To amend title XIX of the Social Security Act to clarify policy with respect to collecting reimbursement from third-party payers for medical assistance paid under the Medicaid program, and for other purposes.

To amend title XIX of the Social Security Act to clarify policy with respect to collecting reimbursement from third-party payers for medical assistance paid under the Medicaid program, and for other purposes. 1. 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) 2. Clarification of role of MCOs with respect to third-party liability (a) In general Section 1902(a)(25) of the Social Security Act ( 42 U.S.C. 1396a(a)(25) (E) that, if the State contracts with a managed care entity pursuant to section 1932 for the purpose of providing items and services under this title— (i) such contract shall specify whether— (I) the State is delegating to the managed care entity all or some of its right of recovery for an item or service for which payment has been made under the State plan; and (II) the State is transferring to the managed care entity all or some of the assignment to the State of any right of an individual or other entity to payment from a health insurer (including self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974), service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service) for an item or service for which payment has been made under the State plan; and (ii) if the State delegates its rights under clause (i)(I) clause (i)(II) (I) to provide to such managed care entity, upon the request of such entity, the information described in subparagraph (I)(i); (II) if a right of recovery was delegated under clause (i)(I) (III) if an assignment of rights was transferred under clause (i)(II) (IV) respond to an inquiry made by such entity in the same manner that the insurer would respond to an inquiry by a State under subparagraph (I)(iii); and (V) agree not to deny a claim submitted by a managed care entity for which the State has delegated or transferred rights under clause (i) . (b) Treatment of collected amounts Section 1903(d)(2)(B) of the Social Security Act ( 42 U.S.C. 1396b(d)(2)(B) For purposes of this subparagraph, reimbursements made by a third party to managed care entities 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. Requiring coordination of beneficiary information with respect to third-party liability Section 1902(a)(25) of the Social Security Act ( 42 U.S.C. 1396a(a)(25) (F) that, if the State contracts with a health insurer (as defined for purposes of subparagraph (E)) for the purposes of providing items and services under this title such contract shall require that— (i) if such insurer contracts with a pharmacy benefit manager to manage benefits under the health plan offered by such insurer, such contract shall require that the pharmacy benefit manager regularly report to the State (or, as applicable, to an authorized contractor or agent of the State) any data obtained by the pharmacy benefit manager that is relevant, as determined by the State, to assisting the State in determining whether such a health insurer is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service available under the plan; and (ii) such insurer cooperates (including by granting requests of the State for information, or for permission to utilize information, that is relevant to determining whether such a health insurer is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service available under the plan, regardless of the State in which the insurer is licensed) with the State Medicaid plan (including any State Medicaid agency or authorized agent or contractor of such program or entity) for the proper coordination of benefits offered through the plan of such insurer and medical assistance under the State plan to effectuate the principle of the program under this title being the payer of last resort; . 4. Development of model uniform fields for States to report third-party information Not later than January 1, 2015, 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 third-party health insurers (including self-insured plans, group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974), service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service) and other relevant information for ascertaining the legal responsibility of such third parties to pay for care and services available under the State plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. 5. 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) In the case of expenditures for medical assistance provided during 2014 and subsequent years for newly eligible individuals (as such term is defined in section 1905(y)) 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 services, the Secretary shall apply the Federal medical assistance percentage for the State under section 1905(b), notwithstanding the application of section 1905(y). 6. Penalty for non-compliance Subject to section 6(b), for any fiscal year beginning on or after the date that is 1 year after the effective date under section 6, in the case of a State that fails to comply with the additional requirements for the State plan for medical assistance under title XIX of the Social Security Act that are imposed by the amendments made by this Act, the Secretary of Health and Human Services shall reduce the Federal medical assistance percentage (as defined in section 1905(b) of the Social Security Act ( 42 U.S.C. 1396d(b) 7. Effective date (a) In general Except as provided in subsection (b) (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.

Summary: Amends title XIX (Medicaid) of the Social Security Act (SSA) to repeal the requirement that state plans for medical assistance pay for covered prenatal or preventive pediatric care services, or other covered services provided to an individual on whose behalf a state agency is enforcing child support, without regard to a third party's liability for payment for such services, and then seek reimbursement from the third party. Requires a state plan to require any contract with a managed care entity to specify whether the state is: (1) delegating to the entity all or some of its right of recovery for payment of an item or service, and (2) transferring to the entity all or some of the assignment to the state of any right of an individual or other entity to payment from a health insurer for an item or service. Requires any state that makes such a delegation or transfer to have in effect laws requiring such health insurers, as a condition of doing business, to: (1) provide the managed care entity certain information upon request; (2) accept the delegated right of recovery and the transferred assignment of rights; and (3) agree not to deny a claim submitted by a managed care entity, for which the state has delegated or transferred rights, in the same manner that the insurer may not deny a claim submitted by a state. Requires the state plan of any state that contracts with a health insurer to require that any contract of the health insurer with a pharmacy benefit manager to manage benefits under the insurer's health plan shall require that the pharmacy benefit manager regularly report to the state any relevant data it obtains to assist the state in determining whether the insurer is legally responsible for paying a claim for a health care item or service available under the plan. Requires such a contract also to require the insurer to cooperate with the state Medicaid plan for the proper coordination of benefits offered in order to effectuate the principle of the Medicaid program's being the payer of last resort. Directs the Secretary of Health and Human Services (HHS) to develop and make available to the states a model uniform reporting field that states may use for reporting to the Secretary within CME Form 64 (or any successor form) information identifying third-party health insurers and other relevant information for ascertaining the legal responsibility of such third parties to pay for care and services under Medicaid. Requires the Secretary to apply the federal medical assistance percentage (FMAP) for the state in determining the amount, if any, of any overpayment with respect to Medicaid services for newly eligible individuals. Prescribes an administrative penalty for non-compliance with the additional Medicaid requirements imposed by this Act.