36-264. Coordination of benefits; third party payments; definition

A. The department of health services shall establish a benefit recovery program for state funded services to persons who receive services pursuant to this article which are covered in whole or in part by a first party health insurance medical benefit. The department of health services shall coordinate benefits provided under this article so that any costs for services payable by the department are costs avoided or recovered from any available provider of first party health insurance medical benefits, subject to the specific scope of benefits of the provider of first party medical insurance benefits. The department may require that health care service providers are responsible for the coordination of benefits provided pursuant to this article. The department shall act as a payor of last resort unless this is specifically prohibited by federal law.

B. The director of the department of health services shall require each parent or legal guardian of a child receiving services under this article to assign to the department rights that the individual or his parents or guardian has to first party health insurance medical benefits to which the individual is entitled and which relate to the specific services which the person has received or will receive pursuant to this program. This state has a right to subrogation against a provider of first party health insurance medical benefits to enforce the assignment of first party health insurance medical benefits for services provided under the provisions of this article.

C. The provisions of this section are controlling over the provisions of a first party health insurance medical benefits policy issued after the effective date of this section. If the policy provisions exclude or limit coverage on the basis of a child's eligibility for services under this article, the department shall monitor payments from providers of first party health insurance medical benefits which are collected by providers of medical care.

D. The provisions of this section shall apply to a health care services organization subject to the provisions of title 20, chapter 4, article 9 in which a child is enrolled and who is receiving services pursuant to this article. If a health care services organization's enrolled child requires services under this article and if the benefits for the services are contractually available through the health care services organization, the health care services organization may require the enrolled child to receive the services through the health care services organization's contracted provider network up to the coverage limits set forth in the health care services organization's evidence of coverage. If the health care services organization elects not to provide the covered services either directly or through its contracted provider network or is unable to provide the covered services directly or through its contracted provider network and the services are covered benefits as set forth in the health care services organization's evidence of coverage, then the health care services organization shall reimburse the department for the services provided through the department for the enrolled child. The health care services organization shall not be required to reimburse the department for services beyond the coverage limits set forth in the health care services organization's evidence of coverage for the enrolled child. The amount of reimbursement paid by a health care services organization to the department shall not be greater than the level of compensation the health care services organization pays to its contracted provider network. A health care services organization may impose prior authorization, referral and other utilization review requirements in providing or paying for services to an enrolled child under this section.

E. For purposes of this section, "first party health insurance medical benefits" include benefits payable from a hospital, medical, dental and optometric service corporation subject to the provisions of title 20, chapter 4, article 3, a health care services organization subject to the provisions of title 20, chapter 4, article 9, an insurer providing disability insurance subject to the provisions of title 20, chapter 6, article 4, an insurer providing group disability insurance subject to the provisions of title 20, chapter 6, article 5, and any other available first party health insurance medical benefits, but does not include monies available under a social services block grant or an optional state supplemental payment program if federal monies are available.

36-264. Coordination of benefits; third party payments; definition

A. The department of health services shall establish a benefit recovery program for state funded services to persons who receive services pursuant to this article which are covered in whole or in part by a first party health insurance medical benefit. The department of health services shall coordinate benefits provided under this article so that any costs for services payable by the department are costs avoided or recovered from any available provider of first party health insurance medical benefits, subject to the specific scope of benefits of the provider of first party medical insurance benefits. The department may require that health care service providers are responsible for the coordination of benefits provided pursuant to this article. The department shall act as a payor of last resort unless this is specifically prohibited by federal law.

B. The director of the department of health services shall require each parent or legal guardian of a child receiving services under this article to assign to the department rights that the individual or his parents or guardian has to first party health insurance medical benefits to which the individual is entitled and which relate to the specific services which the person has received or will receive pursuant to this program. This state has a right to subrogation against a provider of first party health insurance medical benefits to enforce the assignment of first party health insurance medical benefits for services provided under the provisions of this article.

C. The provisions of this section are controlling over the provisions of a first party health insurance medical benefits policy issued after the effective date of this section. If the policy provisions exclude or limit coverage on the basis of a child's eligibility for services under this article, the department shall monitor payments from providers of first party health insurance medical benefits which are collected by providers of medical care.

D. The provisions of this section shall apply to a health care services organization subject to the provisions of title 20, chapter 4, article 9 in which a child is enrolled and who is receiving services pursuant to this article. If a health care services organization's enrolled child requires services under this article and if the benefits for the services are contractually available through the health care services organization, the health care services organization may require the enrolled child to receive the services through the health care services organization's contracted provider network up to the coverage limits set forth in the health care services organization's evidence of coverage. If the health care services organization elects not to provide the covered services either directly or through its contracted provider network or is unable to provide the covered services directly or through its contracted provider network and the services are covered benefits as set forth in the health care services organization's evidence of coverage, then the health care services organization shall reimburse the department for the services provided through the department for the enrolled child. The health care services organization shall not be required to reimburse the department for services beyond the coverage limits set forth in the health care services organization's evidence of coverage for the enrolled child. The amount of reimbursement paid by a health care services organization to the department shall not be greater than the level of compensation the health care services organization pays to its contracted provider network. A health care services organization may impose prior authorization, referral and other utilization review requirements in providing or paying for services to an enrolled child under this section.

E. For purposes of this section, "first party health insurance medical benefits" include benefits payable from a hospital, medical, dental and optometric service corporation subject to the provisions of title 20, chapter 4, article 3, a health care services organization subject to the provisions of title 20, chapter 4, article 9, an insurer providing disability insurance subject to the provisions of title 20, chapter 6, article 4, an insurer providing group disability insurance subject to the provisions of title 20, chapter 6, article 5, and any other available first party health insurance medical benefits, but does not include monies available under a social services block grant or an optional state supplemental payment program if federal monies are available.