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Coordination of Benefits

Medicaid is called the payer of last resort when a client has other insurance or Medicare; federal regulations require that all available resources be used before Medicaid considers payment. This means that if a client is able to provide for their care, the client must pay for medical benefits first. If there is a responsible third-party who should be paying for the client's health benefits, for example, a health insurance provider, that responsible third-party should be paying first. Coordinating benefits makes sure that the correct party pays first by, 1) cost-avoiding claims where a known other party should be paying, or 2) cost-recovering from a claim Medicaid paid that should have been paid by someone else.

 

 

  1st Party Cost-avoidance

  3rd Party Cost-avoidance

  Trust Review

  Resource Review

  Transfers w/o Fair Consideration

  Third Party Insurance

  Health Insurance Buy-in (HIBI)

  Medicare Buy-In

  Non-custodial Parent Medical Support

  Long-term Care Partnership Program

 

 1st Party Cost-recovery

  3rd Party Cost-recovery

  Estate Recovery

  Trust Recovery

  Client Recovery

  Third Party Data Matching & Post-pay Recovery

  Tort & Casualty

 

1st Party = Client (Benefits Coordination)

2nd Party = Provider (Program Integrity)

3rd Party = Others, such as insurers & tortfeasors (Benefits Coordination)

 

  • A client's commercial insurance, as opposed to an insurance policy belonging to an at-fault party, must be billed first. The Colorado Medical Assistance Program is always the payer of last resort.
  • Lower of Pricing is used to calculate reimbursement.
  • If a client is not insured by a commercial insurance company, bill the Colorado Medical Assistance Program.
  • A provider may not bill the client for the difference, nor place a lien for medical assistance against the client's right to recover against at-fault parties, or bill the at-fault party's insurance