Coordination Of Benefits And Third Party Liability (COB .
Coordination of Benefitsand Third Party Liability(COB/TPL)In Medicaid2020
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AcknowledgmentThe COB/TPL Handbook was completed by the COB/TPL Team in the Division of Health Homes,PACE, and COB/TPL (DHPC), Disabled and Elderly Health Programs Group (DEHPG), Center forMedicaid and CHIP Services, with technical support and assistance provided by Manatt, Phelps,& Phillips, LLP, under contract with Mathematica Policy Research, Inc. Members of theCOB/TPL Team were Nancy Dieter, Technical Director; Barry Levin (2014), Cathy Sturgill, andGinger Boscas (2015 - ), Health Insurance Specialists. The COB/TPL Handbook was developed atthe direction of Nancy Klimon, Former Director, and Carrie Smith, Director, DHPC (2015 - 2019).The COB/TPL Handbook was revised in 2020 at the direction of former Director, Carrie Smith,and Mary Pat Farkas, Director, by the COB/TPL team in the DHPC, DEHPG, CMCS. Members ofthe COB/TPL team Cathy Sturgill, Technical Director; Ginger Boscas, Sara Rhoades (2016 2020), Trista Chester (2017 - ), Andrea Ormiston (2020 - ), Health Insurance Specialists.3
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ABOUT THIS HANDBOOK1. Purpose: The purpose of the Handbook is to provide an overview of COB/TPL policy on avariety of individual subjects.2. Intended Audience: The Handbook is intended for CMS Central Office (CO) and RegionalOffice (RO) staff working on COB/TPL issues, state Medicaid agency staff, and all otherparties interested in Medicaid COB/TPL policies.3. Content: The Handbook contains policy guidance on a variety of COB/TPL topics that iscurrent at the time of publication.An Acronyms and Abbreviations list is included immediately after this summary.TIP: Acronyms will appear in the Handbook as blue, underlined text. Position the cursor overthe acronym and the full term will be displayed.4. Updates: Changes to the Handbook may only be made by CMS CO COB/TPL Team staff.Requests for changes to current information, or addition of information to address newtopics should be forwarded to the Centers for Medicare & Medicaid Services, 7500 SecurityBlvd., Mail Stop S2-16-25, Baltimore, MD 21244, Attn: Technical Director (TD) forCOB/TPL/DHPC/DEHPG/CMCS.5. Organization of the Handbook:a. Chapters are major subject groupings and are designated with Roman numerals.b. Sections discuss major topics within chapters and are designated with capitalletters.c. Subsections discuss single topics within sections and are designated with numbers.d. Divisions discuss single topics within subsections and are designated with lowercase letters.e. The Table of Contents lists chapters, sections, subsections, and divisions, with pagenumbers.f. The Index lists all topics in alphabetical order, with location identified by chapter,section, subsection, and division references.g. A Reference section located at the back of the Handbook includes lists of statutesand regulations.5
h. An Appendix located at the back of the Handbook includes COB/TPL trainingpresentations.TIP: Topics in the Handbook can be accessed quickly from the Table of Contents.Position the cursor over the topic and press Ctrl Click to move directly to the topic.6. Questions about format or content of the Handbook should be directed to the TD forCOB/TPL.6
ACRONYMS AND ABBREVIATIONSAcronym(the) ERSDEHPGDHPCDMEPDHHSDMEPOSDODDRA of SMSPOAAOBRA 93OCSEPACEPBMQDWIAbbreviationSocial Security ActAmerican Indian/Alaska NativeAssignment of RightsBipartisan Budget ActChildren and Adults Health Programs Group, CMCS/CMSCode of Federal RegulationsChildren’s Health Insurance ProgramCenter for Medicaid & CHIP ServicesCenters for Medicare & Medicaid Services(CMS) Central OfficeCoordination of BenefitsCoordination of Benefits/Third Party LiabilityDivision of Eligibility and Enrollment (formerly DEEO, Division of Eligibility,Enrollment, and Outreach) (CAHPG)Defense Eligibility Enrollment Reporting SystemDefense Eligibility Enrollment Reporting SystemDivision of Health Homes, PACE, and COB/TPL (DEHPG)Division of Medicaid Eligibility Programs (formerly DEE, CAHPG)Department of Health and Human ServicesDurable Medical Equipment, Prosthetics, Orthotics, and SuppliesDepartment of DefenseDeficit Reduction Act of 2005Division of State Systems GroupEarly and Periodic Screening, Diagnosis and Treatment(Medicare) Full Benefit Dual EligibleFederal Emergency Management AgencyFederal Medical Assistance PercentageFederal Financial ParticipationFederal Poverty LevelIntermediate Care Facility/Individuals with Intellectual DisabilitiesIndian Health ServiceModified Adjusted Gross IncomeManaged Care OrganizationMedicaid Management Information SystemMedicare Savings ProgramOlder Americans ActOmnibus Budget Reconciliation Act of 1993Office of Child Support EnforcementProgram of All Inclusive Care for the ElderlyPharmacy Benefit Manager(Medicare) Qualified Disabled and Working Individual7
