HR 4320 IHCommentsClose CommentsPermalink

To amend title XIX of the Social Security Act to strengthen the Medicaid third-party liability requirements.CommentsClose CommentsPermalink

December 6, 2007

Mr. ENGEL introduced the following bill; which was referred to the Committee on Energy and CommerceCommentsClose CommentsPermalink

To amend title XIX of the Social Security Act to strengthen the Medicaid third-party liability requirements.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

SECTION 1. STRENGTHENING THE MEDICAID THIRD-PARTY LIABILITY REQUIREMENT.

(a) State and Health Provider Right To Make Inquiries and Third-Party Responsibilities- Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended--CommentsClose CommentsPermalink





(1) in subsection (a)(25)--CommentsClose CommentsPermalink





(A) by striking `and' at the end of subparagraph (H);CommentsClose CommentsPermalink





(B) by adding `and' at the end of subparagraph (I); andCommentsClose CommentsPermalink





(C) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





`(J) that the State shall provide assurances satisfactory to the Secretary that the State has in effect laws requiring the State to make inquiries to third parties, including health insurers, self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974), service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, operating in any State;'; andCommentsClose CommentsPermalink





(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink





`(dd) Responsibilities of Third Parties-CommentsClose CommentsPermalink





`(1) IN GENERAL- Third parties described in subsection (a)(25)(J) shall--CommentsClose CommentsPermalink





`(A) provide, with respect to individuals who are eligible for, or are provided, medical assistance under the State plan, upon the request of the State, information to determine during what period the individual (or the individual's spouse or 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 identifying number of the plan) in a manner prescribed by the Secretary;CommentsClose CommentsPermalink





`(B) accept the State's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under the State plan;CommentsClose CommentsPermalink





`(C) respond to any inquiry by the State regarding a claim for payment for any health care item or service that is submitted not later than 3 years after the date of the provision of such health care item or service; andCommentsClose CommentsPermalink





`(D) agree not to deny a claim submitted by the State solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if--CommentsClose CommentsPermalink





`(i) the claim is submitted by the State within the 3-year period beginning on the date on which the item or service was furnished; andCommentsClose CommentsPermalink





`(ii) any action by the State to enforce its rights with respect to such claim is commenced within 6 years of the State's submission of such claim.CommentsClose CommentsPermalink





`(2) INQUIRIES OF THIRD PARTIES- Entities providing services and items to individuals receiving medical assistance under this title (or to individuals the entity reasonably believes may receive medical assistance under this title) may make inquiries to third parties described in subsection (a)(15)(J) that are, by statute, contract, or agreement, legally responsible for payment of a claim, operating in any State, for the purpose of determining eligibility and coverage for those individuals.'.CommentsClose CommentsPermalink





(b) Referrals to the Secretary; Maintaining the Integrity of the Medicaid Program- Section 1909 of such Act (42 U.S.C. 1396h) is amended--CommentsClose CommentsPermalink





(1) in subsection (b), by adding at the end the following new paragraph:CommentsClose CommentsPermalink





`(5) The law contains a requirement for making a referral to the Secretary for the purposes of subsection (e).'; andCommentsClose CommentsPermalink





(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink





`(e) Federal Civil Penalties and Payments to States-CommentsClose CommentsPermalink





`(1) FEDERAL CIVIL PENALTIES-CommentsClose CommentsPermalink





`(A) IN GENERAL- Upon referral from a State, if the Secretary finds that a third party, including any third party described in section 1902(a)(25)(J), that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, failed to reply to inquiries about an individual sent pursuant to such section, the Secretary shall impose a civil penalty upon that third party of not less than $5,000 and not more than $10,000, plus 3 times the amount of the claim for that individual without regard to any other legal responsibility of the third party for payment of a claim for a health care item or service for that individual.CommentsClose CommentsPermalink





`(B) FAILURE DEFINED- For purposes of subparagraph (A), the term `failed' means the failure of a third party described to provide the information required by section 1902(a)(25)(J) about an individual within 10 days of the date the inquiry is first made to the party.CommentsClose CommentsPermalink





`(2) PAYMENTS TO STATES- The Secretary shall pay a State an amount equal to the Federal medical assistance percentage of any amount obligated to the United States under paragraph (1).'.CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall take effect on January 1, 2009.CommentsClose CommentsPermalink