,i #aacth ,,congress #ast ,session ,h4 ,r4 #cfei ,,in ,,the ,,house ,,of ,,representatives ,december #e1 #bjac,mr4 ,burgess introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce ,a ,,bill ,to amend title ,,xix of the ,social ,security ,act to clarify policy with respect to collecting reimbursement from third-party payers for medical assistance paid under the ,medicaid program1 and for other purposes4 #a4 ,removal of special treatment of certain types of care and payments under ,medicaid third-party liability rules ,section #aijb7;a77#be7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#be77 is amended by striking subparagraphs 7,e7 and 7,f74 #b4 ,clarification of role of ,m,c,os with respect to third-party liability 7a7 ,in general ,section #aijb7;a77#be7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#be771 as amended by section #a1 is further amended by inserting1 after subparagraph 7,d71 the following3 7,e7 that1 if the ,state contracts with a managed care entity pursuant to section #aicb for the purpose of providing items and services under this title-- 7i7 such contract shall specify whether-- 7,i7 the ,state is delegating to the managed care entity all or some of its right of recovery for an item or service for which payment has been made under the ,state plan2 and 7,,ii7 the ,state is transferring to the managed care entity all or some of the assignment to the ,state of any right of an individual or other entity to payment from a health insurer 7including self-insured plans1 group health plans 7as defined in section #fjg7a7 of the ,employee ,retirement ,income ,security ,act of #aigd71 service benefit plans1 managed care organizations1 pharmacy benefit managers1 or other parties that are1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service7 for an item or service for which payment has been made under the ,state plan2 and 7ii7 if the ,state delegates its rights under clause 7i77,i7 or transfers assignment of rights under clause 7i77,,ii71 the ,state shall have in effect laws requiring such health insurers1 as a condition of doing business in the ,state-- 7,i7 to provide to such managed care entity1 upon the request of such entity1 the information described in subparagraph 7,i77i72 7,,ii7 if a right of recovery was delegated under clause 7i77,i71 accept the authority of the managed care entity to exercise such right2 7,,iii7 if an assignment of rights was transferred under clause 7i77,,ii71 accept such transfer of assignment of rights2 7,,iv7 respond to an inquiry made by such entity in the same manner that the insurer would respond to an inquiry by a ,state under subparagraph 7,i77iii72 and 7,v7 agree not to deny a claim submitted by a managed care entity for which the ,state has delegated or transferred rights under clause 7i7 in the same manner that the insurer may not deny a claim submitted by a ,state under subparagraph 7,i77iv72 4 7b7 ,treatment of collected amounts ,section #aijc7;d77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7d77#b77;,b77 is amended by adding at the end the following3 ,for purposes of this subparagraph1 reimbursements made by a third party to managed care entities pursuant to section #aijb7;a77#be77;,e7 shall be treated in the same manner as reimbursements made to a ,state under the previous sentence44 #c4 ,requiring coordination of beneficiary information with respect to third-party liability ,section #aijb7;a77#be7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#be771 as amended by section #b1 is further amended by inserting1 after subparagraph 7,e71 the following3 7,f7 that1 if the ,state contracts with a health insurer 7as defined for purposes of subparagraph 7,e77 for the purposes of providing items and services under this title such contract shall require that-- 7i7 if such insurer contracts with a pharmacy benefit manager to manage benefits under the health plan offered by such insurer1 such contract shall require that the pharmacy benefit manager regularly report to the ,state 7or1 as applicable1 to an authorized contractor or agent of the ,state7 any data obtained by the pharmacy benefit manager that is relevant1 as determined by the ,state1 to assisting the ,state in determining whether such a health insurer is1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service available under the plan2 and 7ii7 such insurer cooperates 7including by granting requests of the ,state for information1 or for permission to utilize information1 that is relevant to determining whether such a health insurer is1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service available under the plan1 regardless of the ,state in which the insurer is licensed7 with the ,state ,medicaid plan 7including any ,state ,medicaid agency or authorized agent or contractor of such program or entity7 for the proper coordination of benefits offered through the plan of such insurer and medical assistance under the ,state plan to effectuate the principle of the program under this title being the payer of last resort2 4 #d4 ,development of model uniform fields for ,states to report third-party information ,not later than ,january #a1 #bjae1 the ,secretary of ,health and ,human ,services shall1 in consultation with the ,states1 develop and make available to the ,states a model uniform reporting field that ,states may use for purposes of reporting to the ,secretary within ,,cms ,form #fd 7or any successor form7 information identifying third-party health insurers 7including self-insured plans1 group health plans 7as defined in section #fjg7a7 of the ,employee ,retirement ,income ,security ,act of #aigd71 service benefit plans1 managed care organizations1 pharmacy benefit managers1 or other parties that are1 by statute1 contract1 or agreement1 legally responsible for payment of a claim for a health care item or service7 and other relevant information for ascertaining the legal responsibility of such third parties to pay for care and services available under the ,state plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq474 #e4 ,state incentive to pursue third-party liability for newly eligibles ,section #aijc7;d77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7d77#b77;,b771 as amended by section #b1 is amended by adding at the end the following3 ,in the case of expenditures for medical assistance provided during #bjad and subsequent years for newly eligible individuals 7as such term is defined in section #aije7y77 described in subclause 7,,viii7 of section #aijb7;a77#aj77;,a77i71 in determining the amount1 if any1 of overpayment under this subparagraph with respect to such services1 the ,secretary shall apply the ,federal medical assistance percentage for the ,state under section #aije7;b71 notwithstanding the application of section #aije7y744 #f4 ,penalty for non-compliance ,subject to section #f7;b71 for any fiscal year beginning on or after the date that is #a year after the effective date under section #f1 in the case of a ,state that fails to comply with the additional requirements for the ,state plan for medical assistance under title ,,xix of the ,social ,security ,act that are imposed by the amendments made by this ,act1 the ,secretary of ,health and ,human ,services shall reduce the ,federal medical assistance percentage 7as defined in section #aije7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7b77 for such ,state by a percentage point for such fiscal year during which such requirements are not met4 ,to the extent that a ,state fails to comply with such additional requirements for consecutive fiscal years1 the reductions under the previous sentence shall be cumulative for each such subsequent fiscal year4 #g4 ,effective date 7a7 ,in general ,except as provided in subsection 7b71 this ,act 7other than section #d7 and the amendments made by this ,act shall take effect on the date of enactment of this ,act and shall apply to medical assistance provided on or after such date4 7b7 ,exception if ,state legislation required ,in the case of a ,state plan for medical assistance under title ,,xix of the ,social ,security ,act that the ,secretary of ,health and ,human ,services determines requires ,state legislation 7other than legislation appropriating funds7 in order for the plan to meet the additional requirement imposed by the amendments made under this section1 the ,state plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the ,state legislature that begins after the date of the enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of such session shall be deemed to be a separate regular session of the ,state legislature4