AcronymQIQMBQMB OnlyRAROSLMBSLMB OnlySMASMMSSASSI(the) e) Qualifying IndividualQualified Medicare Beneficiary(See QMB)Remittance Advice(CMS) Regional OfficeSpecified Low-Income Medicare Beneficiary(See SLMB)State Medicaid AgencyState Medicaid ManualSocial Security AdministrationSupplemental Security IncomeMedicaid state planTechnical Advisory GroupTechnical DirectorTax Equity and Fiscal Responsibility Act of 1982Third Party LiabilityUnited States CodeDepartment of Veterans Affairs8
Table of ContentsABOUT THIS HANDBOOK. 5ACRONYMS AND ABBREVIATIONS . 7COB/TPL Overview . 13Chapter I: COB/TPL Core Concepts . . . 16A. Federal and State Partnership in COB/TPL Activities 16B.Federal Funding of COB/TPL Activities. 17C.Assignment of Rights (AOR) . 181.Relationship to Medicaid COB/TPL Activities. 182.AOR: General Requirements Related to Medicaid Eligibility . 18D. Payer of Last Resort . 201. General Requirements . 202. Exceptions . 20Chapter II: Coordination of Benefits (COB) 23A. State Plan Requirements . 231. Required Elements in State Plan . 232. State Laws Related to COB/TPL. 24B. Identifying Liable Third Parties . 251. Defining Third Party Payers . 252. Obtaining Health Insurance Information during Eligibility Determinations . 263. Exchanging Data with Other State Databases . 274. Diagnosis and Trauma Code Edits . 275. Incorporating TPL into Information Systems . 286. TPL Action Plans . 297. Waiver of Requirements . 30C. Payment of Claims . 311. Paying Claims with Established TPL . 312. Paying Claims with No Established TPL . 333. Suspension or Termination of Recovery Efforts . 344. Waiver of Requirements . 345. Never-covered services . 35D. Medical Child Support Payments . 371. Relationship to Medicaid COB/TPL Activities . 379
2. General Information. 373. Court-Ordered Health Insurance Coverage for Medical Child Support . 384. Court-Ordered Cash Payments for Medical Child Support . 385. Distribution of Collections . 39E. Dually Eligible Beneficiaries . 401. Introduction: Medicare and Medicaid Coverage for Dually Eligible Beneficiaries . 402. Medicare Coverage . 403. Types of Dually Eligible Beneficiaries . 414. Medicaid Coverage for Medicare Costs . 435. Medicaid Coverage for Medicare Advantage Plans (Medicare Part C) Enrollees. 446. Medicaid Payment Methodologies for Medicare Cost-Sharing. 467. Medicare Bad Debt Provider Enrollment . 51F. Managed Care . 521. General Requirements . 522. COB/TPL Activities by MCOs . 533. Other Managed Care Issues . 54G. Data and Systems . 561. State Systems . 562. State Medicaid Eligibility Determination Systems . 563. State MMIS . 56Chapter III: Liens and Recovery TPL 58A. Liens . 581. Description of Liens . 582. When Liens Are Permitted . 583. Restrictions on Placing Liens . 594. Termination of Liens. 59B. Estates . 611. General Overview of Estate Recovery. 612. What Services Must or May be Included in an Estate Recovery Claim . 623. When Recovery is Permitted. 634. What Assets May Be Recovered . 645. What Assets May NOT Be Recovered . 65C. Casualty/Tort Recovery . 6710
1. General Overview of Casualty/Tort Recovery. 672. Ahlborn Limitations on Settlement Funds Subject to Recovery . 673. SMAs’ Ability to Reduce Total Recovery . 684. Tort Recovery in Global Settlements . 695. Settlement of Claims for Medicare/Medicaid Dually Eligible Beneficiaries . 69Chapter IV: Other Topics 71A. Adoption & Surrogacy . 711. Adoption . 712. Surrogacy . 71B. Indemnity Plans. 72C. American Indians/Alaskan Natives . 731. IHS is a Secondary Payer to Medicaid . 732. Estate Recovery . 733. Federal Share for Reimbursement of COB/TPL Collections . 73D. Department of Veterans Affairs (VA) . 741. COB: General Rule . 742. Exception to COB: Payment for Nursing Home Care . 743. Exception to COB: Payment for Emergency Treatment at Non-VA Facilities . 74E. Department of Defense (DOD)/TRICARE . 751. TRICARE for Life . 752. Timely Filing. 76F. CMS 64 Reporting . 771. 9A – Third Party Liability (TPL) Collections. 772. 9B – Probate Collections . 77G. Health Savings Accounts (HSA) . 77H. Contingency Fee Contracts . 771. SMM 2975.4A . 772. SMM 2975.5 . 773. 45 CFR 92.36(a) . 774. SMM 2975.1, section 1903(a)(7) of the Social Security Act, 42 CFR 433.15(b)(7). 785. 45 CFR 92.36(a) . 78REFERENCE . 79List of Statutory Provisions . 7911
List of Regulations . 81INDEX . 8312
