State Practice 2: Identifying TPL Insurers

29 Aug State Practice 2: Identifying TPL Insurers

This is the second post in a three part series in which we discuss what steps states should follow to develop an effective TPL plan.  In part one, we discussed the need for insurers to cooperate in the active identification of other coverage. In this installment, we discuss how to get the data needed for healthcare cost containment and, more importantly cost avoidance.


Insist on Full Eligibility Files, Not Partial Eligibility Files

A common procedure is that insurers only provide the state with information on known Medicaid members. This is known as a partial eligibility file. A full eligibility file is one that lists all covered members. With a partial eligibility file scenario, insurers are required to check in order to determine who in the file also have Medicaid coverage.

With a lack of technological skills, such searches aren’t as effective with most of the insurers. Besides, there is an inherent conflict of interest with insurers performing this process, which lends to a less than robust match that then means complete health insurance coverage is not ascertained for all individuals. What this points to is to the importance of state DRA-compliant laws that require the sharing by insurers of full eligibility files.

An added advantage with full eligibility files is that anyone who possesses commercial coverage from out of state is then listed. This involves a person who lives in one state, works in another state and gets third party insurance from the state that they work in, not the state of residence.

This phenomenon occurs throughout the country. A resident of Virginia is covered by Virginia Medicaid, but has employer coverage in Washington, D.C. Or, a resident of Vancouver, Washington is enrolled in Washington State Medicaid and has additional coverage from an employer just across the Columbia River in Portland, Oregon. State Medicaid agencies not only must obtain eligibility data from within their own state, but get similar data from neighboring states.

Another situation requiring extra data collection by state Medicaid agencies is when children are eligible for Medicaid coverage because a non-custodial parent resides in a state different from the residency of the child. It might involve a state that’s on the other side of the country. It follows that every state needs to see a provider’s full eligibility files in order to catch these circumstances.


Outline Detailed Data

Details are also important in making sure accuracy leads to a good and useful TPL match. Data fields, such as the effective dates of the insurance coverage, the termination date of the insurance, health services that are covered, the insurance plan type, the social security number and the date of birth of the policy holder should be required by states of insurers on data provided for TPL purposes.

So, detailed data includes:

  1. The termination date of the policy
  2. The effective dates of insurance coverage
  3. Services covered by the policy
  4. The health insurance plan type
  5. The policy holder’s social security number
  6. The policy holder’s date of birth


Make Sure Data Moves Quickly

Time-frame limits should be outlined by state DRA-compliant statutes in order to warrant the judicious and expedited delivery of third party identification with the following stipulations: 1) a limited number of days for the signature of data use agreements; 2) a time limit on the transfer of the first set of data; and 3) a limit on the number of times data should be shared.


Allow Data for Other Programs

Data use agreements should be expanded beyond just Medicaid programs. They should also apply to a wealth of other government programs, such as health insurance exchanges, the Children’s Health Insurance Program (CHIP), and child support.