By Maxey H.B. No. 1894
76R3486 CLG-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to Medicaid third-party recoveries; providing a penalty.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Section 32.042, Human Resources Code, is amended
1-5 to read as follows:
1-6 Sec. 32.042. INFORMATION REQUIRED FROM HEALTH INSURERS.
1-7 (a) An insurer shall maintain a file system that contains:
1-8 (1) the name, address, including claim submission
1-9 address, group policy number, employer's mailing address, social
1-10 security number, and date of birth of each subscriber or
1-11 policyholder covered by the insurer; and
1-12 (2) the name, address, including claim submission
1-13 address, and date of birth of each dependent of each subscriber or
1-14 policyholder covered by the insurer.
1-15 (b) The state's Medicaid third-party recovery division shall
1-16 identify state medical assistance recipients who have third-party
1-17 health coverage or insurance as provided by this subsection. The
1-18 department shall provide to an insurer Medicaid data tapes that
1-19 identify medical assistance recipients and request that the insurer
1-20 identify each subscriber or policyholder of the insurer whose name
1-21 also appears on the Medicaid data tape. An insurer shall comply
1-22 with a request under this subsection not later than the 60th day
1-23 after the date the request was made. An insurer is only required
1-24 under this subsection to provide the department with the
2-1 information maintained under Subsection (a) by the insurer or made
2-2 available to the insurer from the plan. [A third-party
2-3 administrator is subject to this subsection to the extent the
2-4 information described in this subsection is made available to the
2-5 third-party administrator from the plan.]
2-6 (c) An insurer may not be required to provide information in
2-7 response to a request under this section more than once every six
2-8 months [during a calendar year].
2-9 (d) An insurer shall provide the information required under
2-10 this section only if the department certifies that the identified
2-11 individuals are applicants for or recipients of services under
2-12 Medicaid or are legally responsible for an applicant for or
2-13 recipient of Medicaid services.
2-14 (e) The department shall enter into an agreement to
2-15 reimburse an insurer for necessary and reasonable costs incurred in
2-16 providing information requested under this section. The department
2-17 may enter into an agreement with insurers that provides procedures
2-18 for requesting and providing information under this section. An
2-19 agreement under this subsection may not be inconsistent with any
2-20 law relating to the confidentiality or privacy of personal
2-21 information or medical records. The procedures agreed to under
2-22 this subsection must [include financial arrangements to reimburse
2-23 an insurer for necessary costs incurred in providing the requested
2-24 information and must] state the time and manner the procedures take
2-25 effect.
2-26 (f) Information required to be furnished to the department
2-27 under this section is limited to information necessary to determine
3-1 whether health benefits have been or should have been claimed and
3-2 paid under a health insurance policy or plan for medical care or
3-3 services received by an individual for whom Medicaid coverage would
3-4 otherwise be available.
3-5 (g) Information regarding an individual certified to an
3-6 insurer as an applicant for or recipient of medical assistance may
3-7 only be used to identify the records or information requested and
3-8 may not violate the confidentiality of the applicant or recipient.
3-9 The department shall establish guidelines not later than the date
3-10 on which the procedures agreed to under Subsection (e) take effect.
3-11 (h) This section applies to a plan administrator in the same
3-12 manner and to the same extent as an insurer.
3-13 (i) In this section:
3-14 (1) "Insurer"[, "insurer"] means a group health
3-15 services corporation, a health maintenance organization, a
3-16 self-funded or self-insured welfare or benefit plan or program to
3-17 the extent the regulation of the plan or program is not preempted
3-18 by federal law, and any other entity that provides health coverage
3-19 in this state through an employer, union, trade association, or
3-20 other organization or other source.
3-21 (2) "Plan administrator" means a third-party
3-22 administrator, prescription drug payer or administrator, pharmacy
3-23 benefit manager, or dental payer or administrator.
3-24 SECTION 2. Subchapter B, Chapter 32, Human Resources Code,
3-25 is amended by adding Section 32.0421 to read as follows:
3-26 Sec. 32.0421. ADMINISTRATIVE PENALTY FOR FAILURE TO PROVIDE
3-27 INFORMATION. (a) The department may impose an administrative
4-1 penalty on a person who does not comply with a request for
4-2 information made under Section 32.042(b).
4-3 (b) The amount of the penalty may not exceed $10,000 for
4-4 each day of noncompliance that occurs after the 180th day after the
4-5 date of the request. The amount shall be based on:
4-6 (1) the seriousness of the violation, including the
4-7 nature, circumstances, extent, and gravity of the violation;
4-8 (2) the economic harm caused by the violation;
4-9 (3) the history of previous violations;
4-10 (4) the amount necessary to deter a future violation;
4-11 (5) efforts to correct the violation; and
4-12 (6) any other matter that justice may require.
4-13 (c) The enforcement of the penalty may be stayed during the
4-14 time the order is under judicial review if the person pays the
4-15 penalty to the clerk of the court or files a supersedeas bond with
4-16 the court in the amount of the penalty. A person who cannot
4-17 afford to pay the penalty or file the bond may stay the enforcement
4-18 by filing an affidavit in the manner required by the Texas Rules of
4-19 Civil Procedure for a party who cannot afford to file security for
4-20 costs, subject to the right of the department to contest the
4-21 affidavit as provided by those rules.
4-22 (d) The attorney general may sue to collect the penalty.
4-23 (e) A proceeding to impose the penalty is considered to be a
4-24 contested case under Chapter 2001, Government Code.
4-25 SECTION 3. Not later than September 1, 2000, the Texas
4-26 Department of Health shall submit a report to the legislature
4-27 relating to third-party Medicaid recoveries made by the department
5-1 under Section 32.042, Human Resources Code, as amended by this Act.
5-2 The report must include:
5-3 (1) cost avoidance and cost savings from liable third
5-4 parties; and
5-5 (2) recommendations to increase the amount of
5-6 third-party Medicaid recoveries made by the department.
5-7 SECTION 4. This Act takes effect September 1, 1999.
5-8 SECTION 5. The importance of this legislation and the
5-9 crowded condition of the calendars in both houses create an
5-10 emergency and an imperative public necessity that the
5-11 constitutional rule requiring bills to be read on three several
5-12 days in each house be suspended, and this rule is hereby suspended.