COB/TPL OverviewCoordination of Benefits:Medicaid and Other Coverage: A Medicaid beneficiary may have a third party resource (healthinsurance, or another person or entity) that is liable to pay for the beneficiary’s health care.Who are “third parties”? Health Insurers (includes private or employer-based coverage, Medicare and TRICARE)Other government programsOther liable people or entitiesWhy identify third parties? To ensure that Medicaid does not pay more than required, and to help recover Medicaidpayments, when a third party is responsible to pay for all or some of the health carereceived by the Medicaid beneficiary.Third parties should pay to the limit of their legal liability. Third party payment reducesor eliminates Medicaid payment.Coordination of Benefits (COB): Primary and Last PayersWhen a person has Medicaid and there is another liable third party: Health insurance, including Medicare and TRICARE, generally pays first, to the limit ofcoverage liability.Other third parties generally pay after settlement of claimsMedicaid is last payer for services covered under Medicaid, except in those limitedcircumstances where there is a federal statute making Medicaid primary to a specific federalprogram. The statute must expressly state that the other federal program: Pays only for claims not covered by Medicaid; or,Is authorized, but not required, to pay for health care items or services.Types of Third Party PaymentsThird party payments include health insurance benefits, settlements or court awards forcasualty/tort (accident) claims, product liability claims (global settlements), medicalmalpractice, worker’s compensation claims, etc.13
Special types of third party payments include liens (TEFRA and other), and a claim against theestate of a deceased beneficiary.COB: Medicaid and Medicare CoverageBeneficiaries who have both Medicare and Medicaid are “dually eligible.”There are several types of dual eligibility: Full Benefit Dual Eligible beneficiaries (FBDE),Qualified MedicareBeneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), QualifyingIndividuals (QI), Qualified Disabled Working Individuals (QDWI), and QMB Plus & SLMB Plus(dually eligible beneficiaries who are also eligible in anothe
Ginger Boscas (2015 - ), Health Insurance Specialists. The COB/TPL Handbook was developed at the direction of Nancy Klimon, Former Director, and Carrie Smith, Director, DHPC(2015 - 2019). The COB/TPL Handbook was revised in 2020 at the directionof former Director, Carrie Smith,
Coordination Chemistry Coordination compounds neutral coordination compounds include the metal and its bound ligands the number of bonds in a coordination complex does not correlate with the formal oxidation state of the metal coordination complexes can also be charged –complex cations or complex anions in a complex ion,
Coordination Chemistry!Coordination compound!Compound that contains 1 or more complexes!Example "[Co(NH 3) 6]Cl 3 "[Cu(NH 3) 4][PtCl 4] "[Pt(NH 3) 2Cl 2] Coordination Chemistry!Coordination sphere!Metal and ligands bound to it!Coordination number!number of donor atoms bonded to the central
Coordination Chemistry II: Isomers and Coordination Geometries Chapter 9 Monday, November 16, 2015. A Real World Example of Stuff from Class! Isomerism Coordination complexes often have a variety of isomeric forms. Structural I
MAPPING CARE COORDINATION NORT H WEST REGIONAL REPORT . 8 . Figure 3: Northwest Region Primary Responsibilities in Providing Care Coordination . Infrastructure/Supports Needed to Improve Care Coordination ("Wishes") The final level of the Care Coordination Framework includes the systems-level actions that are needed to
benefits of caring for country. These benefits include: health and wellbeing benefits; cultural and socio-political benefits; economic benefits; and, environmental benefits. The discussion includes some of the barriers to achieving benefits, as well as anticipated and realised benefits of caring for country.
834 Other long-term employee benefits are all employee benefits other than short-term employee benefits, post-employment benefits and termination benefits. Termination benefits are employee benefits provided in exchange for the termination of an employee's employment as a result of either: (a) an entity's decision to terminate an employee's employment before the normal retirement
coordination forum; one from a sister global NGO coordination forum; and one independent expert. 4. Topline recommendations To NGO coordination structures: f Ensure all changes to forum governance and membership criteria are undertaken consciously and carefully, reflecting upon criteria in a way that ensures both current members and potential new
should occur simultaneously with the utility coordination process and integration of utility accommodation. This chapter includes utility coordination general information, miscellaneous information and policies, utility coordination procedure, design considerations, reimbursement and agreements, risk analysis, and definitions.
