Mass. Gen. Laws ch. 118E, sec. 23 — MA Code / Part I / Title XVII / Chapter 118E / Section 23
Subrogation rights; health insurance benefits; garnishment of wages
Status: in_force

Section 23. As used in this section, health care insurer, health insurer and health insurance shall include, but not be limited to, any health insurance company, health maintenance organization, group or nongroup health plan, self-insured plan, service benefit plan, managed care organization, pharmacy benefit manager, dental benefit manager, accountable care organization, managed care entity, casualty insurer, workers' compensation insurer, malpractice insurer, short-term limited duration insurance, association health plan or other public or private third party that is, by law, contract, agreement or arrangement legally responsible for payment of a claim for health care benefits. Notwithstanding any general or special law to the contrary, the division shall be subrogated to the rights of a recipient of medical assistance under this chapter and may take any action available to such recipient to secure benefits under a policy issued by a health care insurer that is or may be liable to pay for health care benefits obtained by a recipient of medical assistance to the extent of any health care benefits provided by the division on behalf of such recipient or such recipient's dependents. A health care insurer shall reimburse the division for any health care benefits provided by the division on behalf of a recipient of medical assistance, and shall not reduce the amount of the total reimbursement by a division payment; provided, however, that any part of the total that is a reimbursement for a division payment shall not exceed the amount actually paid by the division. No health care insurer shall require written authorization from the recipient before honoring the division's rights pursuant to this section. A health care insurer shall respond to an inquiry by the division about a claim for payment for health care benefits not later than 60 days after receiving any inquiry and shall not deny a claim for payment for health care benefits solely on the basis of the date of submission of the claim, the type of format for the claim form or a failure to present proper documentation at the point of sale that is the basis of the claim if the claim is submitted by the division within a 3–year period beginning on the date on which the service was furnished and if any action by the division to enforce its rights with respect to a claim is filed within 6 years after the submission of the claim to the health insurer. A health care insurer shall: (i) accept the division's authorization that the item or service is covered under the state plan or waiver of such plan, as if the authorization were the prior authorization made by the health care insurer for the item or service; and (ii) not deny a claim submitted by the division for failure to obtain prior authorization for an item or service. Prior authorization made by the health care insurer or any other entity on behalf of the health care insurer, including, but not limited to, a third-party administrator, shall mean any review to determine coverage of an item or service before the item or service is provided and before a claim is submitted for payment, including, but not limited to, prior approvals, pre-certifications or medical necessity determinations. A recipient of medical assistance or a person legally obligated to support and have actual or legal custody of a recipient of medical assistance shall inform the division of any health insurance available to such recipient upon initial application and redetermination for eligibility for assistance and shall make known the nature and extent of any health insurance coverage to any person or institution that provides medical benefits to the recipient or the recipient's dependent. A health care insurer shall not take into account that an individual is eligible for or is receiving benefits from the division when enrolling an individual or issuing a policy or agreement covering the individual or when administering or renewing a policy or agreement or when making a payment for health care benefits to the individual or on behalf of the individual, nor shall a policy or agreement issued, administered or renewed by a health care insurer contain a provision denying or reducing health care benefits to an individual who is eligible for or is receiving benefits from the division. A provider of medical assistance under this chapter shall determine whether a recipient for whom it provides medical care or services which are or may be eligible for reimbursement under this chapter is a subscriber or beneficiary of a health insurance plan. The division shall be the payor of last resort and a provider shall request payment for medical care or services it provides from a health insurer which is or may be liable for the medical care or services so provided prior to requesting payment from the division. Payment by the division under the medical assistance programs established by this chapter shall constitute payment in full. Subsequent to any such payment, a provider shall not recover from a health insurer an amount greater than the amount so paid by the division for a service for which the division is to be the payor of last resort. Notwithstanding any general or special law to the contrary, all holders of health insurance information including, but not limited to, health insurers doing business in the commonwealth or providing coverage to residents of the commonwealth, all private and public entities who employ individuals in the commonwealth and all agencies of the commonwealth, shall provide sufficient information to the division, or its designee, or, in the case of such agencies, shall make other arrangements mutually satisfactory to both agencies, to enable the division: (a) to identify whether any of the following persons are or could be beneficiaries under a policy of insurance in the commonwealth: (i) persons applying for or receiving medical assistance or benefits pursuant to this chapter or health services through an agency under the executive office of health and human services, and (ii) persons for whom hospitals and community health centers claim reimbursement payments from the Health Safety Net Trust Fund under section 69; and (b) to determine the nature of the coverage that is or was provided, including cost, scope, terms, periods of coverage, and any identifying name, address or number of the policy of insurance. Upon request from the department of revenue, the division shall make information received from holders of health insurance information available to the department to determine whether a person is covered by insurance as required by chapter 111M. All public and private entities who employ individuals in the commonwealth shall provide, when requested by an employee applying for or receiving benefits provided by the division, written information to the employee describing the availability of health insurance, if any, provided by or through the employer. The failure of an employer to provide an employee with the information shall not be grounds for denial of benefits by the division. The division may, after notice and opportunity for hearing, garnish the wages, salary or other employment income of and shall, with the assistance of the department of revenue pursuant to section 3 of chapter 62D, withhold amounts from state tax refunds to any person who: (a) is required by a court or an administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance pursuant to this chapter; or (b) has received payment from a third party for the costs of those services to the child, but has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services, to the extent necessary to reimburse the division for expenditures for those costs.

