2023 Connecticut General Statutes › Title 17b - Social Services › Chapter 319v - Medical Assistance › Section 17b-265. (Formerly Sec. 17-134f). - Department subrogated to right of recovery of applicant or recipient. Utilization of personal health insurance. Insurance coverage of medical assistance recipients. Limitations.

(a) In accordance with 42 USC 1396k, the Department of Social Services shall be subrogated to any right of recovery or indemnification that an applicant or recipient of medical assistance or any legally liable relative of such applicant or recipient has against an insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, for the cost of all health care items or services furnished to the applicant or recipient, including, but not limited to, hospitalization, pharmaceutical services, physician services, nursing services, behavioral health services, long-term care services and other medical services, not to exceed the amount expended by the department for such care and treatment of the applicant or recipient. In the case of such a recipient who is an enrollee in a care management organization under a Medicaid care management contract with the state or a legally liable relative of such an enrollee, the department shall be subrogated to any right of recovery or indemnification which the enrollee or legally liable relative has against such a private insurer or other third party for the medical costs incurred by the care management organization on behalf of an enrollee.
(b) An applicant or recipient or legally liable relative, by the act of the applicant's or recipient's receiving medical assistance, shall be deemed to have made a subrogation assignment and an assignment of claim for benefits to the department. The department shall inform an applicant of such assignments at the time of application. Any entitlements from a contractual agreement with an applicant or recipient, legally liable relative or a state or federal program for such medical services, not to exceed the amount expended by the department, shall be so assigned. Such entitlements shall be directly reimbursable to the department by third party payors. The Department of Social Services may assign its right to subrogation or its entitlement to benefits to a designee or a health care provider participating in the Medicaid program and providing services to an applicant or recipient, in order to assist the provider in obtaining payment for such services. In accordance with subsection (b) of section 38a-472, a provider that has received an assignment from the department shall notify the recipient's health insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, of the assignment upon rendition of services to the applicant or recipient. Failure to so notify the health insurer or other legally liable third party shall render the provider ineligible for payment from the department. The provider shall notify the department of any request by the applicant or recipient or legally liable relative or representative of such applicant or recipient for billing information. This subsection shall not be construed to affect the right of an applicant or recipient to maintain an independent cause of action against such third party tortfeasor.
(c) Claims for recovery or indemnification submitted by the department, or the department's designee, shall not be denied solely on the basis of the date of the submission of the claim, the type or format of the claim, the lack of prior authorization or the failure to present proper documentation at the point-of-service that is the basis of the claim, if (1) the claim is submitted by the state within the three-year period beginning on the date on which the item or service was furnished; and (2) any action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of the claim.
(d) When a recipient of medical assistance has personal health insurance in force covering care or other benefits provided under such program, payment or part-payment of the premium for such insurance may be made when deemed appropriate by the Commissioner of Social Services. The commissioner shall limit reimbursement to medical assistance providers for coinsurance and deductible payments under Title XVIII of the Social Security Act to assure that the combined Medicare and Medicaid payment to the provider shall not exceed the maximum allowable under the Medicaid program fee schedules.
(e) No self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care plan, or any plan offered or administered by a health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, shall contain any provision that has the effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to an insured or beneficiary who is eligible for or who received medical assistance under this chapter. No insurer, as defined in section 38a-497a, shall impose requirements on the state Medicaid agency, which has been assigned the rights of an individual eligible for Medicaid and covered for health benefits from an insurer, that differ from requirements applicable to an agent or assignee of another individual so covered.
(f) The Commissioner of Social Services shall not pay for any services provided under this chapter if the individual eligible for medical assistance has coverage for the services under an accident or health insurance policy.
(g) An insurer or other legally liable third party, upon receipt of a claim submitted by the department or the department's designee, in accordance with the requirements of subsection (c) of this section, for payment of a health care item or service covered under a state medical assistance program administered by the department, shall, not later than ninety days after receipt of the claim or not later than ninety days after the effective date of this section, whichever is later, (1) make payment on the claim, (2) request information necessary to determine its legal obligation to pay the claim, or (3) issue a written reason for denial of the claim. Failure to pay, request information necessary to determine legal obligation to pay or issue a written reason for denial of a claim not later than one hundred twenty days after receipt of the claim, or not later than one hundred twenty days after the effective date of this section, whichever is later, creates an uncontestable obligation to pay the claim. The provisions of this subsection shall apply to all claims, including claims submitted by the department or the department's designee prior to July 1, 2021.
(h) On and after July 1, 2021, an insurer or other legally liable third party who has reimbursed the department for a health care item or service paid for and covered under a state medical assistance program administered by the department shall, upon determining it is not liable and at risk for cost of the health care item or service, request any refund from the department not later than twelve months from the date of its reimbursement to the department.
