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 recipien
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 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 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 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.
(b) 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. 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 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 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) 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.
(e) Notwithstanding the provisions of subsection (c) of section 38a-553, 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 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.
(f) 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; June Sp. Sess. P.A. 07-2, S. 20.)
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; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by dividing existing provisions into Subsecs.
(a) and (b), amended redesignated Subsec. (a) by deleting "private", adding "legally liable", delineating entities deemed
an insurer or a legally liable third party, adding "legally responsible for payment of a claim for a health care item or service",
re responsibilities of third party, providing that health care items or services include behavioral health services and long-term
care services and making technical changes, amended redesignated Subsec. (b) by adding "In accordance with subsection (b)
of section 38a-472" re provider's notice to department of receipt of an assignment, replacing "private insurer" with "health
insurer", adding "legally liable", and delineating entities deemed a health insurer or a legally liable third party, added new
Subsec. (c) re time parameters for submission of claims for recovery or indemnification by department, redesignated
existing Subsecs. (b) to (d) as Subsecs. (d) to (f), and amended redesignated Subsec. (e) by redefining types of health
insurance plans that shall not contain provisions which have effect of denying or limiting enrollment benefits or excluding
coverage because services are rendered to individual who is receiving medical assistance and making a technical change,
effective July 1, 2007.
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. Cited. 216 C. 85.
Annotation to present section:
Cited as "17b-260 et seq. (providing for supplemental medical assistance)". 233 C. 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. 287 C. 82. 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. Id. 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. Id.