§ 1908. Medicaid; payer of last resort; release of information
(a) Any clause in an insurance contract, plan, or agreement that limits or excludes payments
to a recipient is void.
(b) Medicaid shall be the payer of last resort to any insurer that contracts to pay health
care costs for a recipient.
(c) Every applicant for or recipient of Medicaid under this subchapter is deemed to have
authorized all third parties to release to the Agency all information needed by the
Agency to secure or enforce its rights under this subchapter. The Agency shall inform
an applicant or recipient of the provisions of this subsection at the time of application
for Medicaid benefits.
(d) On and after July 1, 2016, an insurer shall:
(1) Accept the Agency’s right of recovery and the assignment of rights and shall not charge
the Agency or any of its authorized agents fees for the processing of claims or eligibility
requests. Data files requested by or provided to the Agency shall provide the Agency
with eligibility and coverage information that will enable the Agency to determine
the existence of third-party coverage for Medicaid recipients, the period during which
Medicaid recipients may have been covered by the insurer, and the nature of the coverage
provided, including information such as the name, address, and identifying number
of the plan.
(2) If the insurer requires prior authorization for an item or service, accept the Agency’s
authorization that the item or service is covered under the Medicaid state plan or
waiver as if such authorization were the insurer’s prior authorization.
(e)(1) Upon request, to the extent permitted under the federal Health Insurance Portability
and Accountability Act and other federal privacy laws and notwithstanding any State
privacy law to the contrary, an insurer shall transmit to the Agency, in a manner
prescribed by the Centers for Medicare and Medicaid Services or as agreed between
the insurer and the Agency, an electronic file of all of the insurer’s identified
subscribers or policyholders and their dependents.
(2) An insurer shall comply with a request under the provisions of this subsection not
later than 60 days following the date of the Agency’s request and shall be required
to provide the Agency with only the information required by this section.
(3) The Agency shall request the data from an insurer once each month. The Agency shall
not request subscriber or policyholder enrollment data that precede the date of the
request by more than three years.
(4) The Agency shall use the data collected pursuant to this section solely for the purposes
of determining whether a Medicaid recipient also has or has had coverage with the
insurer providing the data.
(5) The Agency shall ensure that all data collected and maintained pursuant to this section
are collected and stored securely and that such data are stored no longer than necessary
to determine whether Medicaid benefits may be coordinated with the insurer, or as
otherwise required by law. Insurers shall not be liable for any security incidents
caused by the Agency in the collection or maintenance of the data.
(f)(1) Each insurer shall submit a file containing information required to coordinate benefits,
such as the name, address, group policy number, coverage type, Social Security number,
and date of birth of each subscriber or policyholder and each dependent covered by
the insurer, including the policy effective and termination dates, claims submission
address, and employer’s mailing address.
(2) The Agency shall adopt rules governing the exchange of information pursuant to this
section. The rules shall be consistent with laws relating to the confidentiality or
privacy of personal information and medical records, including the Health Insurance
Portability and Accountability Act.
(g) From funds recovered pursuant to this subchapter, the federal government shall be
paid a portion equal to the proportionate share originally provided by the federal
government to pay for medical assistance to a recipient or minor. (Added 1995, No. 152 (Adj. Sess.), § 2; amended 2007, No. 65, § 110c; 2015, No. 172 (Adj. Sess.), § E.306.7; 2021, No. 20, § 300; 2023, No. 51, § 2, eff. July 1, 2023.)