Medicaid third party liability

(a)

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) and redesignating the subsequent subparagraphs accordingly.(b)

Clarification of role of health insurers with respect to third party liability

Section 1902(a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)), as amended by subsection (b)—(1)in subparagraph (F), by striking at the end and;(2)in subparagraph (G), by striking the period at the end and inserting ; and; and (3)by adding at the end the following new subparagraph:

(H)that, in the case of a State after January 1, 2023, 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)—(i)such contract shall specify—(I)whether the State is 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)whether the State is 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); and(ii)in the case of a State that elects an option described in subclause (I) or (I) of clause (i) 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 (G) confer to the health insurer the authority of the State with respect to the requirements specified in clauses (i) through (iv) of such subparagraph.

(c)

Increasing state flexibility with respect to third party liability

Section 1902(a)(25)(G) of the Social Security Act (42 U.S.C. 1396a(a)(25)(I)), as redesignated by subsection (a), 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)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 respective State’s plan (or under a waiver of the plan); and(II)after January 1, 2023, 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 inserting not later than 60 days after receiving before respond to; 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,.(d)

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 third party (as described in such paragraph) 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) of the Social Security Act (42 U.S.C. 1396b(i)) is amended—(A)in paragraph (26), by striking ; or and inserting ;;(B)in paragraph (27), by striking of the State. and inserting of the State; or; and (C)by inserting after paragraph (27) the following:

(28)with respect to any amounts after January 1, 2023, 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 coverage provided through a third party (as described in such paragraph) and the plan of such coverage in which the individual is enrolled.