1-1 By: Nelson S.B. No. 1248
1-2 (In the Senate - Filed March 11, 1999; March 11, 1999, read
1-3 first time and referred to Committee on Human Services;
1-4 April 6, 1999, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 4, Nays 0; April 6, 1999,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1248 By: Carona
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to Medicaid third-party recoveries; providing a penalty.
1-11 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-12 SECTION 1. Section 32.042, Human Resources Code, is amended
1-13 to read as follows:
1-14 Sec. 32.042. INFORMATION REQUIRED FROM HEALTH INSURERS.
1-15 (a) An insurer shall maintain a file system that contains:
1-16 (1) the name, address, including claim submission
1-17 address, group policy number, employer's mailing address, social
1-18 security number, and date of birth of each subscriber or
1-19 policyholder covered by the insurer; and
1-20 (2) the name, address, including claim submission
1-21 address, and date of birth of each dependent of each subscriber or
1-22 policyholder covered by the insurer.
1-23 (b) The state's Medicaid third-party recovery division shall
1-24 identify state medical assistance recipients who have third-party
1-25 health coverage or insurance as provided by this subsection. The
1-26 department shall provide to an insurer Medicaid data tapes that
1-27 identify medical assistance recipients and request that the insurer
1-28 identify each subscriber or policyholder of the insurer whose name
1-29 also appears on the Medicaid data tape. An insurer shall comply
1-30 with a request under this subsection not later than the 60th day
1-31 after the date the request was made. An insurer is only required
1-32 under this subsection to provide the department with the
1-33 information maintained under Subsection (a) by the insurer or made
1-34 available to the insurer from the plan. A plan [third-party]
1-35 administrator is subject to this subsection to the extent the
1-36 information described in this subsection is made available to the
1-37 plan [third-party] administrator from the plan.
1-38 (c) An insurer may not be required to provide information in
1-39 response to a request under this section more than once every six
1-40 months [during a calendar year].
1-41 (d) An insurer shall provide the information required under
1-42 this section only if the department certifies that the identified
1-43 individuals are applicants for or recipients of services under
1-44 Medicaid or are legally responsible for an applicant for or
1-45 recipient of Medicaid services.
1-46 (e) The department shall enter into an agreement to
1-47 reimburse an insurer for necessary and reasonable costs incurred in
1-48 providing information requested under this section. The department
1-49 may enter into an agreement with insurers that provides procedures
1-50 for requesting and providing information under this section. An
1-51 agreement under this subsection may not be inconsistent with any
1-52 law relating to the confidentiality or privacy of personal
1-53 information or medical records. The procedures agreed to under
1-54 this subsection must [include financial arrangements to reimburse
1-55 an insurer for necessary costs incurred in providing the requested
1-56 information and must] state the time and manner the procedures take
1-57 effect.
1-58 (f) Information required to be furnished to the department
1-59 under this section is limited to information necessary to determine
1-60 whether health benefits have been or should have been claimed and
1-61 paid under a health insurance policy or plan for medical care or
1-62 services received by an individual for whom Medicaid coverage would
1-63 otherwise be available.
1-64 (g) Information regarding an individual certified to an
2-1 insurer as an applicant for or recipient of medical assistance may
2-2 only be used to identify the records or information requested and
2-3 may not violate the confidentiality of the applicant or recipient.
2-4 The department shall establish guidelines not later than the date
2-5 on which the procedures agreed to under Subsection (e) take effect.
2-6 (h) This section applies to a plan administrator in the same
2-7 manner and to the same extent as an insurer if the plan
2-8 administrator has the information necessary to comply with the
2-9 applicable requirement.
2-10 (i) In this section:
2-11 (1) "Insurer"[, "insurer"] means a group health
2-12 services corporation, a health maintenance organization, a
2-13 self-funded or self-insured welfare or benefit plan or program to
2-14 the extent the regulation of the plan or program is not preempted
2-15 by federal law, and any other entity that provides health coverage
2-16 in this state through an employer, union, trade association, or
2-17 other organization or other source.
2-18 (2) "Plan administrator" means a third-party
2-19 administrator, prescription drug payer or administrator, pharmacy
2-20 benefit manager, or dental payer or administrator.
2-21 SECTION 2. Subchapter B, Chapter 32, Human Resources Code,
2-22 is amended by adding Section 32.0421 to read as follows:
2-23 Sec. 32.0421. ADMINISTRATIVE PENALTY FOR FAILURE TO PROVIDE
2-24 INFORMATION. (a) The department may impose an administrative
2-25 penalty on a person who does not comply with a request for
2-26 information made under Section 32.042(b).
2-27 (b) The amount of the penalty may not exceed $10,000 for
2-28 each day of noncompliance that occurs after the 180th day after the
2-29 date of the request. The amount shall be based on:
2-30 (1) the seriousness of the violation, including the
2-31 nature, circumstances, extent, and gravity of the violation;
2-32 (2) the economic harm caused by the violation;
2-33 (3) the history of previous violations;
2-34 (4) the amount necessary to deter a future violation;
2-35 (5) efforts to correct the violation; and
2-36 (6) any other matter that justice may require.
2-37 (c) The enforcement of the penalty may be stayed during the
2-38 time the order is under judicial review if the person pays the
2-39 penalty to the clerk of the court or files a supersedeas bond with
2-40 the court in the amount of the penalty. A person who cannot afford
2-41 to pay the penalty or file the bond may stay the enforcement by
2-42 filing an affidavit in the manner required by the Texas Rules of
2-43 Civil Procedure for a party who cannot afford to file security for
2-44 costs, subject to the right of the department to contest the
2-45 affidavit as provided by those rules.
2-46 (d) The attorney general may sue to collect the penalty.
2-47 (e) A proceeding to impose the penalty is considered to be a
2-48 contested case under Chapter 2001, Government Code.
2-49 SECTION 3. Not later than September 1, 2000, the Texas
2-50 Department of Health shall submit a report to the legislature
2-51 relating to third-party Medicaid recoveries made by the department
2-52 under Section 32.042, Human Resources Code, as amended by this Act.
2-53 The report must include:
2-54 (1) cost avoidance and cost savings from liable third
2-55 parties; and
2-56 (2) recommendations to increase the amount of
2-57 third-party Medicaid recoveries made by the department.
2-58 SECTION 4. This Act takes effect September 1, 1999.
2-59 SECTION 5. The importance of this legislation and the
2-60 crowded condition of the calendars in both houses create an
2-61 emergency and an imperative public necessity that the
2-62 constitutional rule requiring bills to be read on three several
2-63 days in each house be suspended, and this rule is hereby suspended.
2-64 * * * * *