Mass. Gen. Laws ch. 118E, sec. 22 — MA Code / Part I / Title XVII / Chapter 118E / Section 22
Third party payments; repayment; assignment; subrogation
Status: in_force

Section 22. (a) As used in this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Claimant'', a person who suffers a loss from accident, illness, injury or otherwise for which monies may be provided by liability insurance, workers' compensation or any other third party. ''Date of the loss'', the date on which the accident, illness, injury or other incident occurs. ''Third party'', an individual, agency, program, entity or insurer including, but not limited to, the claimant's own insurer, that is or may be liable to pay monies on account of the claimant's loss. (b) When a claimant or a claimant's heirs, estate or legal representative receives payment from a liability or workers' compensation insurer or any other third party as a result of a loss, the claimant or the claimant's heirs, estate or legal representative shall repay to the executive office of health and human services the total of medical assistance benefits provided from monies allocated in the payment, settlement or compromise of claim or action, court award or judgment for medical expenses. Where the amount allocated to past medical expenses is insufficient to satisfy the executive office's claim for full recovery of medical assistance benefits paid, the executive office may assert its claim and recover from any allocation for future medical expenses. (c) If a payment, settlement or compromise of claim or action, court award or judgment fails to specify what portion of the payment, settlement or compromise of claim or action, court award or judgment is in payment of medical expenses, there shall be a presumption that the payment, settlement or compromise of claim or action, court award or judgment applies first to the medical expenses incurred by the claimant in an amount equal to the medical assistance benefits paid. (d) The executive office of health and human services may dispute any allocation for medical damages that results in less than full recovery of medical assistance benefits paid and have a hearing before a court of competent jurisdiction on the allocation of damages either prior to or after disbursement of payment by the third party. The executive office shall not be precluded from enforcing its recovery rights from any payment, settlement or compromise of claim or action, court award or judgment that excludes the cost of medical assistance benefits paid. Notwithstanding this section or any other general or special law to the contrary, if a claimant received medical assistance through a managed care organization, the executive office may recover the amount that the managed care organization paid for medical services provided. (e) When a claimant or a claimant's heirs, estate or legal representative receives payment from a liability or workers' compensation insurer or any other third party, the claimant or the claimant's heirs, estate or legal representative shall repay to the executive office of health and human services the costs attributable to services provided to the claimant that were paid by the Health Safety Net Trust Fund established in section 66. (f) When a claimant or a claimants' heirs, estate or legal representative receives payment from a liability or workers' compensation insurer or any other third party, the claimant or the claimant's heirs, estate or legal representative shall repay to the department of transitional assistance the total of all financial assistance benefits provided by the department on and after the date of the loss to or on behalf of the claimant, the claimant's spouse or children and any other individual the claimant is required by law to support; provided, however, that if on the date of the loss the claimant was already eligible for financial assistance benefits, the claimant or the claimant's heirs, estate or legal representative shall repay only the increase in financial assistance that occurred as a result of the accident, illness, injury or other incident. (g) The application for and receipt of benefits recoverable under this section, after notice to the third party, shall operate as a lien to secure repayment against monies which may be provided by the third party up to the amount of such recoverable benefits, but the department of transitional assistance, the executive office of health and human services and the executive office of health and human services may also perfect their rights to a lien against any monies which may come into possession of the claimant's attorney from the third party by giving notice to that attorney. (h) If the monies available for repayment are insufficient to satisfy in full any competing claims of the executive office of health and human services, the executive office of health and human services and the department of transitional assistance, then each shall be entitled to its respective pro rata share of the monies that are available. (i) A person receiving public assistance benefits recoverable under this section shall assign to the commonwealth an amount equal to the benefits so provided from the proceeds of any such claim against the third party. (j) A claimant, or if represented by counsel, the claimant's attorney, shall, within 10 calendar days, notify the executive office of health and human services in writing upon engaging in recovery activity including, but not limited to, making an insurance claim or sending a demand letter and upon commencement of a civil action or other proceeding to establish the liability of a third party or to collect monies payable under accident, liability or health insurance, workers' compensation or from any other third party. No settlement, compromise, judgment or award or any recovery in any claim or action shall be made final without first providing the executive office of health and human services, the executive office of health and human services and the department of transitional assistance with written notice and a reasonable opportunity to intervene or otherwise perfect their rights to recovery. (k) The commonwealth shall be subrogated to a claimant's entire cause of action or right to proceed against a third party and to a claimant's claim for monies to the extent of assistance or services provided under this chapter, chapters 118 or 118E. The commonwealth shall also have a separate and independent cause of action to recover, from a third party, assistance provided to a claimant under this chapter or said chapters 118 or 118E, which cause of action shall be in addition to other causes of action. The commonwealth may, by attorneys employed or selected by the commonwealth, commence a civil action or other proceeding to establish the liability of a third party or to collect such monies, or may intervene as of right in a civil action commenced by a claimant against a third party. No third party shall require written authorization from the claimant before honoring the commonwealth's rights under this section. (l) Failure of a claimant without good cause to provide notice as required under this section or to provide such further information deemed necessary by the executive office to pursue its rights under this section shall be grounds for termination of benefits. (m) Notwithstanding any general or special law or rule or regulation to the contrary, a third party shall provide information requested by the executive office of health and human services, the department of transitional assistance and the executive office of health and human services for use by those agencies to recover payments for public assistance benefits or services under this section, section 5G of chapter 18 and section 69.

