§ 40-6-9.1 Data matching – Healthcare coverages. – (a) For purposes of this section, the term "medical assistance program" shallmean medical assistance provided in whole or in part by the department of humanservices pursuant to chapters 5.1, 8, 8.4 of title 40, 12.3 of title 42 and/ortitle 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. Anyreferences to the department shall be to the department of human services.
(b) In furtherance of the assignment of rights to medicalsupport 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 paidout by the department, all health insurers, health maintenance organizations,including managed care organizations, and third party administrators, selfinsured plans, pharmacy benefit managers (PBM), and other parties that are bystatute, contract, or agreement, legally responsible for payment of a claim fora health care item of service doing business in the state of Rhode Island shallpermit and participate in data matching with the department of human services,as provided in this section, to assist the Department to identify medicalassistance program applicants, beneficiaries and/or persons responsible forproviding medical support for such applicants and beneficiaries who may alsohave health care insurance or coverage in addition to that provided or to beprovided by the medical assistance program and to determine any third partyliability in accordance with this section.
The department shall take all reasonable measures todetermine the legal liability of all third parties (including health insurers,self-insured plans, group health plans (as defined in § 607(1) of theEmployee 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 thatare, by statute, contract, or agreement, legally responsible for payment of aclaim for a health care item or service), to pay for care and services onbehalf of a medical assistance recipient, including collecting sufficientinformation to enable the department to pursue claims against such thirdparties.
In any case where such a legal liability is found to existand medical assistance has been made available on behalf of the individual(beneficiary), the department shall seek reimbursement for such assistance tothe extent of such legal liability and in accordance with the assignmentdescribed in § 40-6-9.
To the extent that payment has been made by the departmentfor medical assistance to a beneficiary in any case where a third party has alegal liability to make payment for such assistance, and to the extent thatpayment has been made by the department for medical assistance for health careitems or services furnished to an individual, the department (state) isconsidered to have acquired the rights of such individual to payment by anyother party for such health care items or services in accordance with §40-6-9.
Any health insurer (including a group health plan, as definedin § 607(1) of the employee retirement income security act of 1974[29 U.S.C. § 1167(1)], a self-insured plan, a service benefitplan, a managed care organization, a pharmacy benefit manager, or other partythat is, by statute, contract, or agreement, legally responsible for payment ofa claim for a health care item or service), in enrolling an individual or inmaking any payments for benefits to the individual or on the individual'sbehalf, is prohibited from taking into account that the individual is eligiblefor or is provided medical assistance under a plan under 42 U.S.C. § 1396et seq. for such state, or any other state.
(c) All health insurers, including, but not limited to,health maintenance organizations, third party administrators, nonprofit medicalservice corporations, nonprofit hospital service corporations, subject to theprovisions of chapters 18, 19, 20 and 41 of title 27, as well as, self-insuredplans, group health plans (as defined in § 607(1) of the EmployeeRetirement 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, legallyresponsible for payment of a claim for a health care item or service) doingbusiness in this state shall:
(i) Provide member information within fourteen (14) calendardays of the request to the department to enable the medical assistance programto identify medical assistance program recipients, applicants and/or personsresponsible for providing medical support for those recipients and applicantswho are or could be enrollees or beneficiaries under any individual or grouphealth insurance contract, plan or policy available or in force and effect inthe state;
(ii) With respect to individuals who are eligible for, or areprovided, medical assistance by the department, upon the request of thedepartment, provide member information within fourteen (14) calendar days ofthe request to determine during what period the individual or their spouses ortheir dependents may be (or may have been) covered by a health insurer and thenature of the coverage that is or was provided by the health insurer (includingthe name, address, and identifying number of the plan);
(iii) Accept the state's right of recovery and the assignmentto the state of any right of an individual or other entity to payment from theparty for an item or service for which payment has been made by the department;
(iv) Respond to any inquiry by the department regarding aclaim for payment for any health care item or service that is submitted notlater than three (3) years after the date of the provision of such health careitem or service; and
(v) Agree not to deny a claim submitted by the state basedsolely on procedural reasons such as on the basis of the date of submission ofthe claim, the type or format of the claim form, or a failure to present properdocumentation at the point-of-sale that is the basis of the claim, if–
(I) The claim is submitted by the state within the three (3)year period beginning on the date on which the item or service was furnished;and
(II) Any action by the state to enforce its rights withrespect to such claim is commenced within six (6) years of the state'ssubmission of such claim.
