36-596. Coordination of benefits; third party
payments; definition
A. The department of economic security shall establish a benefit recovery program
for state funded services to persons who receive services pursuant to this chapter which
are covered in whole or in part by a first party health insurance medical benefit. The
department shall coordinate benefits provided by this chapter so that any costs for
services payable by the department are costs avoided or recovered from any available
provider or 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 coordination of
benefits pursuant to this chapter. 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 economic security shall require each
individual or his parent or guardian to assign to the department rights that the
individual or his parent 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 chapter. The 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 chapter.
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 chapter, 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
who is receiving services pursuant to this chapter is enrolled. If a health care
services organization's enrolled child requires services under this chapter 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 be not 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.
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