Commonwealth Coordinated Care: Third Party Liability Coverage

Earlier this week, the Department of Medical Assistance Services (DMAS) issued a memorandum intended to provide clarity and guidance related to exemption criteria for beneficiaries eligible for enrollment in the Commonwealth Coordinated Care (CCC) program.  The specific item in question is exemption for individuals with other comprehensive group or individual health insurance coverage, referred to as TPL (third party liability) coverage.  

According to the DMAS memo, these individuals have been exempt from both voluntary and passive enrollment from the start of the CCC program, in accordance with the three-way contract between CMS, DMAS, and the MMPs (Medicare-Medicaid plans) which states:

Section “Individuals with other comprehensive group or individual health insurance coverage, other than full benefit Medicare; insurance provided to military dependents; and any other insurance purchased through the Health Insurance Premium Payment Program (HIPP).”

The definition of what qualifies as other comprehensive group or individual health insurance coverage has been the source of confusion for beneficiaries, their families, for providers and even for agencies and organizations tasked with providing enrollment assistance.

Individuals who have full Medicare and Medicaid coverage are identified in the Virginia Medicaid Management Information System (VaMMIS) as potential CCC enrollees.  Exemptions occur based on established system edits or may come through information provided from CMS.   Individuals with other TPL insurance are exempt based on coverage information (to include coverage type) which is entered into VaMMIS by the Department of Social Services.  It is for this reason that it is imperative for individuals to contact their local DSS office to update their information so we have accurate data that is as up-to-date as possible in the VaMMIS system. DSS can only update VaMMIS when they receive information from the individual (or we believe authorized representatives acting on behalf of the beneficiary).

DMAS indicates that it received feedback that some individuals who currently have Medicare supplement information listed in the TPL file in VaMMIS received initial program notification letters due to the lack of up-to-date information.  Since this initial mailing on February 28, 2014, the Department has confirmed that individuals with a Medicare supplement policy (sometimes referred to as Medigap policies) and individuals with health insurance through their retirement are considered to have other health insurance coverage and are exempt from eligibility in the CCC program. The Department is working to ensure that VaMMIS reflects the correct TPL edits for these Medicare supplement policies, so that these individuals will not receive any further correspondence or notifications about the CCC program.  

DMAS further indicates that individuals (or their authorized representatives) that continue to have questions about eligibility requirements for the CCC program are encouraged to contact the enrollment broker helpline (855-889-5243) (TTY 1-800-817-6608) M-F 8:30-6:00, or VICAP (Virginia Insurance Counseling Assistance Program) at 1-800-552-3402.