As shared on previous bulletins, the Texas Medicaid Healthcare Partnership (TMHP) posted a provider notice regarding Third Party Liability (TPL) for SHARS interim claims. As outlined in the bulletin, Texas Medicaid instituted TPL policy requirements using a "pay and recover later" method for SHARS providers on October 1, 2017. Using the pay and recover TPL process for SHARS means that Medicaid pays the school district for services before third party reimbursement is sought (e.g., private insurance held by the parents of a student with a disability).
Expectation for District/ Charter School Providers:
- verify whether the document is a bill. Some documents may include an Explanation of Benefits (EOB) that may or may not indicate that money is owed; and
- if it is an insurance bill, contact the TMHP Contact Center at 1-800-925-9126.
To assist in the communicate of the policy to families, HHSC has developed "parent friendly language" that may be used in discussion with SHARS families:
Texas Medicaid is a “payer of last resort.” That means that everyone who is legally responsible for paying for your health-care services must pay what they owe before Texas Medicaid will pay. For example, if you have other health insurance, that insurance company must pay its share before Texas Medicaid will pay. Anyone who is legally responsible for paying is called a “third party” and the responsibility to pay is called “third-party liability.”
It can be hard for you to work with all of the third parties who are responsible for paying for your health-care services. To make it easier for you, Texas Medicaid pays your claims and then goes to the third parties for their share of the costs. This way of handling payment is called “pay and recover.”
On October 1, 2017, Texas Medicaid began using the pay-and-recover method for the School Health and Related Services (SHARS) program. This new way of getting payments will have very little impact on you. You will not have to pay anything, because Texas Medicaid pays your insurance co-payments and deductibles. However, your lifetime benefits for your private insurance might be affected. It will depend on your insurance company and policy. You should read your policy and call your insurance company if you have any questions.
The Individuals with Disabilities Education Act (IDEA) entitles children to a free and appropriate public education. If you think this change might cost you money, you should talk with your school district.