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).
DHS 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 eCIS. 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/Tricare).
Workers compensation (if an accident occurs at work).
Patient pay.
REMINDER: With the exception of patient pay liability, 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 liability or resource. Caseworkers will complete a Firm 176K/HS 176KM and OIG 173 forms in cases involving accidents or lawsuits. (See Supplemental Handbook, Chapter 915, Reimbursement.)
The CAO will enter information about medical resources into eCIS. Correct data entry is important to ensure proper billing and proper review of eligibility for children as children with a TPL that meets the definition of Minimum Essential Coverage (MEC) are not eligible to be reviewed for the Children’s Health Insurance Program (CHIP). See Section 338.23, Minimum Essential Coverage (MEC) for more information.
Exception: For medical coverage under the Health Insurance Premium Payment (HIPP) program, HIPP program staff will enter medical resource information into eCIS. (See Section 338.22.)
NOTE: MA should be continued through the end of the postpartum period even if a pregnant MA recipient is refusing to furnish TPL information.
The Bureau of Program Integrity, Division of Third Party Liability completes automated matches with various sources to find third-party resources that are not in eCIS.
Resources that are found are systematically added to the eCIS record by the Division of Third Party Liability.
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, HIPP 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, 22, 65, 66, 67, 80, and 86.
The CAO reviews all new applications (such as PA 600, PA 600 HC, or PA 600 WD or COMPASS) and renewals (such as PA 600R, PA 600-HCR, or PA 600 WD or COMPASS) to see whether an applicant or recipient has health insurance through a past or current job.
The questions below must be answered in eCIS for all employers:
Is there available Health Insurance from the current Employer?
Has individual’s employment ended in the last 30 days?
Is anyone pregnant in the household?
The following questions are optional:
Is the employer no longer offering coverage to children?
Cost to the employee for family coverage
Frequency of payment
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.
When the answer to the first or second question is “yes,” eCIS 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 eCIS, 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 they will get the HIPP letter and application in the mail and that they 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 their 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 call the HIPP regional office. (See Appendix G 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 eCIS. After a recipient is enrolled into the HIPP program, the HIPP staff is responsible for putting current resource information in eCIS. HIPP resources have a source ID of "HIP". The CAO does not make changes to HIPP resources in the TPL. If an incorrect HIPP resource is found, the CAO should notify 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 eCIS, including cases when recipients are referred to HIPP to add other members to the existing insurance plan.
Example: A parent applies for MA for themself and their two children. The parent is working and has insurance benefits for themself only. The employer offers free health insurance for employees, but family members must pay a premium. The CAO enters the TPL in eCIS for the parent and refers the case to HIPP. If cost effective, the HIPP program will pay the premium to add the children 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.
The CAO will issue an advance notice to the recipient, using reason code 042, option D failure to provide information. The notice states “You no longer qualify for this benefit because you failed to provide information needed to decide if you qualify. The following information was not received:” In the “Name” section of the notice, the CAO will enter the name of the line number indicated on the HIPP notice. In the “Item(s)” section, the CAO will enter “HIPP cooperation is a condition of eligibility.” For the due date, the CAO will enter the date the HIPP notice was received by the CAO. The CAO will narrate the action taken.
NOTE: The CAO will only close the MA of the individual named on the HIPP notice. Also, individuals who are not able to enroll themselves in the employer group health plan, such as children are not closed for failure to cooperate with HIPP
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.
338.23 Minimum Essential Coverage (MEC)
Minimum Essential Coverage (MEC) is defined as health care coverage that satifies the shared responsibility provision in the Affordable Care Act (ACA).
For information about what health care coverage meets the definition of MEC, see the MEC Desk Guide.
338.231 MEC and Children aged 6-18
Children aged 6-18 with household income between 100 and 133 percent of the Federal Poverty Limit (FPL) and who meet all other eligibility factors will also use an indication of MEC to determine category of eligibility under Modified Adjusted Gross Income (MAGI-related MA).
Additionally, any child aged 18 and under with an indication of MEC is not eligible to be reviewed for the Children’s Health Insurance Program (CHIP).
A “Minimal Essential Coverage?” check box on the Individual Attributes screen must be completed when health insurance is indicated for the child. Category placement will be determined in the following way:
NOTE: MG 00 will continue to be assigned to children age 6-18 with household income at or below 100 percent FPL regardless of health insurance.
