2230 Third Party Liability | Medicaid

If a TPL exists a Form DMA 285, Health Insurance Information Questionnaire, must be signed and placed in the case record or scanned into DIS. A copy of the front and back of the Medical Insurance card, if available, should also be scanned into DIS. The reported TPL must be entered into Gateway on corresponding page as this is electronically transmitted to HMS. Do not submit Form DMA 285 if Medicare is the only TPL.

Form DMA 285 is not needed if the AU reported their TPL while using one of the following:

If an AU has no TPL, completion of the DMA 285 is not required if application for Medicaid is made with the following forms that include the assignment of TPL rights:

The assignment of TPL rights must be done at each application and renewal. If a renewal is completed by phone, a renewal form must be sent to the A/R for signature, and the form must be returned to prevent penalization/loss of coverage.

For MAGI Family Medicaid COAs a separate DMA 285 is not required if the Form 94A Medicaid streamlined application, or pre-populated renewal (web services) has the TPL information included, and the form is signed.

For Q-Track applications, a DMA 285 is not required to be completed even when the AU has TPL. A copy of the application may be submitted in lieu of the DMA 285 with a copy of the insurance card attached, if possible.

Mail, fax, or email Form DMA 285 to:

Health Management Systems
100 Crescent Centre Pkwy, Suite 1000
Tucker, Georgia 30084
Phone 678-564-1162, Press 3
Email: gatpl@gainwelltechnologies.com

or

fax # 770-937-0180

Any trust, such as a Special Needs Trust, Qualified Income Trust (QIT), Pooled Trust or other similar legal document is considered a TPL and is to be reported to DCH. Annotate Form 285 to indicate there is a trust document. Attach a copy of the trust or legal document and mail or email to the TPL Trust Unit.

If mailed, send the trust document (including QITs that adhere to a DCH approved format along with the QIT Certification form) and Form DMA 285, Health Insurance Information Questionnaire, to:

Georgia Department of Community Health
ATTN: Trust Unit
100 Crescent Centre Pkwy, Suite 1000
Tucker, GA 30084
Email: gatrustunit@gainwelltechnologies.com
Fax: 678-564-1169

Mail QITs that do not adhere to one of the DCH approved formats to:

Georgia Department of Community Health
ATTN: Trust Unit
100 Crescent Centre Pkwy, Suite 1000
Tucker, GA 30084
Email: gatrustunit@gainwelltechnologies.com
Fax: 678-564-1169

Include Form 947 - QIT Approved Format Deviation Form, found in Appendix F - TOC; explaining how the trust differs from the DCH approved QIT format and proof that a QIT account has been opened.

When the A/R with a trust/QIT dies or becomes ineligible, send the TPL Unit a copy of the original DMA 285. Annotate in red at the top of the form that the A/R is deceased/ineligible, the date of death/ineligibility, and whether the TPL is a trust or QIT.

Qualified Income Trust
Fax: 678-564-1169
QIT email: gatrustunit@gainwelltechnologies.com

Special Needs Trusts
Contact numbers: 678-564-1168;
Fax: 678-564-1169
Special Needs Trust email: gatrustunit@gainwelltechnologies.com

ABD and SSI Medicaid recipients who refuse to cooperate with the TPL process, are ineligible for Medicaid effective the month following the expiration of timely notice. ABD and SSI applicants who refuse to assign TPLs during the SSI application process are ineligible for Medicaid until TPL is assigned at the county DFCS office.

Family Medicaid A/Rs must provide information regarding a TPL held by a non-custodial parent unless good cause is asserted and upheld. Good cause for refusing to cooperate is based on Division of Child Support Services good cause and non-cooperation standards.

Complete Form 138 - Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate with DCSS to document waiver of the TPL requirement because of Good Cause for non-cooperation with DCSS.

An adult A/R is penalized for failure to cooperate with the TPL process. If there are two adults in the AU, both would be penalized if there is no TPL cooperation.

Recipients of Newborn Medicaid are not required to provide information regarding TPLs.

A child is never penalized or excluded from the AU because of an adult’s failure to cooperate with TPL.

Refer to Section 2657 - Penalized Individuals for information regarding Family Medicaid failure to comply with TPL requirements.

Children covered by other public or private health insurance (except vision or dental insurance) are ineligible to receive PeachCare for Kids®. PeachCare for Kids® enrollees may only be denied/terminated for TPL at application or renewal due to continuous eligibility restrictions.

For A/Rs who have insurance that pays for care in a nursing facility, determine if the insurance payment can be assigned to the facility. If the payments can be assigned, complete Form DMA 285 notifying DCH that the nursing facility will be paid directly from the insurance carrier. If payments cannot be assigned to the facility, treat the payments made to the A/R as income in the month received and include in the patient liability budget.

The Form 124 - Health Insurance Premium Payment (HIPP) Referral is used to notify DCH via HMS of the potential purchase of an A/R’s health insurance. HIPP referrals may come from DFCS, a hospital, or other medical providers.

When DCH/HMS receives a referral for a “priority” applicant (person has cancer, diabetes, etc.), a decision is normally pended for 30 days awaiting the outcome of the Medicaid determination. If the applicant is not approved for Medicaid within the 30 days, the HIPP request is denied, and the applicant is sent a denial letter.

If the referral is for a “non-priority” applicant, then a survey letter is sent to the applicant requesting the name of the employer, insurance company, etc. The applicant has 30 days from the date of the survey letter to return the letter to HMS. If the applicant is not made eligible for Medicaid by the time the survey letter is received by HMS, the HIPP referral is denied, and a denial letter is mailed to the applicant. If the applicant is made eligible for Medicaid by the time the survey letter is returned, the approval process for HIPP begins. If the applicant fails to return the survey letter within the 30 days from the date on the letter, the HIPP referral is denied, and a denial letter is mailed to the applicant. The earliest HIPP payments will begin is the first month of Medicaid eligibility. Payments are not made for any month(s) in which the A/R is not Medicaid eligible. HIPP payments are not retroactive.

Do NOT make HIPP referrals for an A/R:

Refer only the primary policy to HIPP if an A/R has multiple health insurance policies.

Complete a Form 124 - Health Insurance Premium Payment (HIPP) Referral, if appropriate, and forward the original to Health Management Systems or document why a HIPP referral was not made.

Mail or fax the HIPP Referral Form along with Form DMA 285, Health Insurance Information Questionnaire, to:

Health Management Systems
100 Crescent Centre Pkwy, Suite 1000
Tucker, Georgia 30084
Phone 678-564-1162, Press 1
Email: hippga@gainwelltechnologies.com

or

fax # 800-817-1769

If the A/R receives payments based on disability from an insurance policy, treat the payments as follows:

Pharmacies should never deny filling an A/R’s prescription because of an insurance issue. However, follow the instructions below if the insurance continues to be a barrier to getting prescriptions filled or Medicaid claims paid:

For children in placement, when there are difficulties in verifying a child’s insurance coverage or termination of insurance coverage with an insurance carrier due to HIPAA and custody issues, RevMax RMS should submit form DMA 285 with all known information, including: RMS name and contact number; contact date(s) and name for insurance carrier and issue details. Submit form to:

Health Management Systems
100 Crescent Centre Pkwy, Suite 1000
Tucker, Georgia 30084

or fax # 770-937-0180