(1967, P.A. 759, S. 1(f); P.A. 75-420, S. 4, 6; P.A. 77-614, S. 608, 610; P.A. 83-145; P.A. 84-367, S. 2, 3; P.A. 90-283, S. 1; June Sp. Sess. P.A. 91-8, S. 6, 63; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; 93-418, S. 32, 41; May Sp. Sess. P.A. 94-5, S. 6, 30; P.A. 95-257, S. 12, 21, 58; 95-305, S. 3, 6; P.A. 99-279, S. 17, 45; June Sp. Sess. P.A. 07-2, S. 20; P.A. 09-8, S. 5; P.A. 10-179, S. 78; P.A. 11-44, S. 84; 11-61, S. 126; P.A. 12-119, S. 5; P.A. 15-247, S. 29; June Sp. Sess. P.A. 15-5, S. 388; June Sp. Sess. P.A. 21-2, S. 334.)
History: P.A. 75-420 replaced welfare commissioner with commissioner of social services; P.A. 77-614 replaced commissioner of social services with commissioner of income maintenance, effective January 1, 1979; P.A. 83-145 made the existing section Subsec. (b) and added Subsec. (a) dealing with subrogation to any right of recovery, assignment of claim for benefits and entitlements and right of action against third party tortfeasors; P.A. 84-367 added Subsec. (c) prohibiting a provision denying or limiting insurance benefits because services are rendered to an insured who is eligible for or received medical assistance and added Subsec. (d) prohibiting the commissioner from paying for services if the individual has coverage under an accident or health insurance policy; P.A. 90-283 in Subsec. (a) subrogated the department to any right of recovery of a legally liable relative of an applicant or recipient of medical assistance and added provisions whereby the department may assign its right of subrogation; June Sp. Sess. P.A. 91-8 amended Subsec. (b) to require a limitation on reimbursement to medical assistance providers for coinsurance and deductible payments to not exceed the maximum allowable under the Medicaid fee schedules, except for those providers licensed by the department of health services; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced commissioner of health services with commissioner of public health and addiction services, effective July 1, 1993; P.A. 93-418 changed reference to insurer to a private insurer or third party and made other technical changes, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (c) to prevent insurers from imposing requirements on the department of social services which deny or limit benefits which have been assigned pursuant to this section, effective July 1, 1994; Sec. 17-134f transferred to Sec. 17b-265 in 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 95-305 amended Subsec. (c) by deleting a provision that an insurer, health care center or issuer of any service plan contract for hospital or medical expense coverage shall not impose requirements on the Department of Social Services which limit or deny benefits and adding a provision prohibiting an insurer from imposing certain requirements on the state Medicaid agency, effective July 1, 1995; P.A. 99-279 amended Subsec. (a) to provide that the department shall be subrogated to any right of recovery or indemnification which an enrollee in a managed care organization under a Medicaid managed care contract or legally liable relative has against a private insurer or other third party for the medical costs incurred by the managed care organization on behalf of an enrollee and made technical changes, effective July 1, 1999; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by dividing existing provisions into Subsecs. (a) and (b), amended redesignated Subsec. (a) by deleting “private”, adding “legally liable”, delineating entities deemed an insurer or a legally liable third party, adding “legally responsible for payment of a claim for a health care item or service”, re responsibilities of third party, providing that health care items or services include behavioral health services and long-term care services and making technical changes, amended redesignated Subsec. (b) by adding “In accordance with subsection (b) of section 38a-472” re provider's notice to department of receipt of an assignment, replacing “private insurer” with “health insurer”, adding “legally liable”, and delineating entities deemed a health insurer or a legally liable third party, added new Subsec. (c) re time parameters for submission of claims for recovery or indemnification by department, redesignated existing Subsecs. (b) to (d) as Subsecs. (d) to (f), and amended redesignated Subsec. (e) by redefining types of health insurance plans that shall not contain provisions which have effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to individual who is receiving medical assistance and making a technical change, effective July 1, 2007; P.A. 09-8 made technical changes in Subsec. (b); P.A. 10-179 amended Subsec. (a) by replacing references to managed care with references to care management, effective July 1, 2010; P.A. 11-44 amended Subsec. (d) by adding provision requiring Commissioner of Public Health to limit reimbursement payments to providers whose rates are established under Ch. 368d, effective July 1, 2011; P.A. 11-61 amended Subsec. (d) by deleting provision added by P.A. 11-44, effective July 1, 2011; P.A. 12-119 added references to third-party administrator in Subsecs. (a), (b) and (e) and amended Subsec. (c) to add “the lack of prior authorization”, effective June 15, 2012; P.A. 15-247 amended Subsec. (e) by deleting reference to Sec. 38a-553(c), effective July 10, 2015; June Sp. Sess. P.A. 15-5 amended Subsec. (d) to delete exception re providers whose rates are established pursuant to Ch. 368d, effective July 1, 2015; June Sp. Sess. P.A. 21-2 amended Subsec. (d) by deleting “Effective January 1, 1992,” and added Subsecs. (g) and (h) re deadlines for payments or refunds, effective July 1, 2021.