIS sends a letter to the recipient. When the third answer is also “yes,” the case is treated as a priority referral and is tracked by the HIPP program. The client letter explains the HIPP program, and an application for the program, as well as a self-addressed stamped envelope is sent with the letter.
It is important for the applicant or recipient to give correct answers to the first two questions about health insurance that may be available through current or past employment. The IMCW reviews the answers to make sure the answers are correct.
The CAO enters the answers into CIS, which will automatically create a letter to the recipient and refer the case to HIPP. If the applicant or recipient answered "yes" to either of the first two questions, the caseworker must review the HIPP program with the individual. The IMCW tells the individual that he or she will get the HIPP letter and application in the mail and that he or she must complete and return the application to the HIPP program.
The CAO lets the applicant or recipient know that cooperation with the HIPP program is a condition of MA eligibility and that not cooperating could mean the loss of his or her MA benefits. The CAO explains that HIPP staff determine cost effectiveness and must send a letter explaining the determination.
The CAO should contact a HIPP regional office with any questions about HIPP. If an applicant or recipient contacts the CAO with a question about a HIPP letter, the CAO tells the individual to write or call the HIPP regional office. (See Appendix I for a list of regional offices and contact information.)
In emergency situations, such as when the applicant or recipient may miss an open enrollment period or group health insurance is about to lapse, the CAO will call the HIPP regional office to complete the referral process.
HIPP program staff determine eligibility for the HIPP program and send letters to both the individual and the CAO if the application is cost effective.
Group health insurance is treated like any other third-party resource. Eligible services not covered by group insurance will be paid by MA.
HIPP program staff enter resource information for coverage under the program into CIS and the TPL. After a recipient is enrolled into the HIPP program, the HIPP staff is responsible for putting current resource information in the TPL. HIPP resources have a source ID of "HIP" in the TPL. The CAO does not make changes to HIPP resources in the TPL. If an incorrect HIPP resource is found on the TPL, the CAO notifies the HIPP regional office.
Employer group health insurance premiums are not used as medical expense deductions for recipients in the HIPP program. The CAO continues data entry of third-party resources in CIS and the TPL, including cases when recipients are referred to HIPP to add other members to the existing insurance plan.
Example: A grandmother applies for MA for herself and her two grandchildren. The grandmother is working and has insurance benefits for herself only. The employer offers free health insurance for employees, but family members must pay a premium. The CAO enters the resource on the TPL for the grandmother and refers the case to HIPP. If cost effective, the HIPP program will pay the premium to add the grandchildren to the employee's insurance plan and update the TPL.
To stay eligible for MA, a recipient whose group health plan is cost effective must cooperate with the HIPP program. If a recipient does not cooperate with the HIPP program, HIPP staff sends a notice to the CAO. The CAO issues an advance notice to stop the individual’s MA benefits.
NOTE: A recipient’s failure to cooperate only affects case members who can enroll themselves in the employer group health insurance plan. Ineligible household members remain ineligible until they enroll in the group health insurance plan found cost effective or the insurance is no longer available.
Updated February 14, 2012, Replacing March 8, 2008