§ 42-4-204 — Department subrogated to right of recovery of applicant or recipient; utilization of personal health insurance; insurance coverage of recipients

Wyoming § 42-4-204

• Jurisdiction: Wyoming
• Title 42: Welfare
• Ch. 4: MEDICAL ASSISTANCE AND SERVICES
• Art. 2: MEDICAID BENEFIT RECOVERY

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(a) The department shall be subrogated to any right of
recovery or indemnification arising from an accident or
occurrence resulting in expenditures by the department, which an
applicant or recipient of medical assistance or any legally
liable party has against an insurer, health insurer, self-
insured plan, group health plan, service benefit plan, managed
care organization, pharmacy benefit manager or other party that
is, by statute, contract or agreement, legally responsible for
payment of a claim for health care items or services, including
but not limited to hospitalization, pharmaceutical services,
physician services, nursing services and other medical services,
not to exceed the amount expended by the department for the care
and treatment of the applicant or recipient. An applicant or
recipient or legally liable party, by the act of applying for,
or recipient receiving medical assistance, shall be deemed to
have made a subrogation assignment and an assignment of claim
for benefits to the department. The department shall inform an
applicant of the assignments at the time of application. In
addition, any entitlements from a contractual agreement with an
applicant or recipient or legally liable party, a state or
federal program or a claim or action against any responsible
third party for medical services, not to exceed the amount
expended by the department, shall be so assigned. The
entitlements shall be directly reimbursable to the department by
third party payors. The department may assign its right to
subrogation or its entitlement to benefits to a designee or a
health care provider participating in the medicaid program and
providing services to an applicant or recipient, in order to
assist the provider in obtaining payment for the services. A
provider that has received an assignment from the department
shall notify the insurer of the assignment upon rendering of
services to the applicant or recipient. Failure to so notify
the insurer shall render the provider ineligible for payment
from the department. Once the insurer has been billed or
notified the provider may not request payment through the
medicaid program until a payment, denial or other explanation of
benefits, not including mistakes in billing, is received from
the insurer. The provider shall notify the department of any
request by the applicant or recipient or his legally liable
party or representative for billing information.
(b) When a recipient of medical assistance has access to
personal health insurance through his employer, payment or part
payment of the premium for the insurance may be made by the
department when deemed appropriate by the director of the
department.
(c) No individual accident policy, group accident policy,
health policy, accident and health policy, medical expense
policy or medical service plan contract, delivered, issued for
delivery or renewed in this state on or after July 1, 1995, and
no self-insured plan, managed care policy or plan, pharmacy
benefit management plan or policy or other policy or plan issued
by any other party that is, by statute, contract or agreement
legally responsible for payment of a claim for items or
services, delivered, issued for delivery or renewed in this
state on or after July 1, 2007, shall contain any provision
denying or limiting insurance benefits because services are
rendered to an insured who is eligible for or who received
medical assistance under this chapter. This section shall
supersede any statutory provision to the contrary. No such
policy, plan or contract, when enrolling an individual, shall
take into account the individual's eligibility for medical
assistance under this chapter. This subsection applies to all
such policies, plans and contracts issued by any person
including, but not limited to:
(i) An insurer;
(ii) A group health plan as defined in section 607(1)
of the Employee Retirement Income Security Act of 1974;
(iii) A managed care organization, pharmacy benefit
manager or other party that is, by statute, contract or
agreement, legally responsible for payment of a claim for a
health care item or service;
(iv) An entity offering a service benefit plan;
(v) A self-insured plan.
(d) Medicaid shall not pay for any services provided under
this chapter if the individual eligible for medical assistance
has coverage for the services under an accident or health
insurance policy or other source.
(e) In addition to the separate requirements set forth in
W.S. 42-4-205, all health insurers, including all self-insured
plans, group health plans as defined in section 607(1) of the
Employee Retirement Income Security Act of 1974, 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 health care
item or service, shall agree, as a condition of doing business
in the state of Wyoming, to:
(i) Provide, with respect to the individuals who are
eligible for or are provided medical assistance by the
department of health, information to determine the period during
which the individual or the individuals' spouses or dependents
may be or may have been covered by a health insurer and the
nature of the coverage provided, including the name and address
of the insurer and identifying number of the plan, in a manner
prescribed by the secretary;
(ii) 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 another party for an item or service for
which payment has been made under the state plan;
(iii) Respond within sixty (60) days to any inquiry
by the state regarding a claim for payment for any health care
item or service that is submitted not later than three (3) years
after the date of the provision of such health care item or
service; and
(iv) Agree not to deny a claim submitted by the state
solely on the basis of the date of submission of the claim, the
type or format of the claim form, a failure to obtain required
prior authorization or a failure to present proper documentation
at the point of sale that is the basis of the claim, if:
(A) 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
(B) 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 the claim.