Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 4 - Conditions of Participant Participation, Rights and Responsibilities › Section 13 CSR 70-4.120 - Department is the Payer of Last Resort, Department's Claim for Recovery, Participant's Duty of Cooperation

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment brings 13 CSR 70.120 into
				  compliance with U.S. Supreme Court decision Gallardo v. Marstiller by removing
				  language limiting recovery to funds dedicated to past medical expenses. The
				  amendment also updates the definition of medical expenses.
(1) Definitions. The following definitions
				shall apply for purposes of this regulation.
(A) "Assignment" is the legal transfer from a
				participant to the division of the participant's right to recovery of medical
				expenses from a liable third party.
(B) "Assist" shall include, but not be
				limited to, providing full disclosure of all relevant information regarding a
				claim against a liable third party or insurer to the division; fully completing
				any and all forms requested by the division, provision of a Health Insurance
				Portability and Accountability Act (HIPAA) release to the division when
				requested; execution of any authorizations necessary to obtain release of any
				information the division requires in pursuit of the recovery; filing claims
				with potentially liable insurers when requested by the division; providing
				documentation of any and all settlement agreements, awards, or judgments
				related to claims against liable third parties; and timely responding to
				requests for information from insurers after a claim has been
				submitted.
(C) "Division" means the
				MO HealthNet Division of the Department of Social Services.
(D) "Identify" shall mean providing complete
				names, addresses, telephone numbers, and other relevant contact and location
				information of all potentially liable third parties, their attorneys, agents,
				and insurers.
(E) "Liable third
				party" includes any person, corporation, or institution, any employer as
				defined under Missouri's workers' compensation laws, and any public agency or
				private agency, who is liable, either pursuant to contract or otherwise, to an
				individual receiving public assistance on account of personal injury, disease,
				or disability or benefits arising from a health insurance plan to which the
				individual may be entitled.
(F)
				"Medical expense" and "medical expenses" are the cost of items and services
				provided under the Missouri State Medicaid Plan by the division on behalf of a
				participant which are related to the participant's claim against a liable third
				party, expressly excluding payments to vendors.
(G) "Medical treatment" means medical
				treatment rendered to a participant related to the participant's claim against
				a liable or potentially liable third party or insurer.
(H) "Notify" shall mean a written
				communication to the division of all relevant facts and information known which
				may be delivered to the division by United States Postal Service, facsimile
				transmission, or email.
1. In any case where
				written communication by a participant not represented by an attorney or other
				legal representative is not possible or is not reasonable due to disability
				requiring accommodation, the participant may substitute oral communication to
				the division either in person or by telephonic communication. The division
				shall provide the participant with written confirmation of the substitute oral
				communication and detail its contents.
2. Communication to the division from a
				licensed attorney or legal representative of a participant shall be in writing,
				or if done orally be followed up by written confirmation of that communication
				and its detailed contents.
(I) "Participant" is an individual who
				applies for, is determined eligible for, and receives MO HealthNet benefits
				provided under sections
				208.151
				to
				208.158
				or section
				208.204,
				RSMo.
(J) "Person" is any human
				being or other entity legally recognized as a person under Missouri law,
				including but not limited to, a corporation, cooperative, partnership, limited
				liability company, sole proprietorship, mutual insurer, and governmental entity
				or subdivision.
(K) "Timely" shall
				mean within a reasonable time, however-
1. In
				no case shall notification to the division occur later than ten (10) business
				days from the date of discovery or knowledge of the act or information to be
				disclosed by the participant to the division; and
2. In no case shall notification to the
				division occur less than thirty (30) days prior to an anticipated or potential
				settlement, compromise, judgment, award, or agreement regarding a participant's
				claim against a liable third party or potentially liable
				insurer.