WAG 23-08-04-d: TPL Payments

Different procedures apply to TPL payments for long term care services and to TPL payments for other medical services.

Services Other Than Long Term Care

1. (FCRC) Complete Payment Transmittal Slip (Form 3021), checking the "Third Party Liability" section if a client brings a TPL payment to the Family Community Resource Center.
   1. Send the payment and completed Form 3021 to:
      • Bureau of Fiscal Operations
      • Refunds and Recoveries Unit
      • PO Box 19407
      • Springfield, IL 62794-9407
2. (FCRC) Verify that a provider was paid by a client if the client receives a TPL payment and reports that they have paid the provider.
   1. Notify the TPL Section, by memo, including:
      • name of provider,
      • date of service, and
      • date and amount of payment.
   2. (TPL Section) Makes sure the provider refunds the correct amount to HFS.

Long Term Care Services Only

TPL long term care resources include health insurance and indemnity policies. Payment may be received by either the long term care facility or the client.

(1) Payment Received by Long Term Care Facility

When a long term care facility receives a TPL payment, from any source, the facility:

1. (LTC Facility) Notifies the Family Community Resource Center using Long Term Care Facility Notification (Form 1156) containing the following:
   • date TPL payment is received,
   • amount of TPL payment,
   • service dates covered by the TPL payment,
   • date and amount of any TPL funds returned to the client, and
   • date and amount of any long term care credit funds returned to the client.
2. (LTC Facility) Determines the amount paid by HFS for the service dates covered by the TPL payment.
3. (LTC Facility) Completes Long Term Care Facility - Third Party Liability Payment Transmittal (Form 3461).
   1. Sends Form 3461 and a check for the lesser of:
      • the amount of the TPL payment, or
      • DPA's payment,

        to the TPL Section. 

4. (LTC Facility) Sends a copy of Form 3461 to the Family Community Resource Center.

   When notified by Form 1156 that TPL funds and/or long term care credit funds have been returned to a client:

5.  (FCRC) Budget the amount of TPL funds returned as income for the month of receipt by the client. Do not budget TPL funds that are kept by the facility.
   1. Treat the amount of long term care credit funds returned as an asset effective the month following the month of receipt.

      NOTE: Do not budget the long term care credit funds returned as income.

      Example: Mrs. D resides in a long term care facility and has a TPL resource that covers long term care services. The HFS rate for this facility is $2,200 and the private rate is $2,500. Mrs. D's long term care credit obligation is $1,000. HFS pays the $1,200 remainder. 

6. The facility sends the Family Community Resource Center Form 1156 with the following:
   • facility received the TPL payment 06/10,
   • amount of the TPL payment is $2,600,
   • the TPL payment covered service 04/01 through 04/30,
   • on 06/25 the facility returned $100 of the TPL funds to the client, and
   • on 06/25 the facility refunded the client's $1,000 long term care credit amount that was paid for the period 04/01 through 04/30.

The facility also sends the Family Community Resource Center Form 3461 showing the HFS payment of $1,200, for the period 04/01 through 04/30, has been refunded.

Budget the $100 TPL funds returned to the client as income. Since the TPL funds were returned to the client on 06/25, budget the $100 for June.

Treat the $1,000 long term care credit funds returned to the client as an asset. Since the funds were returned on 06/25, treat the $1,000 as an asset effective for July. Do not budget the amount returned as income.

(2) Payment Kept by Resident

1. (FCRC) Send a memo to BLTC to request the long term care MMIS claims history for the service dates covered by the TPL payment.
   1. (BLTC) Indicates the amount HFS paid for the covered service dates on the MMIS claims history.
2. (FCRC) Request reimbursement from the client for the lesser of:
   • the TPL payment, or
   • the HFS payment.
3. (FCRC) Complete Form 3021.
   • Send Form 3021 and the payment to:
   • Bureau of Fiscal Operations
   • Refunds and Recoveries Unit
   • P.O. Box 19407
   • Springfield, IL 62794-9407
4. (FCRC) Budget any TPL funds in excess of the HFS rate as income for the month of receipt by the client. Do not budget TPL funds that are less than or equal to the HFS rate.
5. (FCRC) Treat any TPL funds remaining in the following month(s) as an asset, subject to the appropriate asset limit.

   Example: Mr. J resides in a long term care facility and has a TPL resource that covers long term care services. The HFS rate for the facility is $2,200 and the private rate is $2,300. Mr. J has a long term care credit obligation of $800. HFS pays the remaining amount of $1,400.

   Mr. J notifies the Family Community Resource Center that on 07/15 he received a TPL payment in the amount of $2,300. This TPL payment covered the service dates of 05/01 through 05/31. 

   Send a memo to BLTC asking for the long term care MMIS claims history for the period 05/01 through 05/31.

   BLTC shows on the MMIS claims history that HFS paid $1,400 for the service dates of 05/01 through 05/31.

   Request reimbursement from the client for $1,400 (the lesser amount of the TPL payment of $2,300 and the HFS payment of $1,400). 

   Send the payment, along with a completed Form 3021, to the Bureau of Fiscal Operations - Refunds and Recoveries Unit.

   Budget the amount of TPL funds in excess of the HFS rate ($2,300 - $2,200 = $100) as income for July. 

6. (FCRC) Suggest to the client that they send the TPL payment directly to the long term care facility if HFS has not yet paid for the service dates covered by the TPL payment.

   NOTE: The facility is responsible for refunding the correct amount to HFS. 

   1. Set a control to determine when HFS pays if the client does not send the TPL payment to the long term care facility.