Third Party Health Insurance Frequently Asked Questions
- FAQs also available in Portable Document Format (PDF)
Children's Waiver
Frequency Asked Questions
Third Party Health Insurance (TPHI)
1. Q: What is Third Party Health Insurance (TPHI)?
A: Third Party Health Insurance is any health insurance obtained through an employer; or liability insurance, such as Worker's Compensation; Accident-only coverage, such as No-fault; or disability insurance. Dental, prescription, or hospital indemnity coverage are also examples of TPHI.
2. Q: Can an individual have Third Party Health Insurance and Medicaid at the same time?
A: Yes, an individual can have both TPHI and Medicaid at the same time.
3. Q: If an individual has TPHI and Medicaid which insurance pays first or primary?
A: The TPHI is the primary payor. Medicaid is always the payor of last resort.
4. Q: What is comprehensive Third-Party Health Insurance?
A: To be considered Comprehensive Third-Party Health Insurance all the following services must be covered:
- inpatient hospital stays;
- physician hospital care;
- home health care;
- emergency room;
- clinic services;
- physician office services;
- x-ray;
- laboratory service;
- hospice;
- substance abuse inpatient facility
- substance abuse outpatient care;
- mental health inpatient facility;
- mental health outpatient care; and
- prescriptions
5. Q: How does comprehensive Third-Party Health Insurance affect enrollment in Mainstream Medicaid Managed Care?
A: If any of the comprehensive TPHI coverage services are missing, the coverage is not considered to be comprehensive. A Medicaid consumer that has TPHI Comprehensive Health Insurance is excluded from enrollment in a Mainstream Medicaid Managed Care Plan.
6. Q: If an individual only has dental insurance, in addition to Medicaid, can the individual still be in a Medicaid Managed Care Plan?
A: Yes. Having only dental insurance is not considered to be comprehensive Third-Party Insurance and is not an exclusion from Mainstream Medicaid Managed Care.
If an individual is eligible for Medicaid and is not otherwise excluded (not allowed to join) or exempted (allowed to join but not required) from enrollment, an individual would be eligible to enroll in a Mainstream Medicaid Managed Care Plan.
March 2021
