[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 938 Introduced in House (IH)]
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115th CONGRESS
1st Session
H. R. 938
To amend title XIX of the Social Security Act to provide clarification
with respect to the liability of third party payers for medical
assistance paid under the Medicaid program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 7, 2017
Mr. Burgess (for himself and Mr. Flores) introduced the following bill;
which was referred to the Committee on Energy and Commerce
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to provide clarification
with respect to the liability of third party payers for medical
assistance paid under the Medicaid program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicaid Third Party Liability
Act''.
SEC. 2. MEDICAID THIRD PARTY LIABILITY.
(a) Clarification of Definitions Applicable to Third Party
Liability.--
(1) In general.--Section 1902 of the Social Security Act
(42 U.S.C. 1396a) is amended by adding at the end the following
new subsection:
``(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.''.
(2) Conforming amendments.--Section 1902(a)(25) of the
Social Security Act (42 U.S.C. 1396a(a)(25)) is amended--
(A) in subparagraph (A), in the matter preceding
clause (i), by striking ``third parties'' and all that
follows through ``item or service)'' and inserting
``responsible third parties'';
(B) in subparagraph (G), by striking ``health
insurer'' and all that follows through ``item or
service)'' and inserting ``responsible third party'';
(C) in subparagraph (I), in the matter preceding
clause (i), by striking ``health insurers'' and all
that follows through ``item or service'' and inserting
``responsible third parties''; and
(D) by inserting ``responsible'' before ``third''
each place it appears in subparagraphs (A)(i), (A)(ii),
(C), (D), and (H).
(b) Removal of Special Treatment of Certain Types of Care and
Payments Under Medicaid Third Party Liability Rules.--Section
1902(a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)) is
amended by striking subparagraphs (E) and (F).
(c) Clarification of Role of Health Insurers With Respect to Third
Party Liability.--
(1) In general.--Section 1902(a)(25) of the Social Security
Act (42 U.S.C. 1396a(a)(25)), as amended by subsection (b), is
further amended by inserting after subparagraph (D) the
following new subparagraphs:
``(E) that, in the case of a State that provides
medical assistance under this title through a contract
with 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), 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);
``(F) that, in the case of a State that elects an
option described in clause (i) or (ii) of subparagraph
(E) with respect to 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 State shall provide
assurances to the Secretary that the State laws
referred to in subparagraph (I) confer to the health
insurer the authority of the State with respect to the
requirements specified in clauses (i) through (iv) of
such subparagraph;''.
(2) Treatment of collected amounts.--Section 1903(d)(2)(B)
of the Social Security Act (42 U.S.C. 1396b(d)(2)(B)) is
amended by adding at the end the following: ``For purposes of
this subparagraph, reimbursements made by a responsible third
party to health insurers (including group health plans, as
defined in section 607(1) of the Employee Retirement Income
Security Act of 1974, self-insured plans, fully-insured plans,
service benefit plans, managed care organizations, pharmacy
benefit managers, and any other health plan determined
appropriate by the Secretary) pursuant to section
1902(a)(25)(E) shall be treated in the same manner as
reimbursements made to a State under the previous sentence.''.
(3) Effective date.--The amendments made by this subsection
shall take effect on October 1, 2017.
(d) Increasing State Flexibility With Respect to Third Party
Liability.--Section 1902(a)(25)(I) of the Social Security Act (42
U.S.C. 1396a(a)(25)(I)) is amended--
(1) in clause (i), by striking ``medical assistance under
the State plan'' and inserting ``medical assistance under a
State plan (or under a waiver of the plan)'';
(2) by striking clause (ii) and inserting the following new
clause:
``(ii) accept--
``(I) any State's right of recovery
and the assignment to any 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 respective State's plan
(or under a waiver of the plan); and
``(II) as a valid authorization of
the responsible third party for the
furnishing of an item or service to an
individual eligible to receive medical
assistance under this title, an
authorization made on behalf of such
individual under the State plan (or
under a waiver of such plan) for the
furnishing of such item or service to
such individual;'';
(3) in clause (iii)--
(A) by striking ``respond to'' and inserting ``not
later than 60 days after receiving''; and
(B) by striking ``; and'' at the end and inserting
``, respond to such inquiry; and''; and
(4) in clause (iv), by inserting ``a failure to obtain a
prior authorization,'' after ``claim form,''.
(e) State Incentive To Pursue Third Party Liability for Newly
Eligibles.--Section 1903(d)(2)(B) of the Social Security Act (42 U.S.C.
1396b(d)(2)(B)), as amended by subsection (c)(2), is amended by adding
at the end the following: ``In the case of expenditures for medical
assistance provided during 2017 and subsequent years for individuals
described in subclause (VIII) of section 1902(a)(10)(A)(i), in
determining the amount, if any, of overpayment under this subparagraph
with respect to such medical assistance, the Secretary shall apply the
Federal medical assistance percentage for the State under section
1905(b), notwithstanding the application of section 1905(y).''.
SEC. 3. COMPLIANCE WITH THIRD PARTY INSURANCE REPORTING.
(a) In General.--Section 1903 of the Social Security Act (42 U.S.C.
1396b) is amended by inserting after subsection (m) the following new
subsection:
``(n)(1) For any year beginning after 2020 (except as provided in
paragraph (2)), unless a State complies with the requirements of
section 1902(a)(25) with respect to each calendar quarter in such year,
the Federal medical assistance percentage shall be reduced by 1
percentage point for calendar quarters in each subsequent year in which
the State fails to so comply (and cumulatively for a failure to so
comply for a period of consecutive years).
