There are many situations in which more than one party is responsible for a health care claim. Finally, many public agencies other than Medicaid provide health coverage, including Medicare, the State Children’s Health Insurance Program, the Indian Health Service, the U.S. Other sources of coverage include worker’s compensation and property and auto insurers. In the United States there are many sources of health coverage, including indemnity health insurers, group health plans, managed care organizations, pharmacy benefit managers, and long-term care insurers.

Third Party Liability in Health Insurance The GAO noted that while states have improved TPL efforts in recent years, the increasing proportion of Medicaid enrollees with private health insurance creates additional opportunities to avoid and recover Medicaid funds ( GAO 2015). Department of Health and Human Services Office of the Inspector General (OIG) estimated that state and federal Medicaid savings from TPL totaled $13.6 billion in 2011, up from $3.7 billion in 2001 (OIG 2013).

Given the large proportion of Medicaid enrollees with access to public and private sources of third-party coverage, the potential savings to the states and federal government through effective recoveries of TPL are significant. The Government Accountability Office (GAO) estimates that out of the 56 million people enrolled in the Medicaid program in 2012, 7.6 million had private coverage and 10.6 million Medicaid enrollees had access to other public coverage, including Medicare and veterans’ and military health programs ( GAO 2015).

Medicaid enrollees also must cooperate with state efforts to pursue other sources of coverage.Ī large number of Medicaid enrollees have additional sources of insurance coverage. To implement the Medicaid TPL requirements, federal rules require states to take reasonable measures to identify potentially liable third parties and process claims accordingly. Federal regulation refers to this requirement as third party liability (TPL), meaning payment is the responsibility of a third party other than the individual or Medicaid. Medicaid is generally the payer of last resort: by law, all other sources of coverage must pay claims under their policies before Medicaid will pay for the care of an eligible individual.

Medicare timely filing limit 2015