Third-party payments may come from health insurance, settlements or court awards (such as accident, product liability, or malpractice claims), or workers’ compensation.
Third-Party Liability (TPL) is the legal requirement for health care carriers to pay all or part of a Medicaid member’s medical claim. Medicaid is the payer of last resort, covering costs only when no other liable payer exists.
In Iowa, Medicaid includes both Fee-for-Service (FFS) and the managed care program, IA Health Link, which began April 1, 2016. Most members are served through two Managed Care Organizations (MCOs): Iowa Total Care* and Amerigroup Iowa. A small percentage remain in FFS.
For FFS members with injuries on or after April 1, 2016, cases must be reported to the Iowa Medicaid Revenue Collections Unit. In all other cases, attorneys and carriers should work directly with the member’s MCO.
Impact for injuries and Lien Recovery
If an injury happened prior to April 1, 2016, the IME Revenue Collections Unit will file a lien for services incurred before April 1, 2016.
If an injury results in claims that include services incurred prior to and after April 1, 2016, the Medicaid Revenue Collections Unit will file a lien for any health service payments related to the injury and incurred prior to April 1, 2016. A service related to the injury on or after April 1, 2016, will be handled by the member’s MCO. The MCO will file a separate lien for services incurred on or after April 1, 2016.
For injuries that occur on or after April 1, 2016; if the member has the Medicaid FFS, the IME Revenue Collections Unit will file a lien for services prior to their MCO assignment. If the member moves their eligibility to an MCO then the member’s MCO will handle liens for any services incurred after assignment. In instances such as this, the attorney’s office or carrier will need to work with both the IME Revenue Collections Unit and member’s MCO.
Medicaid will request more information from a member when a provider submits a claim for payment that shows the Medicaid member may have been involved in an accident or injury. Medicaid members who do not return the requested information may lose their Medicaid coverage. Once Medicaid coverage is lost any months that are lost due to non-cooperation are not eligible for Medicaid coverage. To regain Medicaid eligibility, you may need to reapply for Medicaid.