Section 22. (a) As used in this section, the following words shall have the following meanings unless the context clearly requires otherwise:

''Claimant'', a person who suffers a loss from accident, illness, injury or otherwise for which monies may be provided by liability insurance, workers' compensation or any other third party.

''Date of the loss'', the date on which the accident, illness, injury or other incident occurs.

''Third party'', an individual, agency, program, entity or insurer including, but not limited to, the claimant's own insurer, that is or may be liable to pay monies on account of the claimant's loss.

(b) When a claimant or a claimant's heirs, estate or legal representative receives payment from a liability or workers' compensation insurer or any other third party as a result of a loss, the claimant or the claimant's heirs, estate or legal representative shall repay to the executive office of health and human services the total of medical assistance benefits provided from monies allocated in the payment, settlement or compromise of claim or action, court award or judgment for medical expenses. Where the amount allocated to past medical expenses is insufficient to satisfy the executive office's claim for full recovery of medical assistance benefits paid, the executive office may assert its claim and recover from any allocation for future medical expenses.

(c) If a payment, settlement or compromise of claim or action, court award or judgment fails to specify what portion of the payment, settlement or compromise of claim or action, court award or judgment is in payment of medical expenses, there shall be a presumption that the payment, settlement or compromise of claim or action, court award or judgment applies first to the medical expenses incurred by the claimant in an amount equal to the medical assistance benefits paid.

(d) The executive office of health and human services may dispute any allocation for medical damages that results in less than full recovery of medical assistance benefits paid and have a hearing before a court of competent jurisdiction on the allocation of damages either prior to or after disbursement of payment by the third party. The executive office shall not be precluded from enforcing its recovery rights from any payment, settlement or compromise of claim or action, court award or judgment that excludes the cost of medical assistance benefits paid. Notwithstanding this section or any other general or special law to the contrary, if a claimant received medical assistance through a managed care organization, the executive office may recover the amount that the managed care organization paid for medical services provided.

(e) When a claimant or a claimant's heirs, estate or legal representative receives payment from a liability or workers' compensation insurer or any other third party, the claimant or the claimant's heirs, estate or legal representative shall repay to the executive office of health and human services the costs attributable to services provided to the claimant that were paid by the Health Safety Net Trust Fund established in section 66.

(f) When a claimant or a claimants' heirs, estate or legal representative receives payment from a liability or workers' compensation insurer or any other third party, the claimant or the claimant's heirs, estate or legal representative shall repay to the department of transitional assistance the total of all financial assistance benefits provided by the department on and after the date of the loss to or on behalf of the claimant, the claimant's spouse or children and any other individual the claimant is required by law to support; provided, however, that if on the date of the loss the claimant was already eligible for financial assistance benefits, the claimant or the claimant's heirs, estate or legal representative shall repay only the increase in financial assistance that occurred as a result of the accident, illness, injury or other incident.

(g) The application for and receipt of benefits recoverable under this section, after notice to the third party, shall operate as a lien to secure repayment against monies which may be provided by the third party up to the amount of such recoverable benefits, but the department of transitional assistance, the executive office of health and human services and the executive office of health and human services may also perfect their rights to a lien against any monies which may come into possession of the claimant's attorney from the third party by giving notice to that attorney.

(h) If the monies available for repayment are insufficient to satisfy in full any competing claims of the executive office of health and human services, the executive office of health and human services and the department of transitional assistance, then each shall be entitled to its respective pro rata share of the monies that are available.

(i) A person receiving public assistance benefits recoverable under this section shall assign to the commonwealth an amount equal to the benefits so provided from the proceeds of any such claim against the third party.

(j) A claimant, or if represented by counsel, the claimant's attorney, shall, within 10 calendar days, notify the executive office of health and human services in writing upon engaging in recovery activity including, but not limited to, making an insurance claim or sending a demand letter and upon commencement of a civil action or other proceeding to establish the liability of a third party or to collect monies payable under accident, liability or health insurance, workers' compensation or from any other third party. No settlement, compromise, judgment or award or any recovery in any claim or action shall be made final without first providing the executive office of health and human services, the executive office of health and human services and the department of transitional assistance with written notice and a reasonable opportunity to intervene or otherwise perfect their rights to recovery.

(k) The commonwealth shall be subrogated to a claimant's entire cause of action or right to proceed against a third party and to a claimant's claim for monies to the extent of assistance or services provided under this chapter, chapters 118 or 118E. The commonwealth shall also have a separate and independent cause of action to recover, from a third party, assistance provided to a claimant under this chapter or said chapters 118 or 118E, which cause of action shall be in addition to other causes of action. The commonwealth may, by attorneys employed or selected by the commonwealth, commence a civil action or other proceeding to establish the liability of a third party or to collect such monies, or may intervene as of right in a civil action commenced by a claimant against a third party. No third party shall require written authorization from the claimant before honoring the commonwealth's rights under this section.

(l) Failure of a claimant without good cause to provide notice as required under this section or to provide such further information deemed necessary by the executive office to pursue its rights under this section shall be grounds for termination of benefits.

(m) Notwithstanding any general or special law or rule or regulation to the contrary, a third party shall provide information requested by the executive office of health and human services, the department of transitional assistance and the executive office of health and human services for use by those agencies to recover payments for public assistance benefits or services under this section, section 5G of chapter 18 and section 69.