2005 Connecticut Code - Sec. 17b-265. (Formerly Sec. 17-134f). Department subrogated to right of recovery of applicant or recipient. Utilization of personal health insurance. Insurance coverage of medical assistance recipients. Limitations.

      Sec. 17b-265. (Formerly Sec. 17-134f). Department subrogated to right of recovery of applicant or recipient. Utilization of personal health insurance. Insurance coverage of medical assistance recipients. Limitations. (a) In accordance with 42 USC 1396k, the Department of Social Services shall be subrogated to any right of recovery or indemnification which an applicant or recipient of medical assistance or any legally liable relative has against a private insurer or other third party, as defined in 42 CFR 433.136, for the cost of hospitalization, pharmaceutical services, physician services, nursing services and other medical services, not to exceed the amount expended by the department for such care and treatment of the applicant or recipient. In the case of such a recipient who is an enrollee in a managed care organization under a Medicaid managed care contract with the state or a legally liable relative of such an enrollee, the department shall be subrogated to any right of recovery or indemnification which the enrollee or legally liable relative has against such a private insurer or other third party for the medical costs incurred by the managed care organization on behalf of an enrollee. An applicant or recipient or legally liable relative, by the act of the applicant 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 such assignments at the time of application. Any entitlements from a contractual agreement with an applicant or recipient, legally liable relative or a state or federal program for such medical services, not to exceed the amount expended by the department, shall be so assigned. Such entitlements shall be directly reimbursable to the department by third party payors. The Department of Social Services 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 such services. A provider that has received an assignment from the department shall notify the private insurer or third party of the assignment upon rendition of services to the applicant or recipient. Failure to so notify the private insurer or third party shall render the provider ineligible for payment from the department. The provider shall notify the department of any request by the applicant or recipient or legally liable relative or representative of such applicant or recipient for billing information. This subsection shall not be construed to affect the right of an applicant or recipient to maintain an independent cause of action against such third party tortfeasor.

      (b) When a recipient of medical assistance has personal health insurance in force covering care or other benefits provided under such program, payment or part-payment of the premium for such insurance may be made when deemed appropriate by the Commissioner of Social Services. Effective January 1, 1992, the commissioner shall limit reimbursement to medical assistance providers, except those providers whose rates are established by the Commissioner of Public Health pursuant to chapter 368d, for coinsurance and deductible payments under Title XVIII of the Social Security Act to assure that the combined Medicare and Medicaid payment to the provider shall not exceed the maximum allowable under the Medicaid program fee schedules.

      (c) Notwithstanding the provisions of subsection (c) of section 38a-553, no (1) individual or group accident, health or accident and health policy or medical expense policy or medical service plan contract, delivered, issued for delivery or renewed in this state on or after July 1, 1984, or (2) self-insured or self-funded plan subject to the provisions of the Employee Retirement Income Security Act of 1974 shall contain any provision which has the effect of denying or limiting benefits or excluding coverage because services are rendered to an insured or beneficiary who is eligible for or who received medical assistance under this chapter. No insurer, as defined in section 38a-497a, shall impose requirements on the state Medicaid agency, which has been assigned the rights of an individual eligible for Medicaid and covered for health benefits from an insurer, that differ from requirements applicable to an agent or assignee of another individual so covered.

      (d) The Commissioner of Social Services 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.

      (1967, P.A. 759, S. 1(f); P.A. 75-420, S. 4, 6; P.A. 77-614, S. 608, 610; P.A. 83-145; P.A. 84-367, S. 2, 3; P.A. 90-283, S. 1; June Sp. Sess. P.A. 91-8, S. 6, 63; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; 93-418, S. 32, 41; May Sp. Sess. P.A. 94-5, S. 6, 30; P.A. 95-257, S. 12, 21, 58; 95-305, S. 3, 6; P.A. 99-279, S. 17, 45.)

      History: P.A. 75-420 replaced welfare commissioner with commissioner of social services; P.A. 77-614 replaced commissioner of social services with commissioner of income maintenance, effective January 1, 1979; P.A. 83-145 made the existing section Subsec. (b) and added Subsec. (a) dealing with subrogation to any right of recovery, assignment of claim for benefits and entitlements and right of action against third party tortfeasors; P.A. 84-367 added Subsec. (c) prohibiting a provision denying or limiting insurance benefits because services are rendered to an insured who is eligible for or received medical assistance and added Subsec. (d) prohibiting the commissioner from paying for services if the individual has coverage under an accident or health insurance policy; P.A. 90-283 in Subsec. (a) subrogated the department to any right of recovery of a legally liable relative of an applicant or recipient of medical assistance and added provisions whereby the department may assign its right of subrogation; June Sp. Sess. P.A. 91-8 amended Subsec. (b) to require a limitation on reimbursement to medical assistance providers for coinsurance and deductible payments to not exceed the maximum allowable under the Medicaid fee schedules, except for those providers licensed by the department of health services; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced commissioner of health services with commissioner of public health and addiction services, effective July 1, 1993; P.A. 93-418 changed reference to insurer to a private insurer or third party and made other technical changes, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (c) to prevent insurers from imposing requirements on the department of social services which deny or limit benefits which have been assigned pursuant to this section, effective July 1, 1994; Sec. 17-134f transferred to Sec. 17b-265 in 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 95-305 amended Subsec. (c) by deleting a provision that an insurer, health care center or issuer of any service plan contract for hospital or medical expense coverage shall not impose requirements on the Department of Social Services which limit or deny benefits and adding a provision prohibiting an insurer from imposing certain requirements on the state Medicaid agency, effective July 1, 1995; P.A. 99-279 amended Subsec. (a) to provide that the department shall be subrogated to any right of recovery or indemnification which an enrollee in a managed care organization under a Medicaid managed care contract or legally liable relative has against a private insurer or other third party for the medical costs incurred by the managed care organization on behalf of an enrollee and made technical changes, effective July 1, 1999.

      See Sec. 17b-265a re physicians providing services to dually eligible Medicaid and Medicare clients.

      Annotations to former section 17-134f:

      Cited. 168 C. 336. Cited. 204 C. 17, 19, 20. Cited. 216 C. 85-87, 90.

      Annotation to present section:

      Cited as "17b-260 et seq. (providing for supplemental medical assistance)". 233 C. 557, 565.

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