Medicaid Policy
Medicaid Policy
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Deny Medicaid eligibility to adult applicants who fail to cooperate with Third Party Liability (TPL) without good cause. If an adult recipient cooperates at first, and then later fails to cooperate, sanction the adult from the Medicaid coverage. Do not deny eligibility to or remove dependent children from Medicaid because the adult on the case does not meet TPL requirements. A dependent child is someone who is under age 18; or, for Family category programs, who is between age 18 and 19 in secondary schooling or training full time, and is expected to complete the schooling or training before turning age 19. A child is no longer dependent once the child has married or been emancipated by a court of law.
A person is cooperating if all the TPL information he or she knows has been provided, even if every detail is not known. Do not deny Medicaid eligibility or close a case for failure to cooperate when a third party, such as an ex-spouse, refuses to give the TPL information to the individual. However, the individual needs to provide the name of the ex-spouse and whatever information he or she can about how to contact the ex-spouse.
Use the following procedures when a individual has failed to cooperate.
Failure to complete the TPL questions on the application or the Form 19.
If the adult applicants do not provide the information to complete the TPL questions either on the application or Form 19-TPL Questionnaire, request this information during the application process.
Adult recipients must also report changes in a timely way, and when adding a household member, must provide TPL information for the person they want to add.
If the adult applicants or recipients fail to meet the TPL requirement without good cause, the eligibility worker will code the adults out of the Medicaid coverage. Approve, or continue Medicaid for all eligible children in the household when all other eligibility requirements are met. Before ending eligibility for an adult recipient, provide 10-day notice that benefits will end.
If the adults want to comply later with the TPL requirement, treat it like a new application request with the application date being the date on which they met the TPL requirement. Coverage would start with the month they comply and can include the retroactive period prior to the date they comply. (See Sec. 705-1)
Failure to cooperate with TPL procedures or withholding TPL information AFTER initially meeting the TPL requirements.
The ORS Medicaid Unit will decide when to apply a sanction in this case. If ORS determines that an individual is not cooperating, they will notify the local office. The sanction may be removed ONLY when the ORS Medicaid Unit agrees that the individual is cooperating. See 225-5 #3 for ending the sanction.
Informing the Individual
Workers must tell applicants during the application process that the applicant must provide TPL information to be eligible for Medicaid unless they claim good cause.
• Remember, the children can still be eligible. Do not deny Medicaid for a child because of an adult's refusal to provide TPL information.
If ORS requests a worker to apply a sanction to a recipient who is not cooperating, follow the procedures below.
Advance Notice
Send a notice to the recipient explaining that all adults will be ineligible for Medicaid because of non-cooperation with TPL. Tell them when coverage will end if they do not cooperate. Always give 10-day notice before removing the adults from the coverage.
Remove From the Coverage
After providing the 10-day advance notice, withhold medical assistance only for all adults on the case. Continue Medicaid benefits ONLY for the children.
When Does the Ineligibility or Sanction End?
If the eligibility worker denied eligibility, add the adults back to the case when they comply with the TPL requirement. Eligibility can be reinstated beginning the month they comply. Coverage can also include the retroactive period prior to the date they comply with the TPL requirement.
• If the case is open for the children, do not require a new application. Use the date they meet the TPL requirement as the date of application to determine the retroactive period. (See Sec. 705-1.) Document the request and the date of compliance.
• If there was no open case because there are no covered children, the individual must reapply for Medicaid, unless they have cooperated before the end of the application processing time line.
If ORS requested the sanction, DO NOT restore Medicaid coverage until ORS verifies that the individual is now cooperating. If a sanctioned individual expresses a desire to cooperate, contact ORS. Medicaid coverage may begin at the first of the month in which the individual begins to cooperate, as per the ORS office. You cannot provide coverage for any month or partial month of the retroactive period if the individual was being sanctioned by ORS in such month.