36-264

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.