Clarifying information
When another party (a third party) has been identified as responsible for payment of a health care expense, Apple Health does not pay the health care claim until after the third party has paid. When Apple Health has paid a claim for a health care expense prior to third party payment, the Health Care Authority or Managed Care Organization is entitled to collect third party benefits.
The limit of the recoupment from the settlement, judgment or awards of monies is the amount of the health care expense paid by the Health Care Authority or Managed Care Organization. The method of determining what portion of a settlement represents past medical expenses is left to the state, the parties, and/or the court. Refer all such questions or challenges to Health Care Authority at 1-800-562-3022.
Assignment of rights is effective for all periods of eligibility certification, including any retroactive period of eligibility.
Worker responsibilities
- Other Insurance: If an individual has other insurance, or indicates there is a pending lawsuit or casualty settlement, send TPL information to Health Care Authority's COB unit using tickler type: TPLI to @TPL pool, Site 102 in DMS. The tickler must include the following information:
- How the information was reported
- Where the information is located with the date
- What kind of TPL information was reported
Example: Report via document Subject: MAP in ECR 9/15/09Details: Individual reported new insurance
Example: Report via Phone or Interview Subject: See ACES narrative 9/20/09Details: Individual reports end of insurance
The Medical Coverage Information form (HCA 14-194) can also be used to report insurance and casualty information, but does NOT need to be completed to report the presence of Medicare.
- Completion of HCA 14-194
- Ensure that the individual's name and ACES client ID number is prefilled on the form before sending it to the individual for completion.
- Write "For Information Only" on top of the HCA 14-194 form and send to DMS when the only medical resource is:
- Accident case with potential liability (auto, medical malpractice, homeowners);
- Labor and Industries coverage of an injury;
- Crime Victim and Victim Assistance involvement; or
- Products liability potential coverage.
- No referral to COB/TPL is necessary when the only medical resource is:
- Coordinated Children Services;
- Indian Health
- Veterans coverage (other than active duty military coverage or Champus);
- Life Insurance
- Automobile Insurance (unless related to a current injury);
- Homeowner's or Rental Insurance (unless related to a current injury);
- Medicare (use TPL procedures in ACES for Medicare only); or
- Enrollment in a HMO/HIO under an Agency Medicaid contract.
Note: Coordination of Benefits (COB) automatically receives a copy of the HCA 14-194 form through the DMS System in a "to do" box when the individual completes and returns this form.
- Payment of private health insurance: The Health Care Authority offers a Premium payment program for people who have been determined eligible for Apple Health, and have private health insurance (including individual policies, COBRA policies, and employer-sponsored plans). The Premium Payment Program handles applications for reimbursement of cost effective private health insurance premiums except for Medicare + Choice (managed care). All applicants for the premium payment program must first have been approved for free Apple Health coverage.
- How to apply
- Download an application form (HCA 13-705) for the HCA Premium Payment Program.
- Mail the completed form to:
Premium Payment Program
P O Box 45518
Olympia WA 98599-5518
or send by fax to: 877-893-3810
Questions? Contact a Premium Payment Program specialist at 800-562-3022, ext. 15473
Note: An applicant diagnosed with HIV or AIDS who is not eligible for Apple Health may be eligible for assistance through the Department of Health (DOH). The DOH HIV Client Services Program funds a contract to assist persons who have HIV and/or AIDS with ongoing medical insurance premiums, or to acquire insurance. For more information about this program contact the Early Intervention Program (EIP) at DOH at 1-877-376-9316 or visit the EHIP website.