Sec. 17b-265g. Health insurer. Duties owed to the state and Commissioner of Social Services.
Sec. 17b-265g. Health insurer. Duties owed to the state and Commissioner of
Social Services. Any health insurer, including 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, and which
may or may not be financially at risk for the cost of a health care item or service, shall,
as a condition of doing business in the state, be required to: (1) Provide, with respect
to an individual who is eligible for, or is provided, medical assistance under the Medicaid
state plan, to all third-party administrators, pharmacy benefit managers, dental benefit
managers or other entities with which the health insurer has a contract or arrangement
to adjudicate claims for a health care item or service, and to the Commissioner of Social
Services, or the commissioner's designee, any and all information in a manner and
format prescribed by the commissioner, or commissioner's designee, necessary to determine when the individual, his or her spouse or the individual's dependents may be or
have been covered by a health insurer and the nature of the coverage that is or was
provided by such health insurer including the name, address and identifying number of
the plan; (2) accept the state's right of recovery and the assignment to the state of any
right of an individual or other entity to payment from the health insurer for an item or
service for which payment has been made under the Medicaid state plan; (3) respond
to any inquiry by the commissioner, or the commissioner's designee, regarding a claim
for payment for any health care item or service that is submitted not later than three
years after the date of the provision of the item or service; and (4) agree not to deny a
claim submitted by the state solely on the basis of the date of submission of the claim,
the type or format of the claim form or a failure to present proper documentation at the
point-of-sale that is the basis of the claim, if (A) the claim is submitted by the state or
its agent within the three-year period beginning on the date on which the item or service
was furnished; and (B) any legal action by the state to enforce its rights with respect to
such claim is commenced within six years of the state's submission of such claim.
(June Sp. Sess. P.A. 07-2, S. 19.)
History: June Sp. Sess. P.A. 07-2 effective July 1, 2007.