§ 40-6-9.1. Data matching — Healthcare coverages.
(a) For purposes of this section, the term "medical assistance program� shall mean medical
assistance provided in whole or in part by the executive office of health and human
services pursuant to chapters 8, 8.4 of this title, 12.3 of title 42 and/or Title
XIX or XXI of the federal Social Security Act, as amended, 42 U.S.C. §â€‚1396 et seq. and 42 U.S.C. §â€‚1397aa et seq., respectively. Any references to the office shall be to the executive office
of health and human services.
(b) In furtherance of the assignment of rights to medical support to the executive office
of health and human services under §â€‚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 paid out by
the office, all health insurers, health maintenance organizations, including managed
care organizations, and third-party administrators, self-insured plans, pharmacy benefit
managers (PBM), and other parties that are by statute, contract, or agreement, legally
responsible for payment of a claim for a healthcare item of service doing business
in the state of Rhode Island shall permit and participate in data matching with the
executive office of health and human services, as provided in this section, to assist
the office to identify medical assistance program applicants, beneficiaries, and/or
persons responsible for providing medical support for applicants and beneficiaries
who may also have healthcare insurance or coverage in addition to that provided, or
to be provided, by the medical assistance program and to determine any third-party
liability in accordance with this section.
The office shall take all reasonable measures to determine the legal liability of
all third parties (including health insurers, self-insured plans, group health plans
(as defined in §â€‚ 607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. §â€‚1167(1)]), service benefit plans, health-maintenance organizations, managed care organizations,
pharmacy benefit managers, or other parties that are, by statute, contract, or agreement,
legally responsible for payment of a claim for a healthcare item or service), to pay
for care and services on behalf of a medical assistance recipient, including collecting
sufficient information to enable the office to pursue claims against such third parties.
In any case where such a legal liability is found to exist and medical assistance
has been made available on behalf of the individual (beneficiary), the office shall
seek reimbursement for the assistance to the extent of the legal liability and in
accordance with the assignment described in §â€‚40-6-9.
To the extent that payment has been made by the office for medical assistance to a
beneficiary in any case where a third party has a legal liability to make payment
for the assistance, and to the extent that payment has been made by the office for
medical assistance for healthcare items or services furnished to an individual, the
office (state) is considered to have acquired the rights of the individual to payment
by any other party for the healthcare items or services in accordance with §â€‚40-6-9.
Any health insurer (including a group health plan, as defined in §â€‚607(1) of the Employee
Retirement Income Security Act of 1974 [29 U.S.C. §â€‚1167(1)], a self-insured plan, a service-benefit plan, a managed care organization, a pharmacy
benefit manager, or other party that is, by statute, contract, or agreement, legally
responsible for payment of a claim for a healthcare item or service), in enrolling
an individual, or in making any payments for benefits to the individual or on the
individual's behalf, is prohibited from taking into account that the individual is
eligible for, or is provided, medical assistance under a plan under 42 U.S.C. §â€‚1396 et seq. for this state, or any other state.
(c) All health insurers or liable third parties, including, but not limited to, health
maintenance organizations, third-party administrators, nonprofit medical service corporations,
nonprofit hospital service corporations, subject to the provisions of chapters 18,
19, 20, and 41 of title 27, as well as, self-insured plans, group health plans (as
defined in §â€‚607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. §â€‚1167(1)]), service-benefit plans, managed care organizations, pharmacy benefit managers,
or other parties that are, by statute, contract, or agreement, legally responsible
for payment of a claim for a healthcare item or service) doing business in this state
shall:
(1) Provide member information within fourteen (14) calendar days of the request to the
office to enable the medical assistance program to identify medical assistance program
recipients, applicants and/or persons responsible for providing medical support for
those recipients and applicants who are, or could be, enrollees or beneficiaries under
any individual or group health insurance contract, plan, or policy available or in
force and effect in the state;
(2) With respect to individuals who are eligible for, or are provided, medical assistance
by the office, upon the request of the office, provide member information within fourteen
(14) calendar days of the request to determine during what period the individual or
their spouse or dependents may be (or may have been) covered by a health insurer and
the nature of the coverage that is, or was provided by the health insurer (including
the name, address, and identifying number of the plan);
(3) Accept the state's right of recovery and the assignment to the state of any right
of an individual or other entity to payment from the party for an item or service
for which payment has been made by the office;
(4) Respond to any inquiry by the office regarding a claim for payment for any healthcare
item or service that is submitted not later than three (3) years after the date of
the provision of the healthcare item or service;
(5) Agree not to deny a claim submitted by the state based solely on procedural reasons,
such as on the basis of the date of submission of the claim, the type or format of
the claim form, failure to obtain a prior authorization, or a failure to present proper
documentation at the point-of-sale that is the basis of the claim, if:
(i) The claim is submitted by the state within the three-year (3) period beginning on
the date on which the item or service was furnished; and
(ii) Any action by the state to enforce its rights with respect to the claim is commenced
within six (6) years of the state's submission of such claim;
(6) Agree to respond to any inquiry regarding claims within sixty (60) business days after
receipt of the written documentation by the Medicaid recipient; and
(7) Agree to not deny a claim for failure to obtain prior authorization for an item or
service. In the case of a responsible third party that requires prior authorization
for an item or service furnished to an individual eligible to receive medical assistance
under the state Medicaid program, the third-party health insurer shall accept authorization
provided by the state medical assistance program that the item or service is covered
by Medicaid as if that authorization is a prior authorization made by the third-party
health insurer for the item or service.
(d) This information shall be made available by these insurers and health maintenance
organizations and used by the executive office of health and human services only for
the purposes of, and to the extent necessary for, identifying these persons, determining
the scope and terms of coverage, and ascertaining third-party liability. The executive
office of health and human services shall provide information to the health insurers,
including health insurers, self-insured plans, group health plans (as defined in §â€‚
607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. §â€‚1167(1)]), service-benefit plans, managed care organizations, pharmacy benefit managers,
or other parties that are, by statute, contract, or agreement, legally responsible
for payment of a claim for a healthcare item or service) only for the purposes described
herein.
(e) No health insurer, health maintenance organization, or third-party administrator that
provides, or makes arrangements to provide, information pursuant to this section shall
be liable in any civil or criminal action or proceeding brought by beneficiaries or
members on account of this action for the purposes of violating confidentiality obligations
under the law.
(f) The office shall submit any appropriate and necessary state plan provisions.
(g) The executive office of health and human services is authorized and directed to promulgate
regulations necessary to ensure the effectiveness of this section.