HR 938 — Medicaid Third Party Liability Act

Summary

Medicaid Third Party Liability Act This bill alters provisions related to third-party liability for medical assistance paid under the Medicaid program. Specifically, with respect to such liability, the bill: expands the definition of "responsible third party" to include, among other health insurers, the TRICARE program; eliminates special rules with respect to certain services provided to children; requires the inclusion, in a contract between a state Medicaid program and a health insurer, of certain information regarding whether the state is delegating or transferring to the insurer a right of third-party recovery; provides for the treatment as overpayment of reimbursements made by a responsible third party to a health insurer; disallows a responsible third party from denying a state's claim solely on the basis of a failure to obtain a prior authorization; imposes a timeline for a responsible third party to respond to a state's inquiry regarding a claim for payment; provides for reductions to a state Medicaid program's federal matching rate if the state fails to comply with third-party insurance requirements; and modifies other provisions related to third-party liability under the Medicaid program. Third-party liability requirements applicable under Medicaid shall also apply under the Children's Health Insurance Program (CHIP). The Centers for Medicare & Medicaid Services must: publish on its website, and annually update, best practices for assessing third-party liability; monitor and analyze efforts to assess that liability; in consultation with states, develop and make available a model uniform reporting field for identifying information related to responsible third parties; and provide other specified information and guidance to states.

Bill Text

• Introduced Introduced in House Current html February 07, 2017

Compared against current U.S. Code AI-generated reading aid — verify against the official bill.

The bill clarifies the definitions and roles related to third party liability for medical assistance under the Medicaid program.

• 42 U.S.C. 1396a

  nn) For purposes of subsection (a)(25) and section 1903(d)(2)(B), the term `responsible third party' means a health insurer (including a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, a self-insured plan, a fully-insured plan, a service benefit plan, a managed care organization, a pharmacy benefit manager, and any other health plan determined appropriate by the Secretary), the TRICARE program under chapter 55 of title 10, United States Code, an accountable care organization, or any other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

  This adds a new definition for 'responsible third party' in relation to Medicaid liability.

• 42 U.S.C. 1396a(a)(25)

  third parties and all that follows through ``item or service)'' → responsible third parties'

  This change modifies the terminology used to refer to third parties in the context of Medicaid.

• 42 U.S.C. 1396a(a)(25)

  health insurer and all that follows through ``item or service)'' → responsible third party'

  Updates the language to maintain consistency in referring to responsible third parties.

• 42 U.S.C. 1396a(a)(25)

  health insurers and all that follows through ``item or service'' → responsible third parties'

  Continues the clarification by changing multiple instances to unify the terminology.

• 42 U.S.C. 1396a(a)(25)

  E) that, in the case of a State that provides medical assistance under this title through a contract with a health insurer..., such contract shall specify whether the State is-- (i) delegating to such insurer all or some of its right of recovery from a responsible third party for an item or service for which payment has been made under the State plan (or under a waiver of the plan); and (ii) transferring to such insurer all or some of the assignment to the State of any right of an individual or other entity to payment from a responsible third party for an item or service for which payment has been made under the State plan (or under a waiver of the plan);

  This introduces new contractual requirements for states dealing with health insurers regarding recovery rights.

• 42 U.S.C. 1396a(a)(25)

  F) that, in the case of a State that elects an option described in clause (i) or (ii) of subparagraph (E)...

  Adds more requirements on state assurances regarding third party payments.

• 42 U.S.C. 1396b(d)(2)(B)

  For purposes of this subparagraph, reimbursements made by a responsible third party to health insurers...shall be treated in the same manner as reimbursements made to a State under the previous sentence.

  Clarifies how reimbursements from responsible third parties to health insurers should be treated similarly to state reimbursements.

• 42 U.S.C. 1396a(a)(25)(I)

  medical assistance under the State plan → medical assistance under a State plan (or under a waiver of the plan)'

  Expands the applicability of provisions to any state plan or waivers, not just the state plan.

• 42 U.S.C. 1396a(a)(25)(I)

  respond to → not later than 60 days after receiving

  Imposes a timeline for responses regarding third party inquiries.

• 42 U.S.C. 1396b(i)(25)

  with respect to → (A) with respect to

  Refines the language regarding Medicaid expenditures and insurance verification.

Action History

1. February 07, 2017

   Introduced in House

2. February 07, 2017

   Introduced in House

3. February 07, 2017

   Referred to the House Committee on Energy and Commerce.

4. February 10, 2017

   Referred to the Subcommittee on Health.

Sponsors

• Michael C. Burgess · Primary

Subjects