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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
6.3.3.5 Nursing Home and Hospital Insurance
6.3.3.5.2 Recovery of Payments
Collect insurance coverage information at application, Health Insurance review, person add, or when insurance changes and enter it into CARES Client Assistance for Re-employment & Economic Support. EDS will complete an insurance search and return verified insurance information through the CARES/ MMIS interface.
Casualty claims are those claims for MA benefits resulting from an accident for which a third party may be liable.
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Example: Mike receives treatment for injuries suffered when he was hit by a car. The vehicle owner, the third party, may be responsible for reimbursing MA for those benefits. |
The local Income Maintenance Agency works with the Coordination of Benefits Unit to recover casualty claims.
The Coordination of Benefits Unit also recovers for MA recipients who are SSI recipients. Refer all SSI recipient casualty claims directly to the Coordination of Benefits Unit at:
Bureau of Health Care Systems and Operations
Coordination of Benefits Section
P.O. Box 309
Madison, WI 53701
Telephone: (608) 267-7282
Refer casualty claims for Non-SSI recipients to EDS at 608-221-4567 or call at 608-221-4746 EXT 3109 with MA#, date of accident and insurance/attorney to bill.
The client must cooperate in providing TPL coverage and access information, unless s/he is exempt or there is good cause for refusing to cooperate.
If a caretaker refuses, without good cause, to provide health insurance information about a minor or dependent 18-year- old, the caretaker is ineligible until s/he cooperates.
Do not sanction the following for non-cooperation:
Minors, minor caretakers, and dependent 18-year-olds.
A caretaker requesting child support services for a child receiving SSI.
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).
When good cause is claimed (3.3.5), review the circumstances and decide on whether it is an appropriate claim of good cause. Make the appropriate entry on CARES screen AFMC regarding the good cause determination, and note the reason for the decision in case comments.
Collect all insurance coverage and access information for BadgerCare ( BC ) clients and enter into CARES. EDS will complete an insurance search and return the insurance information through the CARES/MMIS interface.
See 5.7.3.4 for when a client is ineligible for BadgerCare when there is insurance coverage.
All clients must cooperate in providing Third Party Liability ( TPL ) coverage and access information (6.3.2) for nursing home and hospital insurance policies (5.8.6.3.1). All clients must:
Sign over to the State of Wisconsin all their rights to payments from hospital or nursing home insurance (6.3.3.5.1).
Turn over any payments to the State of Wisconsin (6.3.3.5.2) that s/he received from nursing home or hospital insurance while receiving MA.
Any nursing home or hospital insurance payments that exceed the amount that MA has paid in benefits for that client will be refunded to him/her.
Terminate MA eligibility for the individual who is not cooperating in providing TPL insurance information (6.3.3.2), unless they have good cause (6.3.3.3).
To assign hospital or nursing home insurance payments, the client must provide a statement in writing to the insurance company requesting that all future payments be made to the State of Wisconsin. Request a copy of the client’s letter to the insurance company and send it to the following address:
Wisconsin Medicaid
TPL Unit
6406 Bridge Road
Madison, WI 53784-6220
The assignment includes all ongoing payments for as long as MA is received. Terminate MA eligibility for the individual that refuses to sign over these payments.
In some cases, payments can only be signed over to the patient. The client must cooperate in turning over these payments to the State of Wisconsin, or his/her eligibility will end for not cooperating with providing TPL coverage and access information.
The client must write on the back of the check “Pay to the order of the State of Wisconsin” and sign the check.
Collect the payments monthly from the clients along with the corresponding Explanation of Benefits ( EOB ), and send them to the following address:
Wisconsin Medicaid
TPL Unit
6406 Bridge Road
Madison, WI 53784-6220
Close the case for non-cooperation with TPL requirements if the client refuses to turn over the payments.
This page last updated in Release Number: 08-01
Release Date: 01/07/08
Effective Date: 01/07/08
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