``(2) Notwithstanding paragraph (1), the reduction in the Federal
medical assistance percentage shall apply--
``(A) in the case of a failure of the State to comply with
the requirements of section 1902(a)(25) with respect to payment
for items and services furnished to individuals described in
subclause (VIII) of section 1902(a)(10)(A)(i), for any year
beginning after 2018; and
``(B) in the case of a failure of the State to comply with
the requirements of section 1902(a)(25) with respect to payment
for items and services furnished to individuals described in
subdivision (i), (iii), or (iv) of section 1905(a), for any
year beginning after 2019.''.
(b) Verification of Insurance Status Required.--
(1) In general.--Section 1902(a)(25)(A)(i) of the Social
Security Act (42 U.S.C. 1396a(a)(25)(A)(i)) is amended by
inserting ``, including the collection of, with respect to an
individual seeking to receive medical assistance under this
title, information on whether the individual has health
insurance coverage provided through a health insurer (as
described in section 1902(nn)) and the plan of such insurer in
which the individual is enrolled'' after ``sufficient
information''.
(2) FFP unavailable without insurance status
verification.--Section 1903(i)(25) of the Social Security Act
(42 U.S.C. 1396b(i)(25)) is amended--
(A) by striking ``with respect to'' and inserting
``(A) with respect to''; and
(B) by inserting before the semicolon at the end
the following: ``and (B) with respect to any amounts
expended for medical assistance for individuals for
whom the State has not obtained and verified, in
accordance with section 1902(a)(25)(A)(i), information
on whether such an individual has health insurance
coverage provided through a health insurer (as
described in section 1902(nn)) and the plan of such
insurer in which the individual is enrolled''.
SEC. 4. APPLICATION TO CHIP.
(a) In General.--Section 2107(e)(1) of the Social Security Act (42
U.S.C. 1397gg(e)(1)) is amended--
(1) by redesignating subparagraphs (B) through (R) as
subparagraphs (C) through (S), respectively; and
(2) by inserting after subparagraph (A) the following new
subparagraph:
``(B) Section 1902(a)(25) (relating to third party
liability).''.
(b) Mandatory Reporting.--Section 1902(a)(25)(I)(i) of the Social
Security Act (42 U.S.C. 1396a(a)(25)(I)(i)), as amended by section
1(d), is further amended--
(1) by striking ``(and, at State option, child'' and
inserting ``and child''; and
(2) by striking ``title XXI)'' and inserting ``title XXI''.
SEC. 5. TRAINING ON THIRD PARTY LIABILITY.
Section 1936 of the Social Security Act (42 U.S.C. 1396u-6) is
amended--
(1) in subsection (b)(4), by striking ``and quality of
care'' and inserting ``, quality of care, and the liability of
responsible third parties (as defined in section 1902(nn))'';
and
(2) by adding at the end the following new subsection:
``(f) Third Party Liability Training.--With respect to education or
training activities carried out pursuant to subsection (b)(4) with
respect to the liability of responsible third parties (as defined in
section 1902(nn) for payment for items and services furnished under
State plans (or under waivers of such plans)) under this title, the
Secretary shall--
``(1) publish (and update on an annual basis) on the public
Internet website of the Centers for Medicare & Medicaid
Services a dedicated Internet page containing best practices to
be used in assessing such liability;
``(2) monitor efforts to assess such liability and analyze
the challenges posed by that assessment;
``(3) distribute to State agencies administering the State
plan under this title information related to such efforts and
challenges; and
``(4) provide guidance to such State agencies with respect
to State oversight of efforts by medicaid managed care
organizations (as defined in section 1903(m)(1)) to assess such
liability.''.
SEC. 6. DEVELOPMENT OF MODEL UNIFORM FIELDS FOR STATES TO REPORT THIRD
PARTY INFORMATION.
Not later than January 1, 2018, the Secretary of Health and Human
Services shall, in consultation with the States, develop and make
available to the States a model uniform reporting field that States may
use for purposes of reporting to the Secretary within CMS Form 64 (or
any successor form) information identifying responsible third parties
(as defined in subsection (nn) of section 1902 of the Social Security
Act (42 U.S.C. 1396a)) and other relevant information for ascertaining
the legal responsibility of such third parties to pay for care and
services available under the State plan (or under a waiver of the plan)
under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).
SEC. 7. EFFECTIVE DATE.
(a) In General.--Except as provided in subsection (b), this Act and
the amendments made by this Act (other than as specified in the
preceding provisions of this Act) shall take effect on the date of
enactment of this Act and shall apply to medical assistance provided on
or after such date.
(b) Exception if State Legislation Required.--In the case of a
State plan for medical assistance under title XIX of the Social
Security Act that the Secretary of Health and Human Services determines
requires State legislation (other than legislation appropriating funds)
in order for the plan to meet the additional requirement imposed by the
amendments made under this section, the State plan shall not be
regarded as failing to comply with the requirements of such title
solely on the basis of its failure to meet this additional requirement
before the first day of the first calendar quarter beginning after the
close of the first regular session of the State legislature that begins
after the date of the enactment of this Act. For purposes of the
previous sentence, in the case of a State that has a 2-year legislative
session, each year of such session shall be deemed to be a separate
regular session of the State legislature.
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