(d) This information shall be made available by theseinsurers and health maintenance organizations and used by the department ofhuman services only for the purposes of and to the extent necessary foridentifying these persons determining the scope and terms of coverage, andascertaining third party liability. The department of human services shallprovide information to the health insurers, including health insurers,self-insured plans, group health plans (as defined in § 607(1) of theemployee retirement income security act of 1974 [29 U.S.C. §1167(1)]), service benefit plans, managed care organizations, pharmacybenefit managers, or other parties that are, by statute, contract, oragreement, legally responsible for payment of a claim for a health care item orservice) only for the purposes described herein.
(e) No health insurer, health maintenance organization, orthird party administrator which provides or makes arrangements to provideinformation pursuant to this section shall be liable in any civil or criminalaction or proceeding brought by beneficiaries or members on account of thisaction for the purposes of violating confidentiality obligations under the law.
(f) The department shall submit any appropriate and necessarystate plan provisions.
(g) The department of human services is authorized anddirected to promulgate regulations necessary to ensure the effectiveness ofthis section.
§ 40-6-9.1 Data matching – Healthcare coverages. – (a) For purposes of this section, the term "medical assistance program" shallmean medical assistance provided in whole or in part by the department of humanservices pursuant to chapters 5.1, 8, 8.4 of title 40, 12.3 of title 42 and/ortitle 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. Anyreferences to the department shall be to the department of human services.
(b) In furtherance of the assignment of rights to medicalsupport 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 paidout by the department, all health insurers, health maintenance organizations,including managed care organizations, and third party administrators, selfinsured plans, pharmacy benefit managers (PBM), and other parties that are bystatute, contract, or agreement, legally responsible for payment of a claim fora health care item of service doing business in the state of Rhode Island shallpermit and participate in data matching with the department of human services,as provided in this section, to assist the Department to identify medicalassistance program applicants, beneficiaries and/or persons responsible forproviding medical support for such applicants and beneficiaries who may alsohave health care insurance or coverage in addition to that provided or to beprovided by the medical assistance program and to determine any third partyliability in accordance with this section.
The department shall take all reasonable measures todetermine the legal liability of all third parties (including health insurers,self-insured plans, group health plans (as defined in § 607(1) of theEmployee 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 thatare, by statute, contract, or agreement, legally responsible for payment of aclaim for a health care item or service), to pay for care and services onbehalf of a medical assistance recipient, including collecting sufficientinformation to enable the department to pursue claims against such thirdparties.
In any case where such a legal liability is found to existand medical assistance has been made available on behalf of the individual(beneficiary), the department shall seek reimbursement for such assistance tothe extent of such legal liability and in accordance with the assignmentdescribed in § 40-6-9.
To the extent that payment has been made by the departmentfor medical assistance to a beneficiary in any case where a third party has alegal liability to make payment for such assistance, and to the extent thatpayment has been made by the department for medical assistance for health careitems or services furnished to an individual, the department (state) isconsidered to have acquired the rights of such individual to payment by anyother party for such health care items or services in accordance with §40-6-9.
Any health insurer (including a group health plan, as definedin § 607(1) of the employee retirement income security act of 1974[29 U.S.C. § 1167(1)], a self-insured plan, a service benefitplan, a managed care organization, a pharmacy benefit manager, or other partythat is, by statute, contract, or agreement, legally responsible for payment ofa claim for a health care item or service), in enrolling an individual or inmaking any payments for benefits to the individual or on the individual'sbehalf, is prohibited from taking into account that the individual is eligiblefor or is provided medical assistance under a plan under 42 U.S.C. § 1396et seq. for such state, or any other state.
