| 1 | 1 | | General Assembly Raised Bill No. 5284 |
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| 2 | 2 | | February Session, 2012 LCO No. 1163 |
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| 3 | 3 | | *01163_______HS_* |
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| 4 | 4 | | Referred to Committee on Human Services |
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| 5 | 5 | | Introduced by: |
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| 6 | 6 | | (HS) |
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| 7 | 7 | | |
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| 8 | 8 | | General Assembly |
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| 9 | 9 | | |
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| 10 | 10 | | Raised Bill No. 5284 |
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| 11 | 11 | | |
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| 12 | 12 | | February Session, 2012 |
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| 13 | 13 | | |
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| 14 | 14 | | LCO No. 1163 |
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| 15 | 15 | | |
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| 16 | 16 | | *01163_______HS_* |
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| 17 | 17 | | |
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| 18 | 18 | | Referred to Committee on Human Services |
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| 19 | 19 | | |
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| 20 | 20 | | Introduced by: |
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| 21 | 21 | | |
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| 22 | 22 | | (HS) |
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| 23 | 23 | | |
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| 24 | 24 | | AN ACT CONCERNING RECOUPMENT OF STATE ASSISTANCE PAYMENTS. |
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| 25 | 25 | | |
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| 26 | 26 | | Be it enacted by the Senate and House of Representatives in General Assembly convened: |
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| 27 | 27 | | |
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| 28 | 28 | | Section 1. Subsection (a) of section 17b-137 of the general statutes is repealed and the following is substituted in lieu thereof. (Effective from passage): |
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| 29 | 29 | | |
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| 30 | 30 | | (a) (1) (A) Any person who has in his possession or control any property of any person applying for or presently or formerly receiving aid or care or child support enforcement services, as defined in subdivision (2) of subsection (b) of section 46b-231, from the state or who is indebted to such applicant or recipient or has knowledge of any insurance, including health insurance or property currently or formerly belonging to him, or information pertaining to eligibility for such aid or care or services, and any officer who has control of the books and accounts of any corporation which has possession or control of any property belonging to any person applying for or receiving such aid or care or services or who is indebted to him, or has knowledge of any insurance, including health insurance or any person having in his employ any such person, shall, upon presentation by the Commissioner of Social Services, or the Commissioner of Administrative Services, or the Commissioner of Emergency Services and Public Protection, or a support enforcement officer of the Superior Court, or any person deputized by any of them, of a certificate, signed by him, stating that such applicant, recipient or employee has applied for or is receiving or has received such aid or care or services from the state, make full disclosure to [said] such commissioner, such officer or such deputy of any such property, insurance, wages, indebtedness or information. Notwithstanding the provisions of this subparagraph, any health insurer, including a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third- party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, which may or may not be financially at risk for the cost of a health care item or service, shall, upon request of the Commissioner of Social Services, or the commissioner's designee, provide any and all information in a manner and format prescribed by the commissioner, or the commissioner's designee, to identify, determine or establish third-party coverage, including all information necessary to determine during what period a person, his or her spouse or his or her dependents may be, or may have been, covered by a health insurer and the nature of the coverage that is or was provided by the health insurer, including the name, address, [and] date of birth, Social Security number, identifying number of the plan, plan type, types of covered services, effective dates of coverage and termination date for the policy holder. Such information shall be provided by such health insurer to the commissioner or the commissioner's designee not later than ninety days after the commissioner or the designee's initial request, and not less frequently than monthly thereafter. Such information shall also be provided by such health insurer to all third-party administrators, pharmacy benefit managers, dental benefit managers or other entities with which the health insurer has an arrangement to adjudicate claims for a health care item or service. |
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| 31 | 31 | | |
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| 32 | 32 | | (B) At the request of the Commissioner of Social Services, any health insurer, including a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, which may or may not be financially at risk for the cost of a health care item or service, shall be required [, to conduct, or] to allow the commissioner, or the commissioner's designee, to conduct automated data matches to identify insurance coverage for recipients and the parents of recipients who are minors. [Upon completion of such matches the commissioner shall reimburse such companies for the reasonable documented costs of conducting the matches.] |