County Assistance Office (CAO) Action
Health insurance may be reported and available to the CAO on applications, renewals, through client reported changes, or Third-Party Liability (TPL) screens in the case record, etc. If the reported health insurance is considered MEC, the CAO will check the “Minimal Essential Coverage?” box on the Individual Attributes screen when information is available that shows a child, age 18 and under, has MEC health insurance.
See MEC Desk Guide for information about what insurance is MEC. If the box is checked for any other individuals, it will not affect their MA eligibility. However, it is important to check this box for all applying children aged 18 and under due to changes to category of eligibility that may occur.
If health insurance coverage is reported on a new application, on a renewal, or through client reported changes, the CAO will update the MEC indicator on the Individual Attributes screen accordingly. The CAO will not require that the insurance question be answered on the application. The CAO will follow the existing verification policy in Chapter 378.3 to verify health insurance.
NOTE: MA should not be delayed or terminated for an individual whose responsible relative fails to cooperate in identifying and verifying TPL information.
Health insurance may also be systematically updated by TPL batch processes. Any time the CAO takes action on a case with an open MG 19 category, the CAO will review the TPL screens and ensure that the “Minimum Essential Coverage?” box is checked if the TPL screens list MEC insurance.
For COMPASS Real-Time Eligibility, children aged 6-18 with household income between 100 and 133 percent FPL will now be authorized in the MG 00 category if any type of health insurance is reported on the application. Consistent with the existing import process, the reported health insurance and the MEC check box will not be populated in eCIS. The next time a CAO takes action on the case they will need to update the MEC indicator on the Individual Attributes screen.
338.232 1095-B Form and Reporting MA as MEC to the Internal Revenue Service (IRS)
MA recipients may request the CAO generate an IRS 1095-B form which can be filed with a tax return to verify enrollment in MEC coverage. The IRS 1095-B Form will include information about all individuals in the household receiving MEC.
The IRS 1095-B will indicate the months for which the individual was enrolled in MEC. The individual is considered to have received MEC coverage for a month if the individual was covered in an MEC category for at least one day in the month. The IRS 1095-B Form will not be available for the following categories as they are not considered to be MEC:
If an individual was open in multiple cases throughout the year with the same household composition or if there are any additional people on the latest case, the system will generate the 1095-B Form for the latest case only and will show the individual’s full coverage for the year.
If an individual leaves a case and is open in a new case and the household composition has changed, a 1095-B Form will be issued for each case and will show full coverage for the year on each form.
Generating the IRS 1095-B Form
If the individual contacts the CAO for an IRS 1095-B Form, the CAO can either reprint the form through the new “1095-B Form View History/Reprint” screen in the Case Management module or direct the individual to the COMPASS website at www.compass.state.pa.us .
My COMPASS Account (MCA) users will access previously mailed IRS 1095-B Forms through their MCA account.
Non-MCA users will access IRS 1095-B Forms through a hyperlink on the COMPASS homepage.
Both MCA and non-MCA individuals will have to be authenticated prior to accessing their electronic IRS1095-B Form.
NOTE: In shared custody situations, if a parent who is not known to the child’s case requests a 1095-B Form for the child, the CAO will not share this information and will advise the parent to seek the information from other sources.
Updates/Corrections to 1095-B Form
When the individual’s coverage for the prior year changes due to a retroactive eligibility determination an updated form is created. A “Corrected” checkbox will be checked on the updated form.
If the individual requests a correction to the address or demographic information, the CAO is required to make a change in eCIS (and regenerate a form. The corrected form must be regenerated on the new “1095-B Form Correction” screen in the Case Management module of eCIS. The caseworker will choose a year for which a corrected form needs to be generated. A “Corrected” checkbox will be checked on the corrected form.
Domestic Violence (DV)
MA coverage for cases with a DV indicator will not be included on the forms of cases where DV victims and members of their household were open previously.
Example: A mother, father, and child are open in one case from January to June. The mother and child move out in July and are open in a new case with a DV indicator until December. The father stays open in the first case. 1095-B Forms will be available for both cases. The first form will show coverage for:
The second form will show coverage for:
The 1095-B Forms will be mailed to the mailing address for the case. For individuals participating in the Address Confidentiality Program (ACP), the 1095-B Form will be mailed to the ACP address.
Updated August 26, 2025, Replacing February 14, 2012