Summary
Medicaid is the payer of last resort, meaning it pays only after other sources have paid. Denying HCBS waiver services due to third-party insurance may not be appropriate. Medicaid should coordinate with other insurers rather than exclude services. If services are denied, you can appeal the decision. Check if you can appeal directly with Medicaid or through a higher authority, like the Texas Health and Human Services Commission. Consider seeking advice from a legal aid organization specializing in healthcare law. Contact Texas Legal Services Center or Lone Star Legal Aid for assistance.Full Conversation
medicaid waiver services being denied due to third party liability
Hi! It sounds like you're dealing with a complex issue involving Medicaid waivers and third-party liability. In Texas, specific rules might apply.
- *(a)(*) of the Social Security Act refers to state plans for medical assistance and recovery from third parties.
- *(c) waivers provide Home and Community-Based Services (HCBS).
To better assist you, could you provide more details on the third-party liability involved?
employer health insurance
Got it, thanks for sharing more details. In Texas, if your Medicaid waiver services are being denied due to employer health insurance (third-party liability), here are some things to consider:
- Coordination of Benefits: Medicaid is the payer of last resort, meaning it pays only after other sources (like employer health insurance) have paid.
- State Recovery: Under section *(a)(*), Texas Medicaid may seek reimbursement from third parties liable for payment.
For more personalized guidance, could you describe the specific denial reason given by Medicaid and any steps you've already taken?
third party insurance is a source of payment and if there is another source of payment the individual is excluded from services
Case Rating: *
In Texas, Medicaid is indeed the payer of last resort, which means they will only pay after any other third-party insurance (like employer health insurance) has paid. However, denying HCBS waiver services solely because there is third-party insurance may not be appropriate, as Medicaid should coordinate with other insurers rather than exclude services completely.
Key Points to Consider:
- Coordination of Benefits: Medicaid should coordinate with your employer health insurance to cover services not fully paid by your primary insurance.
- Appeal Process: If services are denied, you can appeal the decision. Ensure you document all communications and gather any necessary medical records or letters from healthcare providers.
Would you like more information on the appeal process or have any specific questions about the steps to take?
the state will not give an appeal
Case Rating: *
It sounds like a challenging situation. Here are some steps you might consider:
- Appeal Rights: Check if you can appeal directly with Medicaid or through a higher authority, like the Texas Health and Human Services Commission.
- Legal Aid: Consider seeking advice from a legal aid organization specializing in healthcare law.
Would you like more information on how to contact legal aid organizations in Texas?
yes
Case Rating: *
Sure, here are ways to contact legal aid organizations in Texas that specialize in healthcare law:
- Texas Legal Services Center: Offers a range of legal services including healthcare.
- Website: [www.tlsc.org](http://www.tlsc.org)
- Phone: (*) *-*
- Lone Star Legal Aid: Provides free legal assistance to low-income individuals.
- Website: [www.lonestarlegal.org](http://www.lonestarlegal.org)
- Phone: (*) *-*
Would you like to know more about how to approach them?
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