9.1 Third Party Liability

9.1.1 Third Party Liability Introduction
9.1.2 Third Party Liability Cooperation
9.1.3 Third Party Liability Cooperation Requirements
9.1.4 Third Party Liability Good Cause Claim
9.1.5 Assignment Process

9.1.1 Third Party Liability Introduction

TPLThird Party Liability. The obligation a third party (not Wisconsin Medicaid or the Medicaid member) has to pay the bills for a Medicaid member’s medical services. refers to the obligation a third party (not Wisconsin Medicaid program or the Medicaid memberA recipient of Medicaid; formerly referred to as a "client."), has to pay the bills for a Medicaid member’s medical services. Medicaid is the payer of last resort for the cost of medical care. This means that if a Medicaid member also has coverage under a private health insurance plan, that plan is to be billed first for any medical services. Medicaid then pays any amount remaining after the private insurer has paid what they owe, up to the Medicaid reimbursement rate. Another common example of TPL is when someone receives an insurance settlement resulting from an accident. If Medicaid paid for any medical services resulting from that accident, the Medicaid program is to be reimbursed the cost of those medical services from the proceeds of the insurance settlement. Third party payers include health insurers, court ordered medical support, and any other third party that has a legal obligation to pay for medical services.

9.1.2 Third Party Liability Cooperation

All Medicaid members must assign to the State of Wisconsin their rights to payments for medical services from third-party payers. A member complies with this requirement by signing the application form. The assignment includes all unpaid medical support and all ongoing medical support obligations for as long as Medicaid is received. In addition, Medicaid members must cooperate in identifying and providing information to assist the State in pursuing third parties who may be liable to pay for care and services, unless the individual establishes good cause for not cooperating. If a member fails to cooperate with TPL requirements, they could be sanctioned.

9.1.3 Third Party Liability Cooperation Requirements

The Medicaid member must cooperate in providing TPL information unless he or she is exempt or there is good cause for refusing to cooperate. TPL information could include the name and address of an insurance company, insurance policy number, and the name and address of the policy owner.

If an adultAn adult is anyone age 18 or older. refuses, without good cause, to provide health insurance information for themselves, or anyone for whom they are legally responsible and is receiving Medicaid, the adult is ineligible until he or she cooperates.

Do not sanction the following for non-cooperation:

Minors, including minorA minor is a person less than age 18. caretakers.
A parent or caretaker requesting child support services for a child receiving SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. .
Pregnant woman – She may not be sanctioned during the pregnancy, or for two months after the pregnancy has ended, if the TPL source is the absent parent of her child(ren).

9.1.4 Third Party Liability Good Cause Claim

When good cause is claimed (see Section 8.3 Claiming Good Cause), the IMincome maintenance agency must review the circumstances and decide on whether it is an appropriate claim of good cause. The appropriate entry on the Medical Coverage page in CWWCARES Worker Web regarding the good cause determination must be made, and the reason for the decision must be documented in case comments.

TPL good cause reasons are the same as those for Medical Support.

9.1.5 Assignment Process

At application or a new request for health care on an existing case, the IM agency must give a Notice of Assignment: Child Support, Family Support, Maintenance, and Medical Support (DCF-F-DWSP2477, available in English and Spanish) to each applicant. Applicants and members are not required to sign this form in order to be eligible for health care programs.

Exception: The agency does not need to provide the Notice of Assignment to health care applicants who apply via ACCESS since this information is included in the ACCESS application

This page last updated in Release Number: 23-03
Release Date: 08/14/2023
Effective Date: 08/14/2023