By: Nelson S.B. No. 1248
A BILL TO BE ENTITLED
AN ACT
1-1 relating to Medicaid third-party recoveries; providing a penalty.
1-2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-3 SECTION 1. Section 32.042, Human Resources Code, is amended
1-4 to read as follows:
1-5 Sec. 32.042. INFORMATION REQUIRED FROM HEALTH INSURERS.
1-6 (a) An insurer shall maintain a file system that contains:
1-7 (1) the name, address, including claim submission
1-8 address, group policy number, employer's mailing address, social
1-9 security number, and date of birth of each subscriber or
1-10 policyholder covered by the insurer; and
1-11 (2) the name, address, including claim submission
1-12 address, and date of birth of each dependent of each subscriber or
1-13 policyholder covered by the insurer.
1-14 (b) The state's Medicaid third-party recovery division shall
1-15 identify state medical assistance recipients who have third-party
1-16 health coverage or insurance as provided by this subsection. The
1-17 department shall provide to an insurer Medicaid data tapes that
1-18 identify medical assistance recipients and request that the insurer
1-19 identify each subscriber or policyholder of the insurer whose name
1-20 also appears on the Medicaid data tape. An insurer shall comply
1-21 with a request under this subsection not later than the 60th day
1-22 after the date the request was made. An insurer is only required
1-23 under this subsection to provide the department with the
1-24 information maintained under Subsection (a) by the insurer or made
2-1 available to the insurer from the plan. A plan [third-party]
2-2 administrator is subject to this subsection to the extent the
2-3 information described in this subsection is made available to the
2-4 plan [third-party] administrator from the plan.
2-5 (c) An insurer may not be required to provide information in
2-6 response to a request under this section more than once every six
2-7 months [during a calendar year].
2-8 (d) An insurer shall provide the information required under
2-9 this section only if the department certifies that the identified
2-10 individuals are applicants for or recipients of services under
2-11 Medicaid or are legally responsible for an applicant for or
2-12 recipient of Medicaid services.
2-13 (e) The department shall enter into an agreement to
2-14 reimburse an insurer for necessary and reasonable costs incurred in
2-15 providing information requested under this section. The department
2-16 may enter into an agreement with insurers that provides procedures
2-17 for requesting and providing information under this section. An
2-18 agreement under this subsection may not be inconsistent with any
2-19 law relating to the confidentiality or privacy of personal
2-20 information or medical records. The procedures agreed to under
2-21 this subsection must [include financial arrangements to reimburse
2-22 an insurer for necessary costs incurred in providing the requested
2-23 information and must] state the time and manner the procedures take
2-24 effect.
2-25 (f) Information required to be furnished to the department
2-26 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 if the plan
3-13 administrator has the information necessary to comply with the
3-14 applicable requirement.
3-15 (i) In this section:
3-16 (1) "Insurer"[, "insurer"] means a group health
3-17 services corporation, a health maintenance organization, a
3-18 self-funded or self-insured welfare or benefit plan or program to
3-19 the extent the regulation of the plan or program is not preempted
3-20 by federal law, and any other entity that provides health coverage
3-21 in this state through an employer, union, trade association, or
3-22 other organization or other source.
3-23 (2) "Plan administrator" means a third-party
3-24 administrator, prescription drug payer or administrator, pharmacy
3-25 benefit manager, or dental payer or administrator.
3-26 SECTION 2. Subchapter B, Chapter 32, Human Resources Code,
4-1 is amended by adding Section 32.0421 to read as follows:
4-2 Sec. 32.0421. ADMINISTRATIVE PENALTY FOR FAILURE TO PROVIDE
4-3 INFORMATION. (a) The department may impose an administrative
4-4 penalty on a person who does not comply with a request for
4-5 information made under Section 32.042(b).
4-6 (b) The amount of the penalty may not exceed $10,000 for
4-7 each day of noncompliance that occurs after the 180th day after the
4-8 date of the request. The amount shall be based on:
4-9 (1) the seriousness of the violation, including the
4-10 nature, circumstances, extent, and gravity of the violation;
4-11 (2) the economic harm caused by the violation;
4-12 (3) the history of previous violations;
4-13 (4) the amount necessary to deter a future violation;
4-14 (5) efforts to correct the violation; and
4-15 (6) any other matter that justice may require.
4-16 (c) The enforcement of the penalty may be stayed during the
4-17 time the order is under judicial review if the person pays the
4-18 penalty to the clerk of the court or files a supersedeas bond with
4-19 the court in the amount of the penalty. A person who cannot afford
4-20 to pay the penalty or file the bond may stay the enforcement by
4-21 filing an affidavit in the manner required by the Texas Rules of
4-22 Civil Procedure for a party who cannot afford to file security for
4-23 costs, subject to the right of the department to contest the
4-24 affidavit as provided by those rules.
4-25 (d) The attorney general may sue to collect the penalty.
4-26 (e) A proceeding to impose the penalty is considered to be a
5-1 contested case under Chapter 2001, Government Code.
5-2 SECTION 3. Not later than September 1, 2000, the Texas
5-3 Department of Health shall submit a report to the legislature
5-4 relating to third-party Medicaid recoveries made by the department
5-5 under Section 32.042, Human Resources Code, as amended by this Act.
5-6 The report must include:
5-7 (1) cost avoidance and cost savings from liable third
5-8 parties; and
5-9 (2) recommendations to increase the amount of
5-10 third-party Medicaid recoveries made by the department.
5-11 SECTION 4. This Act takes effect September 1, 1999.
5-12 SECTION 5. The importance of this legislation and the
5-13 crowded condition of the calendars in both houses create an
5-14 emergency and an imperative public necessity that the
5-15 constitutional rule requiring bills to be read on three several
5-16 days in each house be suspended, and this rule is hereby suspended.