Conn. Gen. Stat. § 17b-265

Current with legislation from 2024 effective through June 5, 2024.

Section 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. Allocation of child support obligor funds

(a) In accordance with 42 USC 1396k, the Department of Social Services shall be subrogated to any right of recovery or indemnification that an applicant or recipient of medical assistance or any legally liable relative of such applicant or recipient has against an insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, for the cost of all health care items or services furnished to the applicant or recipient, including, but not limited to, hospitalization, pharmaceutical services, physician services, nursing services, behavioral health services, long-term care 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 care management organization under a Medicaid care management 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 care management organization on behalf of an enrollee. Whenever funds owed to a person are collected pursuant to this section and the person who otherwise would have been entitled to such funds is subject to a court-ordered current or arrearage child support payment obligation in an IV-D support case, such funds shall first be paid to the state for reimbursement of Medicaid funds paid on behalf of such person for medical expenses incurred for injuries related to a legal claim by such person that was the subject of the state's right of subrogation, and remaining funds, if any, shall then be paid to the Office of Child Support Services for distribution pursuant to the federally mandated child support distribution system implemented pursuant to subsection (j) of section 17b-179. Any additional claim of the state to the remainder of such funds, if any, shall be paid in accordance with state law.

(b) An applicant or recipient or legally liable relative, by the act of the applicant's or recipient's 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. In accordance with subsection (b) of section 38a-472, a provider that has received an assignment from the department shall notify the recipient's health insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, of the assignment upon rendition of services to the applicant or recipient. Failure to so notify the health insurer or other legally liable 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.

(c) Claims for recovery or indemnification submitted by the department, or the department's designee, shall not be denied solely on the basis of the date of the submission of the claim, the type or format of the claim, the lack of prior authorization or the failure to present proper documentation at the point-of-service that is the basis of the claim, if (1) the claim is submitted by the state within the three-year period beginning on the date on which the item or service was furnished; and (2) any action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of the claim.

(d)

(1) A party to whom a claim for recovery or indemnification is submitted for an item or service furnished under the Medicaid state plan, or a waiver of such plan, who requires prior authorization for such item or service shall accept authorization provided by the Department of Social Services that the item or service is covered under such plan or waiver as if such authorization were the prior authorization made by such party for the item or service.

(2) The provisions of subdivision (1) of this subsection shall not apply with respect to a claim for recovery or indemnification submitted to Medicare, a Medicare Advantage plan or a Medicare Part D plan.

(e) 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. The commissioner shall limit reimbursement to medical assistance providers 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.

(f) No self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care plan, or any plan offered or administered by a health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, shall contain any provision that has the effect of denying or limiting enrollment 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.

(g) 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.

(h) An insurer or other legally liable third party, upon receipt of a claim submitted by the department or the department's designee, in accordance with the requirements of subsection (c) of this section, for payment of a health care item or service covered under a state medical assistance program administered by the department, shall, not later than sixty days after receipt of the claim or not later than November 30, 2023, whichever is later, (1) make payment on the claim, (2) request information necessary to determine its legal obligation to pay the claim, or (3) issue a written reason for denial of the claim. Failure to pay, request information necessary to determine legal obligation to pay or issue a written reason for denial of a claim not later than one hundred twenty days after receipt of the claim, or not later than January 30, 2024, whichever is later, creates an uncontestable obligation to pay the claim. The provisions of this subsection shall apply to all claims, including claims submitted by the department or the department's designee prior to July 1, 2021.

(i) On and after July 1, 2021, an insurer or other legally liable third party who has reimbursed the department for a health care item or service paid for and covered under a state medical assistance program administered by the department shall, upon determining it is not liable and at risk for cost of the health care item or service, request any refund from the department not later than twelve months from the date of its reimbursement to the department.

Conn. Gen. Stat. § 17b-265

(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 ; June Sp. Sess. P.A. 07-2 , S. 20 ; P.A. 09-8 , S. 5 ; P.A. 10-179 , S. 78 ; P.A. 11-44 , S. 84 ; 11-61 , S. 126 ; P.A. 12-119 , S. 5 ; P.A. 15-247 , S. 29 ; June Sp. Sess. P.A. 15-5 , S. 388 .)

Amended by P.A. 23-0204,S. 292 of the Connecticut Acts of the 2023 Regular Session, eff. 10/1/2023.

Amended by P.A. 22-0118, S. 452 of the Connecticut Acts of the 2022 Regular Session, eff. 7/1/2022.

Amended by P.A. 21-0002, S. 334 of the Connecticut Acts of the 2021 Special Session, eff. 7/1/2021.

Amended by P.A. 15-0005, S. 388 of the Connecticut Acts of the 2015 Special Session, eff. 7/1/2015.

Amended by P.A. 15-0247, S. 29 of the Connecticut Acts of the 2015 Regular Session, eff. 7/10/2015.

Amended by P.A. 12-0119, S. 5 of the the 2012 Regular Session, eff. 6/15/2012.

Amended by P.A. 11-0061, S. 126 of the the 2011 Regular Session, eff. 7/1/2011.

Amended by P.A. 11-0044, S. 84 of the the 2011 Regular Session, eff. 7/1/2011.

Amended by P.A. 10-0179, S. 78 of the February 2010 Regular Session, eff. 7/1/2010.

Amended by P.A. 09-0008, S. 5 of the the 2009 Regular Session, eff. 10/1/2009.

Annotations to former section 17-134f: Cited. 168 Conn. 336 ; 204 Conn. 17 ; 216 Conn. 85 . Annotations to present section: Cited. 233 Conn. 557 . Federal Medicaid statutes reasonably cannot be categorized as plain and unambiguous; determination of whether statutes require state to pursue third party tortfeasor directly for reimbursement, or, alternatively, require state to compensate recipient pro rata for attorney's fees and costs, will encompass text of relevant Medicaid statutes as well as their broader context and purpose; state has met federal obligation to seek reimbursement of Medicaid funds when third parties are found to be liable for a recipient's medical expenses by providing for assignment and subrogation rights and by allowing state to assert lien against funds recovered by Medicaid recipients from third parties; federal statutes governing Medicaid program do not require state to pursue third party tortfeasors directly for reimbursement of Medicaid funds, or, if state chooses to collect reimbursement indirectly from Medicaid recipient, to reduce amount of reimbursement pro rata to compensate recipient for attorney's fees and costs incurred in pursuing third party; Connecticut's reimbursement provisions, this section and Secs. 17b-93 and 17b-94 , satisfy Medicaid reimbursement requirements imposed by federal law. 287 Conn. 82 . Subsec. (a) authorizes a private managed care organization, as department's designee, to seek reimbursement from a Medicaid recipient for medical costs recovered by the Medicaid recipient from a liable third party. 315 C. 674 . Where department through its contract with defendant assigned its statutory right to subrogation under section to defendant, defendant had the right to seek reimbursement from insured for funds received from settlement with tortfeasor third party. 133 CA 202.