84R8048 SCL-F
By: Zerwas H.B. No. 2959
A BILL TO BE ENTITLED
AN ACT
relating to Medicaid interception of certain insurance payments.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 2, Human Resources Code, is
amended by adding Chapter 37 to read as follows:
CHAPTER 37. MEDICAID INTERCEPTION OF CERTAIN INSURANCE PAYMENTS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 37.001. SHORT TITLE. This chapter may be cited as the
Medicaid Interception of Insurance Payments Act.
Sec. 37.002. PURPOSE. The purpose of this chapter is to
regulate the recovery of money paid by the Health and Human Services
Commission under the Medicaid program.
Sec. 37.003. DEFINITIONS. In this chapter:
(1) "Claimant" means an insured under an insurance
policy or self-funded plan or a third-party claimant under a policy
or plan seeking benefits for injuries received as a result of an
accident or loss. The term includes an insured's or third party's
legal representative, family member, or any other individual acting
on the insured's or third party's behalf.
(2) "Commission" means the Health and Human Services
Commission.
(3) "Insurer" means an insurance company holding a
certificate of authority to engage in the business of insurance in
this state.
(4) "Self-funded plan" means a plan that an entity
self-insures for the entity's legal responsibility without the
benefit of primary insurance through the use of a self-insured
retention.
(5) "Self-insurer" means an entity insured under a
self-funded plan. The term includes any entity that is directing
the handling of self-funded plan claims through a third party or as
a result of a policy buyback, cost-sharing agreement, or
coverage-in-place agreement.
Sec. 37.004. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to personal injury protection, medical payments
coverage, and third-party payments for bodily injury from liability
insurance and self-funded plans that insure similar liabilities.
This chapter does not apply to:
(1) a claim under a liability insurance policy that
does not cover bodily injury;
(2) a claim for property damage or loss of use of
property;
(3) a claim made against an accident and health policy
regardless of whether the policy is payable on an expense-incurred
or indemnity basis; and
(4) a workers' compensation claim.
(b) This chapter does not apply to a claimant seeking less
than $2,000 under an insurance policy or self-funded plan or a
Medicaid recipient with respect to whom this state has incurred
less than $2,000 of Medicaid costs in connection with an injury
resulting from an accident or loss.
Sec. 37.005. EFFECT ON OTHER LAW. This chapter does not
limit the commission from recovering any other money allowed under
the laws of this state and federal law.
Sec. 37.006. RULEMAKING AUTHORITY. The executive
commissioner of the commission may adopt rules as necessary to
implement this chapter.
SUBCHAPTER B. MEDICAID INTERCEPTION
Sec. 37.051. AUTOMATIC ASSIGNMENT OF RIGHTS. In accordance
with the laws of this state and applicable rules, when applying for
Medicaid, an applicant or recipient assigns the applicant's or
recipient's rights to any payments under applicable insurance
coverage to the commission.
Sec. 37.052. MATCH PROCESS. (a) This section applies only
to an individual or estate making a bodily injury or wrongful death
claim under an insurance policy or self-funded plan.
(b) At any time before providing a total payment of at least
$2,000 on behalf of or to a claimant on a claim under an insurance
policy or self-funded plan, the insurer or self-insurer shall
exchange information with the commission in accordance with this
chapter.
(c) To facilitate compliance with this chapter, the
commission shall develop and maintain a data match system to
compare claimant information held by insurers and self-insurers
with the commission's database of recipients. The commission shall
seek the comment of insurers and self-insurers in this state in
developing the data match system. The data match system must use
automated data exchanges to the maximum extent possible.
(d) An insurer or self-insurer shall provide the commission
with the name and address of an individual or estate determined by
the commission to be a recipient and may provide the recipient's
date of birth and last four digits of the recipient's social
security number.
(e) An insurer or self-insurer may provide the information
described by Subsection (d) by:
(1) authorizing an insurance claim data collection
organization, to which the insurer or self-insurer subscribes and
to which the insurer or self-insurer submits the required claim
data on at least a weekly basis, to:
(A) receive or access a data file from the
commission and conduct a data match to identify all recipients who
are claimants under an insurance policy or self-funded plan and
submit the required information for each data match to the
commission; or
(B) submit a data file to the commission that
contains the required information for each claim against the
insurer or self-insurer for the commission to conduct a data match;
(2) electronically providing the required information
for each claim against the insurer or self-insurer directly to the
commission; or
(3) receiving or accessing a data file from the
commission and conducting a data match to identify each recipient
who is a claimant under an insurance policy or self-funded plan and
submitting the required information for each data match to the
commission.
(f) On receiving a data match under this section, the
commission shall send the insurer or self-insurer a notice of lien
against the amount payable to the recipient. The notice must
include the amount of the lien and the name of the recipient who is
the subject of the lien.