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| 33 | 33 | | |
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| 34 | 34 | | (2) (A) Such disclosure may be obtained in like manner of the property, wages or indebtedness of any person who is either: (i) Liable for the support of any such applicant or recipient, including the parents of any child receiving aid or services through the Department of Children and Families, or one adjudged or acknowledged to be the father of an illegitimate child; or (ii) the subject of an investigation in a IV-D support case, as defined in subdivision (13) of subsection (b) of section 46b-231. Any company or officer who has control of the books and accounts of any corporation shall make full disclosure to the IV-D agency, as defined in subdivision (12) of subsection (b) of section 46b-231, or to the support enforcement officer of the Superior Court of any such property, wages or indebtedness in all support cases, including IV-D support cases, as defined in subdivision (13) of subsection (b) of section 46b-231. |
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| 35 | 35 | | |
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| 36 | 36 | | (B) The Commissioner of Social Services, the Commissioner of Administrative Services, the Commissioner of Emergency Services and Public Protection or a support enforcement officer of the Superior Court, or any person deputized by any of them, may compel, by subpoena, the attendance and testimony under oath of any person who refuses to disclose in accordance with the provisions of this section, or of any person who is either: (i) Liable for the support of any such applicant or recipient; or (ii) the subject of an investigation in a IV-D support case, as defined in subdivision (13) of subsection (b) of section 46b-231, who refuses to disclose his own financial circumstances, and may so compel the production of books and papers pertaining to such information. |
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| 37 | 37 | | |
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| 38 | 38 | | (C) The Commissioner of Social Services may subpoena the financial records of any financial institution concerning property of any person applying for or presently or formerly receiving aid or care from the state or who is indebted to such applicant or recipient. The Commissioner of Social Services may subpoena such records of any parent or parents of any child applying for or presently or formerly receiving assistance under the aid to families with dependent children program, the temporary family assistance program or the state-administered general assistance program. |
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| 39 | 39 | | |
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| 40 | 40 | | (D) The commissioner, or a support enforcement officer of the Superior Court, or the person deputized by the commissioner or officer shall set a time and place for any examination under this subdivision, and any person summoned who, without reasonable excuse, fails to appear and testify or to produce such books and papers shall be fined fifty dollars for each such offense. |
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| 41 | 41 | | |
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| 42 | 42 | | Sec. 2. Section 17b-265 of the 2012 supplement to the general statutes is repealed and the following is substituted in lieu thereof (Effective from passage): |
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| 43 | 43 | | |
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| 44 | 44 | | (a) In accordance with 42 USC 1396k, the Department of Social Services shall be subrogated to any right of recovery or indemnification that an applicant or recipient of medical assistance or any legally liable relative of such applicant or recipient has against an insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, for the cost of all health care items or services furnished to the applicant or recipient, including, but not limited to, hospitalization, pharmaceutical services, physician services, nursing services, behavioral health services, long-term care services and other medical services, not to exceed the amount expended by the department for such care and treatment of the applicant or recipient. In the case of such a recipient who is an enrollee in a care management organization under a Medicaid care management contract with the state or a legally liable relative of such an enrollee, the department shall be subrogated to any right of recovery or indemnification which the enrollee or legally liable relative has against such a private insurer or other third party for the medical costs incurred by the care management organization on behalf of an enrollee. |
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| 45 | 45 | | |
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| 46 | 46 | | (b) An applicant or recipient or legally liable relative, by the act of the applicant's or recipient's receiving medical assistance, shall be deemed to have made a subrogation assignment and an assignment of claim for benefits to the department. The department shall inform an applicant of such assignments at the time of application. Any entitlements from a contractual agreement with an applicant or recipient, legally liable relative or a state or federal program for such medical services, not to exceed the amount expended by the department, shall be so assigned. Such entitlements shall be directly reimbursable to the department by third party payors. The Department of Social Services may assign its right to subrogation or its entitlement to benefits to a designee or a health care provider participating in the Medicaid program and providing services to an applicant or recipient, in order to assist the provider in obtaining payment for such services. In accordance with subsection (b) of section 38a-472, a provider that has received an assignment from the department shall notify the recipient's health insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, of the assignment upon rendition of services to the applicant or recipient. Failure to so notify the health insurer or other legally liable third party shall render the provider ineligible for payment from the department. The provider shall notify the department of any request by the applicant or recipient or legally liable relative or representative of such applicant or recipient for billing information. This subsection shall not be construed to affect the right of an applicant or recipient to maintain an independent cause of action against such third party tortfeasor. |