(c) All health insurers, including, but not limited to,health maintenance organizations, third party administrators, nonprofit medicalservice corporations, nonprofit hospital service corporations, subject to theprovisions of chapters 18, 19, 20 and 41 of title 27, as well as, self-insuredplans, group health plans (as defined in § 607(1) of the EmployeeRetirement 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, legallyresponsible for payment of a claim for a health care item or service) doingbusiness in this state shall:
(i) Provide member information within fourteen (14) calendardays of the request to the department to enable the medical assistance programto identify medical assistance program recipients, applicants and/or personsresponsible for providing medical support for those recipients and applicantswho are or could be enrollees or beneficiaries under any individual or grouphealth insurance contract, plan or policy available or in force and effect inthe state;
(ii) With respect to individuals who are eligible for, or areprovided, medical assistance by the department, upon the request of thedepartment, provide member information within fourteen (14) calendar days ofthe request to determine during what period the individual or their spouses ortheir dependents may be (or may have been) covered by a health insurer and thenature of the coverage that is or was provided by the health insurer (includingthe name, address, and identifying number of the plan);
(iii) Accept the state's right of recovery and the assignmentto the state of any right of an individual or other entity to payment from theparty for an item or service for which payment has been made by the department;
(iv) Respond to any inquiry by the department regarding aclaim for payment for any health care item or service that is submitted notlater than three (3) years after the date of the provision of such health careitem or service; and
(v) Agree not to deny a claim submitted by the state basedsolely on procedural reasons such as on the basis of the date of submission ofthe claim, the type or format of the claim form, or a failure to present properdocumentation at the point-of-sale that is the basis of the claim, if–
(I) The claim is submitted by the state within the three (3)year period beginning on the date on which the item or service was furnished;and
(II) Any action by the state to enforce its rights withrespect to such claim is commenced within six (6) years of the state'ssubmission of such claim.
(d) This information shall be made available by theseinsurers and health maintenance organizations and used by the department ofhuman services only for the purposes of and to the extent necessary foridentifying these persons determining the scope and terms of coverage, andascertaining third party liability. The department of human services shallprovide information to the health insurers, including health insurers,self-insured plans, group health plans (as defined in § 607(1) of theemployee retirement income security act of 1974 [29 U.S.C. §1167(1)]), service benefit plans, managed care organizations, pharmacybenefit managers, or other parties that are, by statute, contract, oragreement, legally responsible for payment of a claim for a health care item orservice) only for the purposes described herein.
(e) No health insurer, health maintenance organization, orthird party administrator which provides or makes arrangements to provideinformation pursuant to this section shall be liable in any civil or criminalaction or proceeding brought by beneficiaries or members on account of thisaction for the purposes of violating confidentiality obligations under the law.
(f) The department shall submit any appropriate and necessarystate plan provisions.
(g) The department of human services is authorized anddirected to promulgate regulations necessary to ensure the effectiveness ofthis section.
§ 40-6-9.1 Data matching – Healthcare coverages. – (a) For purposes of this section, the term "medical assistance program" shallmean medical assistance provided in whole or in part by the department of humanservices pursuant to chapters 5.1, 8, 8.4 of title 40, 12.3 of title 42 and/ortitle 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. Anyreferences to the department shall be to the department of human services.
(b) In furtherance of the assignment of rights to medicalsupport 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 paidout by the department, all health insurers, health maintenance organizations,including managed care organizations, and third party administrators, selfinsured plans, pharmacy benefit managers (PBM), and other parties that are bystatute, contract, or agreement, legally responsible for payment of a claim fora health care item of service doing business in the state of Rhode Island shallpermit and participate in data matching with the department of human services,as provided in this section, to assist the Department to identify medicalassistance program applicants, beneficiaries and/or persons responsible forproviding medical support for such applicants and beneficiaries who may alsohave health care insurance or coverage in addition to that provided or to beprovided by the medical assistance program and to determine any third partyliability in accordance with this section.
The department shall take all reasonable measures todetermine the legal liability of all third parties (including health insurers,self-insured plans, group health plans (as defined in § 607(1) of theEmployee 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 thatare, by statute, contract, or agreement, legally responsible for payment of aclaim for a health care item or service), to pay for care and services onbehalf of a medical assistance recipient, including collecting sufficientinformation to enable the department to pursue claims against such thirdparties.
