Outside Section 20

MassHealth - Third Party Liability to Satisfy Federal Law

SECTION 20.   Chapter 118E of the General Laws is hereby further amended by striking out section 23, as amended by section 28 of chapter 58 of the acts of 2006, and inserting in place thereof the following section:-

          Section 23. (a) As used in this section, health care insurer, health insurer and health insurance shall include, but not be limited to, any health insurance company, health maintenance organization, group or nongroup health plan, self-insured plan, service benefit plan, managed care organization, pharmacy benefit manager, or other public or private third party that is, by statute, contract, agreement, or arrangement legally responsible for payment of a claim for health care benefits.

          (b) Notwithstanding any general or special law, rule or regulation to the contrary, the division shall be subrogated to the rights of any recipient of medical assistance under this chapter and may take any and all actions available to that recipient to secure benefits under any policy issued by any health care insurer that is or may be liable to pay for health care benefits obtained by a recipient of medical assistance to the extent of any health care benefits provided by the division on behalf of the recipient or the recipient's dependents. A health care insurer shall reimburse the division for any health care benefits provided by the division on behalf of a recipient of medical assistance, and shall not reduce the amount of the total reimbursement by any division payment, but any part of the total that is a reimbursement for a division payment shall not exceed the amount actually paid by the division.

          (c) No health care insurer shall require written authorization from the recipient before honoring the division's rights under this section. A health insurer must respond to any inquiry by the division about a claim for payment for any health care benefits and may not deny any claim for payment for any health care benefits solely on the basis of the date of submission of the claim, the type of format for the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim, if the claim is submitted by the division within a 3-year period beginning on the date on which the service was furnished, and if any action by the division to enforce its rights with respect to a claim is filed within 6 years after the submission of the claim to the health insurer.

          (d) A recipient of medical assistance or any person legally obligated to support and have actual or legal custody of a recipient of medical assistance shall inform the division of any health insurance available to that recipient upon initial application and redetermination for eligibility for assistance and shall make known the nature and extent of any health insurance coverage to any person or institution that provides medical benefits to the recipient or his or her dependent.

          (e) A health care insurer shall not take into account that an individual is eligible for or is receiving benefits from the division when enrolling an individual or issuing a policy or agreement covering the individual, or administering or renewing a policy or agreement, or when making any payment for health care benefits to the individual or on behalf of the individual; nor shall any policy or agreement issued, administered, or renewed by a health care insurer contain any provision denying or reducing health care benefits to an individual who is eligible for or is receiving benefits from the division.

          (f) A provider of medical assistance under this chapter shall determine whether any recipient for whom it provides medical care or services which are or may be eligible for reimbursement under this chapter is a subscriber or beneficiary of a health insurance plan. The division is the payor of last resort, and accordingly a provider shall request payment for medical care or services it provides from a health insurer which is or may be liable for the medical care or services so provided, before payment is requested from the division.

          (g) Payment by the division under the medical assistance programs established by this chapter shall constitute payment in full; after receiving this payment a provider may not recover from any health insurer an amount greater than the amount paid by the division for any service for which the division is to be the payor of last resort.

          (h) Notwithstanding any general or special law or rule or regulation to the contrary, all holders of health insurance information, including, but not limited to, health insurers doing business in the commonwealth, all private and public entities who employ individuals in the commonwealth, and all agencies of the commonwealth, shall provide sufficient information to the division, or in the case of those agencies, shall make other arrangements mutually satisfactory to both agencies, to enable the division: (a) to identify whether any of the following persons are or could be beneficiaries under any policy of insurance in the commonwealth: (1) persons applying for or receiving medical assistance or benefits under this chapter or health services through an agency under the executive office of health and human services, (2) persons for whom hospitals and community health centers claim reimbursement payments from the Health Safety Net Fund, established by section 35 of chapter 118G; and (b) to determine the nature of the coverage that is or was provided, including cost, scope, terms, periods of coverage, and any identifying name, address or number of the policy of insurance. .All public and private entities who employ individuals in the commonwealth shall provide, when requested by any employee applying for or receiving benefits provided by the division, written information to the employee describing the availability of health insurance, if any, provided by or through the employer. The failure of an employer to provide an employee with the information shall not be grounds for denial of benefits by the division.

          (i) The division may, after notice and opportunity for hearing, garnish the wages, salary, or other employment income of, and shall, with the assistance of the department of revenue under section 3 of chapter 62D, withhold amounts from state tax refunds to, any person who: (a) is required by court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under this chapter; (b) has received payment from a third party for the costs of those services to the child; but, (c) has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services, to the extent necessary to reimburse the division for expenditures for those costs.
 
 

Summary:
This section amends the current definition of liable health care payers for MassHealth cost-avoidance and cost-recovery operations to include service benefit plans, managed care organizations, and pharmacy benefit managers among entities with third party liability (TPL). It also prohibits special treatment, such as benefit reduction, premium shifts, or premium increases, by insurers of MassHealth members. While these changes are required to bring MassHealth into compliance with the federal Deficit Reduction Act (DRA), they also provide MassHealth with additional flexibility to recover from TPL parties, and enhance MassHealth's program integrity.