Section 23. As used in this section, health care insurer, health insurer and health insurance shall include, but not be limited to, any health insurance company, health maintenance organization, group or nongroup health plan, self-insured plan, service benefit plan, managed care organization, pharmacy benefit manager, dental benefit manager, accountable care organization, managed care entity, casualty insurer, workers' compensation insurer, malpractice insurer, short-term limited duration insurance, association health plan or other public or private third party that is, by law, contract, agreement or arrangement legally responsible for payment of a claim for health care benefits.

Notwithstanding any general or special law to the contrary, the division shall be subrogated to the rights of a recipient of medical assistance under this chapter and may take any action available to such recipient to secure benefits under a policy issued by a health care insurer that is or may be liable to pay for health care benefits obtained by a recipient of medical assistance to the extent of any health care benefits provided by the division on behalf of such recipient or such recipient's dependents. A health care insurer shall reimburse the division for any health care benefits provided by the division on behalf of a recipient of medical assistance, and shall not reduce the amount of the total reimbursement by a division payment; provided, however, that any part of the total that is a reimbursement for a division payment shall not exceed the amount actually paid by the division.

No health care insurer shall require written authorization from the recipient before honoring the division's rights pursuant to this section. A health care insurer shall respond to an inquiry by the division about a claim for payment for health care benefits not later than 60 days after receiving any inquiry and shall not deny a claim for payment for health care benefits solely on the basis of the date of submission of the claim, the type of format for the claim form or a failure to present proper documentation at the point of sale that is the basis of the claim if the claim is submitted by the division within a 3–year period beginning on the date on which the service was furnished and if any action by the division to enforce its rights with respect to a claim is filed within 6 years after the submission of the claim to the health insurer.

A health care insurer shall: (i) accept the division's authorization that the item or service is covered under the state plan or waiver of such plan, as if the authorization were the prior authorization made by the health care insurer for the item or service; and (ii) not deny a claim submitted by the division for failure to obtain prior authorization for an item or service.

Prior authorization made by the health care insurer or any other entity on behalf of the health care insurer, including, but not limited to, a third-party administrator, shall mean any review to determine coverage of an item or service before the item or service is provided and before a claim is submitted for payment, including, but not limited to, prior approvals, pre-certifications or medical necessity determinations.

A recipient of medical assistance or a person legally obligated to support and have actual or legal custody of a recipient of medical assistance shall inform the division of any health insurance available to such recipient upon initial application and redetermination for eligibility for assistance and shall make known the nature and extent of any health insurance coverage to any person or institution that provides medical benefits to the recipient or the recipient's dependent.

A health care insurer shall not take into account that an individual is eligible for or is receiving benefits from the division when enrolling an individual or issuing a policy or agreement covering the individual or when administering or renewing a policy or agreement or when making a payment for health care benefits to the individual or on behalf of the individual, nor shall a policy or agreement issued, administered or renewed by a health care insurer contain a provision denying or reducing health care benefits to an individual who is eligible for or is receiving benefits from the division.

A provider of medical assistance under this chapter shall determine whether a recipient for whom it provides medical care or services which are or may be eligible for reimbursement under this chapter is a subscriber or beneficiary of a health insurance plan. The division shall be the payor of last resort and a provider shall request payment for medical care or services it provides from a health insurer which is or may be liable for the medical care or services so provided prior to requesting payment from the division.

Payment by the division under the medical assistance programs established by this chapter shall constitute payment in full. Subsequent to any such payment, a provider shall not recover from a health insurer an amount greater than the amount so paid by the division for a service for which the division is to be the payor of last resort.

Notwithstanding any general or special law to the contrary, all holders of health insurance information including, but not limited to, health insurers doing business in the commonwealth or providing coverage to residents of the commonwealth, all private and public entities who employ individuals in the commonwealth and all agencies of the commonwealth, shall provide sufficient information to the division, or its designee, or, in the case of such agencies, shall make other arrangements mutually satisfactory to both agencies, to enable the division: (a) to identify whether any of the following persons are or could be beneficiaries under a policy of insurance in the commonwealth: (i) persons applying for or receiving medical assistance or benefits pursuant to this chapter or health services through an agency under the executive office of health and human services, and (ii) persons for whom hospitals and community health centers claim reimbursement payments from the Health Safety Net Trust Fund under section 69; and (b) to determine the nature of the coverage that is or was provided, including cost, scope, terms, periods of coverage, and any identifying name, address or number of the policy of insurance. Upon request from the department of revenue, the division shall make information received from holders of health insurance information available to the department to determine whether a person is covered by insurance as required by chapter 111M. All public and private entities who employ individuals in the commonwealth shall provide, when requested by an employee applying for or receiving benefits provided by the division, written information to the employee describing the availability of health insurance, if any, provided by or through the employer. The failure of an employer to provide an employee with the information shall not be grounds for denial of benefits by the division.

The division may, after notice and opportunity for hearing, garnish the wages, salary or other employment income of and shall, with the assistance of the department of revenue pursuant to section 3 of chapter 62D, withhold amounts from state tax refunds to any person who: (a) is required by a court or an administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance pursuant to this chapter; or (b) has received payment from a third party for the costs of those services to the child, but has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services, to the extent necessary to reimburse the division for expenditures for those costs.