In any case where such a legal liability is found to existand medical assistance has been made available on behalf of the individual(beneficiary), the department shall seek reimbursement for such assistance tothe extent of such legal liability and in accordance with the assignmentdescribed in § 40-6-9.
To the extent that payment has been made by the departmentfor medical assistance to a beneficiary in any case where a third party has alegal liability to make payment for such assistance, and to the extent thatpayment has been made by the department for medical assistance for health careitems or services furnished to an individual, the department (state) isconsidered to have acquired the rights of such individual to payment by anyother party for such health care items or services in accordance with §40-6-9.
Any health insurer (including a group health plan, as definedin § 607(1) of the employee retirement income security act of 1974[29 U.S.C. § 1167(1)], a self-insured plan, a service benefitplan, a managed care organization, a pharmacy benefit manager, or other partythat is, by statute, contract, or agreement, legally responsible for payment ofa claim for a health care item or service), in enrolling an individual or inmaking any payments for benefits to the individual or on the individual'sbehalf, is prohibited from taking into account that the individual is eligiblefor or is provided medical assistance under a plan under 42 U.S.C. § 1396et seq. for such state, or any other state.
(c) All health insurers, including, but not limited to,health maintenance organizations, third party administrators, nonprofit medicalservice corporations, nonprofit hospital service corporations, subject to theprovisions of chapters 18, 19, 20 and 41 of title 27, as well as, self-insuredplans, group health plans (as defined in § 607(1) of the EmployeeRetirement 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, legallyresponsible for payment of a claim for a health care item or service) doingbusiness in this state shall:
(i) Provide member information within fourteen (14) calendardays of the request to the department to enable the medical assistance programto identify medical assistance program recipients, applicants and/or personsresponsible for providing medical support for those recipients and applicantswho are or could be enrollees or beneficiaries under any individual or grouphealth insurance contract, plan or policy available or in force and effect inthe state;
(ii) With respect to individuals who are eligible for, or areprovided, medical assistance by the department, upon the request of thedepartment, provide member information within fourteen (14) calendar days ofthe request to determine during what period the individual or their spouses ortheir dependents may be (or may have been) covered by a health insurer and thenature of the coverage that is or was provided by the health insurer (includingthe name, address, and identifying number of the plan);
(iii) Accept the state's right of recovery and the assignmentto the state of any right of an individual or other entity to payment from theparty for an item or service for which payment has been made by the department;
(iv) Respond to any inquiry by the department regarding aclaim for payment for any health care item or service that is submitted notlater than three (3) years after the date of the provision of such health careitem or service; and
(v) Agree not to deny a claim submitted by the state basedsolely on procedural reasons such as on the basis of the date of submission ofthe claim, the type or format of the claim form, or a failure to present properdocumentation at the point-of-sale that is the basis of the claim, if–
(I) The claim is submitted by the state within the three (3)year period beginning on the date on which the item or service was furnished;and
(II) Any action by the state to enforce its rights withrespect to such claim is commenced within six (6) years of the state'ssubmission of such claim.
(d) This information shall be made available by theseinsurers and health maintenance organizations and used by the department ofhuman services only for the purposes of and to the extent necessary foridentifying these persons determining the scope and terms of coverage, andascertaining third party liability. The department of human services shallprovide information to the health insurers, including health insurers,self-insured plans, group health plans (as defined in § 607(1) of theemployee retirement income security act of 1974 [29 U.S.C. §1167(1)]), service benefit plans, managed care organizations, pharmacybenefit managers, or other parties that are, by statute, contract, oragreement, legally responsible for payment of a claim for a health care item orservice) only for the purposes described herein.
(e) No health insurer, health maintenance organization, orthird party administrator which provides or makes arrangements to provideinformation pursuant to this section shall be liable in any civil or criminalaction or proceeding brought by beneficiaries or members on account of thisaction for the purposes of violating confidentiality obligations under the law.
(f) The department shall submit any appropriate and necessarystate plan provisions.
(g) The department of human services is authorized anddirected to promulgate regulations necessary to ensure the effectiveness ofthis section.