(g) An insurer or self-insurer may comply with this section
by making a good faith effort to comply. The commission may only
demonstrate a violation of this section by proving an intentional
failure to comply through a pattern and practice of noncompliance.
The commission may not demonstrate a violation through a single
instance of noncompliance.
Sec. 37.053. PAYMENT PROCESS. (a) Subject to this section,
on receipt of a notice of lien under Section 37.052, an insurer or
self-insurer shall withhold the lesser of the amount of the payment
owed to a claimant under an insurance policy or self-funded plan or
the amount described by the notice of lien and shall remit that
amount to the commission.
(b) A lien under this subchapter encumbers the right of the
claimant to payment under the insurance policy or self-funded plan,
and the insurer or self-insurer shall disburse to the claimant only
the portion of the payment remaining after the satisfaction of the
lien.
(c) A lien under this subchapter is inferior to any other
lien or claim for attorney's fees.
(d) If a recipient believes that the payment of the lien
exceeds the amount incurred by this state under the Medicaid
program on behalf of the recipient and notifies the insurer or
self-insurer that the recipient intends to file an administrative
appeal, the insurer or self-insurer may issue a single check made
payable to the recipient and the commission. The insurer or
self-insurer may notify the commission of its intent to issue
payment as a single check under this subsection.
(e) If the notice of lien is received after the insurer or
self-insurer has issued payment to a claimant, the insurer or
self-insurer shall notify the commission of the date of payment,
the amount of payment, and the name and address of the claimant.
The insurer or self-insurer is not obligated to make a payment to
the commission.
(f) An insurer or self-insurer shall pay the commission
under this section not later than the 30th day after the date of
notice of lien unless the recipient requests a hearing under
Section 37.056. If the recipient requests a hearing, the insurer or
self-insurer shall pay the commission in accordance with the result
of the hearing not later than the 10th business day after the date a
decision is rendered.
(g) The time for prompt payment of a claim under Chapter
542, Insurance Code, is tolled from the date the insurer receives
notice of lien under this chapter to the date payment is required to
be made under Subsection (f).
Sec. 37.054. DATA CONFIDENTIALITY. (a) The information
obtained by the commission from an insurer or self-insurer under
this chapter may only be used for the purposes of this chapter.
(b) An insurer or self-insurer, including the insurer's or
self-insurer's directors, agents, or employees, and an insurance
claim data collection organization, including the organization's
agents and employees authorized by the insurer or self-insurer to
act on the insurer's or self-insurer's behalf, shall keep
information concerning a recipient described by this chapter secure
and confidential.
Sec. 37.055. NOTICE OF INTERCEPTION. The commission shall
provide written notice to the claimant and claimant's attorney, if
applicable, that includes the date of the notice, the name of the
recipient, the last four digits of the social security number of the
recipient, the case number, the intercepted amount, the reason for
the interception, and notification of an opportunity to request a
hearing.
Sec. 37.056. REQUEST FOR HEARING. Not later than the 30th
day after the date of the notice under Section 37.055, a claimant or
recipient who has a claim intercepted under this chapter may
request a hearing from the State Office of Administrative Hearings.
Sec. 37.057. LIMITATION OF LIABILITY. (a) An insurer or
self-insurer, including the insurer's or self-insurer's directors,
agents, or employees, or an insurance claim data collection
organization, including the organization's agents and employees
authorized by the insurer or self-insurer to act on the insurer's or
self-insurer's behalf, that provides or attempts to provide
information under this chapter is not liable for damages that occur
as a result of providing or attempting to provide data under this
chapter. This chapter does not create civil liability for an
insurer or self-insurer.
(b) An insurer or self-insurer, including the insurer's or
self-insurer's directors, agents, or employees, or any insurance
claim data collection organization, including the organization's
agents and employees authorized by the insurer or self-insurer to
act on the insurer's or self-insurer's behalf, is not liable for
damages that occur as a result of making a payment to the commission
under this chapter.
(c) A person against whom any action is brought who is found
to be immune from liability under this section is entitled to
recover reasonable attorney's fees and costs from the person who
brought the action. This section does not abrogate or modify in any
way any common law or statutory privilege or immunity otherwise
enjoyed by any person.
Sec. 37.058. STATUTE OF LIMITATIONS. A person must bring an
action to pursue the recovery of money paid to the commission under
this chapter not later than two years after the date of the accident
or loss causing the injury that is the basis for the payment to the
commission. This chapter may not be construed to lengthen any
limitations under an insurance policy or self-funded plan.
SECTION 2. The change in law made by this Act applies only
to a claim made under an insurance policy or self-funded plan on or
after the effective date of this Act. A claim made before the
effective date of this Act is governed by the law applicable to the
claim immediately before the effective date of this Act, and that
law is continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2015.