5.5 Third Party Liability

5.5.1 TPL Cooperation
5.5.2 TPL Cooperation Requirements
5.5.3 TPL Good Cause Claim
5.5.4 Assignment Process

Third Party Liability (TPL) refers to the obligation that a third party (not Wisconsin BadgerCare Plus program or the BadgerCare Plus member), has to pay the bills for a BadgerCare Plus member’s medical services. BadgerCare Plus is the payer of last resort for the cost of medical care. This means that if a BadgerCare Plus member also has coverage under a private health insurance plan, that plan is to be billed first for any medical services. BadgerCare Plus then pays any amount remaining after the private insurer has paid what they owe, up to the BadgerCare Plus reimbursement rate. Another common example of third-party liability is when someone receives an insurance settlement resulting from an accident. If BadgerCare Plus paid for any medical services resulting from that accident, the BadgerCare Plus program is to be reimbursed the cost of those medical services from the proceeds of the insurance settlement. Third-party payers include health insurers, court ordered medical support and any other third party that has a legal obligation to pay for medical services.

5.5.1 TPL Cooperation

All BadgerCare Plus members must assign to the State of Wisconsin their rights to payments for medical services from third party payers. A member complies with this requirement by signing the applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. form. The assignment includes all unpaid medical support and all ongoing medical support obligations for as long as BadgerCare Plus is received. In addition, BadgerCare Plus members must cooperate in identifying and providing information to assist the State in pursuing third parties who may be liable to pay for care and services, unless the individual establishes good cause for not cooperating. If a member fails to cooperate with TPL requirements, they could be sanctioned.

5.5.2 TPL Cooperation Requirements

The BadgerCare Plus member must cooperate in providing TPL information unless they are exempt or there is good cause for refusing to cooperate. TPL information could include the name and address of an insurance company, insurance policy number, and the name and address of the policy owner.

If an adult refuses, without good cause, to provide health insurance information for themselves, or anyone for whom they are legally responsible and is receiving BadgerCare Plus, the adult is ineligible until they cooperate.

Do not sanction the following for non-cooperation:

Minors, including minor caretaker relatives.
A parent or caretaker relative requesting child support services for a child receiving SSI.
Pregnant woman - She may not be sanctioned during the pregnancy, or for two months after the pregnancy has ended, if the TPL source is the absent parent of her child(ren).

5.5.3 TPL Good Cause Claim

When good cause is claimed (see Section 5.3 Claiming Good Cause), the IM agency must review the circumstances and decide on whether it is an appropriate claim of good cause. The appropriate entry on the Medical Coverage page in CWWCARES Worker Web. The web-based pages used in the CARES operations. regarding the good cause determination must be made, and the reason for the decision must be documented in case comments.

TPL good cause reasons are the same as those for medical support.

5.5.4 Assignment Process

At application or a new request for health care on an existing case, the IM agency must provide a Notice of Assignment: Child Support, Family Support, Maintenance, and Medical Support (DCF-F-DWSP2477) (available in English and Spanish) to each applicantA request for BadgerCare Plus coverage. The request must be on the Department's or Federally-facilitated Marketplace’s application, registration form or account transfer (from Federally-facilitated Marketplace) and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process.. Applicants and members are not required to sign this form in order to be eligible for health care programs.

Exception: The IM agency does not need to provide the Notice of Assignment to health care applicants who apply via ACCESS since this information is included in the ACCESS application.

This page last updated in Release Number: 23-03
Release Date: 08/14/2023
Effective Date: 08/14/2023