R.I. Gen. Laws § 40-6-9.1

Current through 2024 Public Law 457

Section 40-6-9.1 - Data matching - Health care coverages

(a) For purposes of this section, the term "medical assistance program" shall mean medical assistance provided in whole or in part by the department of human services pursuant to chapters 5.1, 8, 8.4 of this title, 12.3 of title 42 and/or Title XIX or XXI of the federal Social Security Act, as amended, 42 U.S.C. § 1396 et seq. and 42 U.S.C. § 1397aa et seq., respectively. Any references to the department shall be to the department of human services.

(b) In furtherance of the assignment of rights to medical support to the department of human services under § 40-6-9(b), (c), (d), and (e), and in order to determine the availability of other sources of healthcare insurance or coverage for beneficiaries of the medical assistance program, and to determine potential third-party liability for medical assistance paid out by the department, all health insurers, health-maintenance organizations, including managed care organizations, and third-party administrators, self-insured plans, pharmacy benefit managers (PBM), and other parties that are by statute, contract, or agreement, legally responsible for payment of a claim for a healthcare item of service doing business in the state of Rhode Island shall permit and participate in data matching with the department of human services, as provided in this section, to assist the department to identify medical assistance program applicants, beneficiaries, and/or persons responsible for providing medical support for applicants and beneficiaries who may also have healthcare insurance or coverage in addition to that provided, or to be provided, by the medical assistance program and to determine any third-party liability in accordance with this section.

The department shall take all reasonable measures to determine the legal liability of all third parties (including health insurers, self-insured plans, group health plans (as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)] ), service benefit plans, health-maintenance organizations, 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 healthcare item or service), to pay for care and services on behalf of a medical assistance recipient, including collecting sufficient information to enable the department to pursue claims against such third parties.

In any case where such a legal liability is found to exist and medical assistance has been made available on behalf of the individual (beneficiary), the department shall seek reimbursement for the assistance to the extent of the legal liability and in accordance with the assignment described in § 40-6-9.

To the extent that payment has been made by the department for medical assistance to a beneficiary in any case where a third party has a legal liability to make payment for the assistance, and to the extent that payment has been made by the department for medical assistance for healthcare items or services furnished to an individual, the department (state) is considered to have acquired the rights of the individual to payment by any other party for the healthcare items or services in accordance with § 40-6-9.

Any health insurer (including a group health plan, as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)], a self-insured plan, a service-benefit plan, a managed care organization, a pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a healthcare item or service), in enrolling an individual, or in making any payments for benefits to the individual or on the individual's behalf, is prohibited from taking into account that the individual is eligible for, or is provided, medical assistance under a plan under 42 U.S.C. § 1396 et seq. for this state, or any other state.

(c) All health insurers, including, but not limited to, health-maintenance organizations, third-party administrators, nonprofit medical-service corporations, nonprofit hospital-service corporations, subject to the provisions of chapters 18, 19, 20, and 41 of title 27, as well as, self-insured plans, group health plans (as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)] ), 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 healthcare item or service) doing business in this state shall:

(1) Provide member information within fourteen (14) calendar days of the request to the department to enable the medical assistance program to identify medical assistance program recipients, applicants and/or persons responsible for providing medical support for those recipients and applicants who are, or could be, enrollees or beneficiaries under any individual or group health insurance contract, plan, or policy available or in force and effect in the state;

(2) With respect to individuals who are eligible for, or are provided, medical assistance by the department, upon the request of the department, provide member information within fourteen (14) calendar days of the request to determine during what period the individual or his or her spouse or dependents may be (or may have been) covered by a health insurer and the nature of the coverage that is, or was provided by the health insurer (including the name, address, and identifying number of the plan);

(3) Accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from the party for an item or service for which payment has been made by the department;

(4) Respond to any inquiry by the department regarding a claim for payment for any healthcare item or service that is submitted not later than three (3) years after the date of the provision of the healthcare item or service; and

(5) Agree not to deny a claim submitted by the state based solely on procedural reasons, such as on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if-

(i) The claim is submitted by the state within the three-year (3) period beginning on the date on which the item or service was furnished; and

(ii) Any action by the state to enforce its rights with respect to the claim is commenced within six (6) years of the state's submission of such claim.

(d) This information shall be made available by these insurers and health-maintenance organizations and used by the department of human services only for the purposes of, and to the extent necessary for, identifying these persons, determining the scope and terms of coverage, and ascertaining third-party liability. The department of human services shall provide information to the health insurers, including health insurers, self-insured plans, group health plans (as defined in § 607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)] ), 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 healthcare item or service) only for the purposes described herein.

(e) No health insurer, health-maintenance organization, or third-party administrator that provides, or makes arrangements to provide, information pursuant to this section shall be liable in any civil or criminal action or proceeding brought by beneficiaries or members on account of this action for the purposes of violating confidentiality obligations under the law.

(f) The department shall submit any appropriate and necessary state plan provisions.

(g) The department of human services is authorized and directed to promulgate regulations necessary to ensure the effectiveness of this section.

R.I. Gen. Laws § 40-6-9.1

P.L. 2002 , ch. 65, art. 35, §3; P.L. 2007 , ch. 73, art. 18, §4; P.L. 2008 , ch. 100, art. 17, § 15.