A. Insurers, including group health plans as defined in § 607(1) of theEmployee Retirement Income Security Act of 1974, self-insured plans, healthservices plans, service benefit plans, health maintenance organizations,managed care organizations, pharmacy benefits managers, or other parties thatare, by statute, contract, or agreement legally responsible for payment of aclaim for a health care item or service, are prohibited from including anyclause in health care contracts which would exclude enrolling an individualor in making any payment for benefits to the individual or on theindividual's behalf for health care when the individual is eligible formedical assistance.
B. The Department of Medical Assistance Services shall be the payor of lastresort to any insurer, including a group health plan as defined in § 607(1)of the Employee Retirement Income Security Act of 1974, a self-insured plan,a health services plan, a service benefit plan, a health maintenanceorganization, a managed care organization, a pharmacy benefits manager, orother party that is, by statute, contract, or agreement legally responsiblefor payment of a claim for a health care item or service for persons eligiblefor medical assistance in the Commonwealth. The above entities, as acondition of doing business in the Commonwealth, shall comply with therequirements set forth in 42 U.S.C. 1396a(a) (25) (I) (i)-(iv).
C. To the extent the Department of Medical Assistance Services has madepayment for medical services where a third party has a legal obligation tomake payment for such services, the Commonwealth shall automatically acquireall rights to such payment from the third party.
D. To the extent the Department of Medical Assistance Services is permittedby law to obtain recoveries from third parties, actions at law for suchrecoveries shall be decided under the same laws, rules and standardsincluding applicable bases of liability and defenses as would apply if theindividual receiving the services had brought the action directly; providedthat nothing herein shall affect the sovereign immunity of the Commonwealth.
E. The term "insurer" as used herein shall be deemed to include withoutlimitation "insurance carriers."
(1986, c. 550; 1994, c. 213; 1996, c. 851; 2007, c. 535.)
A. Insurers, including group health plans as defined in § 607(1) of theEmployee Retirement Income Security Act of 1974, self-insured plans, healthservices plans, service benefit plans, health maintenance organizations,managed care organizations, pharmacy benefits managers, or other parties thatare, by statute, contract, or agreement legally responsible for payment of aclaim for a health care item or service, are prohibited from including anyclause in health care contracts which would exclude enrolling an individualor in making any payment for benefits to the individual or on theindividual's behalf for health care when the individual is eligible formedical assistance.
B. The Department of Medical Assistance Services shall be the payor of lastresort to any insurer, including a group health plan as defined in § 607(1)of the Employee Retirement Income Security Act of 1974, a self-insured plan,a health services plan, a service benefit plan, a health maintenanceorganization, a managed care organization, a pharmacy benefits manager, orother party that is, by statute, contract, or agreement legally responsiblefor payment of a claim for a health care item or service for persons eligiblefor medical assistance in the Commonwealth. The above entities, as acondition of doing business in the Commonwealth, shall comply with therequirements set forth in 42 U.S.C. 1396a(a) (25) (I) (i)-(iv).
C. To the extent the Department of Medical Assistance Services has madepayment for medical services where a third party has a legal obligation tomake payment for such services, the Commonwealth shall automatically acquireall rights to such payment from the third party.
D. To the extent the Department of Medical Assistance Services is permittedby law to obtain recoveries from third parties, actions at law for suchrecoveries shall be decided under the same laws, rules and standardsincluding applicable bases of liability and defenses as would apply if theindividual receiving the services had brought the action directly; providedthat nothing herein shall affect the sovereign immunity of the Commonwealth.
E. The term "insurer" as used herein shall be deemed to include withoutlimitation "insurance carriers."
(1986, c. 550; 1994, c. 213; 1996, c. 851; 2007, c. 535.)
A. Insurers, including group health plans as defined in § 607(1) of theEmployee Retirement Income Security Act of 1974, self-insured plans, healthservices plans, service benefit plans, health maintenance organizations,managed care organizations, pharmacy benefits managers, or other parties thatare, by statute, contract, or agreement legally responsible for payment of aclaim for a health care item or service, are prohibited from including anyclause in health care contracts which would exclude enrolling an individualor in making any payment for benefits to the individual or on theindividual's behalf for health care when the individual is eligible formedical assistance.
B. The Department of Medical Assistance Services shall be the payor of lastresort to any insurer, including a group health plan as defined in § 607(1)of the Employee Retirement Income Security Act of 1974, a self-insured plan,a health services plan, a service benefit plan, a health maintenanceorganization, a managed care organization, a pharmacy benefits manager, orother party that is, by statute, contract, or agreement legally responsiblefor payment of a claim for a health care item or service for persons eligiblefor medical assistance in the Commonwealth. The above entities, as acondition of doing business in the Commonwealth, shall comply with therequirements set forth in 42 U.S.C. 1396a(a) (25) (I) (i)-(iv).
C. To the extent the Department of Medical Assistance Services has madepayment for medical services where a third party has a legal obligation tomake payment for such services, the Commonwealth shall automatically acquireall rights to such payment from the third party.
D. To the extent the Department of Medical Assistance Services is permittedby law to obtain recoveries from third parties, actions at law for suchrecoveries shall be decided under the same laws, rules and standardsincluding applicable bases of liability and defenses as would apply if theindividual receiving the services had brought the action directly; providedthat nothing herein shall affect the sovereign immunity of the Commonwealth.
E. The term "insurer" as used herein shall be deemed to include withoutlimitation "insurance carriers."
(1986, c. 550; 1994, c. 213; 1996, c. 851; 2007, c. 535.)