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| 47 | 47 | | |
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| 48 | 48 | | (c) Claims for recovery or indemnification submitted by the department, or the department's designee, shall not be denied solely on the basis of the date of the submission of the claim, the type or format of the claim, the lack of prior authorization or the failure to present proper documentation at the point-of-service that is the basis of the claim, if (1) the claim is submitted by the state within the three-year period beginning on the date on which the item or service was furnished; and (2) any action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of the claim. |
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| 49 | 49 | | |
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| 50 | 50 | | (d) When a recipient of medical assistance has personal health insurance in force covering care or other benefits provided under such program, payment or part-payment of the premium for such insurance may be made when deemed appropriate by the Commissioner of Social Services. Effective January 1, 1992, the commissioner shall limit reimbursement to medical assistance providers, except those providers whose rates are established by the Commissioner of Public Health pursuant to chapter 368d, for coinsurance and deductible payments under Title XVIII of the Social Security Act to assure that the combined Medicare and Medicaid payment to the provider shall not exceed the maximum allowable under the Medicaid program fee schedules. |
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| 51 | 51 | | |
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| 52 | 52 | | (e) Notwithstanding the provisions of subsection (c) of section 38a-553, no self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care plan, or any plan offered or administered by a health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, shall contain any provision that has the effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to an insured or beneficiary who is eligible for or who received medical assistance under this chapter. No insurer, as defined in section 38a-497a, shall impose requirements on the state Medicaid agency, which has been assigned the rights of an individual eligible for Medicaid and covered for health benefits from an insurer, that differ from requirements applicable to an agent or assignee of another individual so covered. |
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| 53 | 53 | | |
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| 54 | 54 | | (f) The Commissioner of Social Services shall not pay for any services provided under this chapter if the individual eligible for medical assistance has coverage for the services under an accident or health insurance policy. |
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| 55 | 55 | | |
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| 56 | 56 | | |
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| 57 | 57 | | |
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| 58 | 58 | | |
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| 59 | 59 | | This act shall take effect as follows and shall amend the following sections: |
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| 60 | 60 | | Section 1 from passage 17b-137(a) |
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| 61 | 61 | | Sec. 2 from passage 17b-265 |
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| 62 | 62 | | |
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| 63 | 63 | | This act shall take effect as follows and shall amend the following sections: |
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| 64 | 64 | | |
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| 65 | 65 | | Section 1 |
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| 66 | 66 | | |
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| 67 | 67 | | from passage |
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| 68 | 68 | | |
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| 69 | 69 | | 17b-137(a) |
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| 70 | 70 | | |
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| 71 | 71 | | Sec. 2 |
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| 72 | 72 | | |
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| 73 | 73 | | from passage |
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| 74 | 74 | | |
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| 75 | 75 | | 17b-265 |
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| 76 | 76 | | |
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| 77 | 77 | | Statement of Purpose: |
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| 78 | 78 | | |
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| 79 | 79 | | To clarify third-party and health plan obligations regarding payment and recoupment of state assistance payments. |
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| 80 | 80 | | |
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| 81 | 81 | | [Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.] |
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