Currently, DHFS may obtain from insurers information DHFS needs to identify a recipient of Medical Assistance (MA) who is eligible for benefits under a disability insurance policy or, if enrolled as the dependent of a beneficiary, would be eligible for benefits; claims submittal information; and types of benefits provided under the policy. DHFS must enter into an agreement with the insurer that identifies the information to be disclosed, safeguards confidentiality, and specifies how the insurer's reasonable costs will be determined and paid from state general purpose revenues and federal moneys. Insurers must provide the information within specified deadlines, and the commissioner of insurance may initiate enforcement proceedings for noncompliance.
This bill expands the sources from which DHFS may receive health care services coverage information about MA recipients to include entities that are responsible for payment of a claim for a health care item or service and makes available compensation for providing the information. The sources, termed "third parties," include, in addition to insurers, self-insured plans, service benefits plans, and pharmacy benefits managers. The bill authorizes DHFS to notify the attorney general of third parties, other than insurers, that fail to provide information requested.
Under the bill, third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under MA, or under a program administered under MA under a federal waiver, has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Lastly, the bill applies the information recovery, acceptance of assignment, recovery of third-party payment, and compensation provisions of current law and as affected by this bill so as to enable DHFS also to identify Badger Care health care program recipients who are eligible, or who would be eligible as dependents, for health care coverage from a third party.
Health
Currently, DHFS administers the Well-Woman Program, under which certain medical services related to breast cancer, cervical cancer, and multiple sclerosis and certain general medical services are provided to underinsured and uninsured women of low income.
This bill requires health insurers, self-insured plans, service benefits plans, and pharmacy benefits managers (third parties) to provide to DHFS information from their records to enable DHFS to identify persons receiving benefits under the Well-Woman Program who are eligible, or would be eligible as dependents, for health care coverage from a third party. These third parties may receive compensation for providing the information, must provide the information within certain deadlines, and may be subject to enforcement proceedings for noncompliance. The third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under the Well-Woman Program has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Other health and family services
Currently, DHFS administers Family Care, a program that provides a flexible benefit of long-term care and services to certain persons who are at least 18 years of age, meet functional and financial eligibility requirements, and have a physical or developmental disability or degenerative brain disorder.
This bill requires health insurers, self-insured plans, service benefits plans, and pharmacy benefits managers (third parties) to provide to DHFS information from their records to enable DHFS to identify persons receiving benefits under Family Care who are eligible, or would be eligible as dependents, for health care coverage from a third party. These third parties may receive compensation for providing the information, must provide the information within certain deadlines, and may be subject to enforcement proceedings for noncompliance. The third parties must accept assignment to DHFS of a right of an individual to receive payment from the third party for a health care item or service for which payment under Family Care has been made. Third parties must also accept the right of DHFS to recover any third-party payment made for which assignment had not been accepted. A third party must respond to an inquiry by DHFS concerning a claim for payment of a health care item or service if the inquiry is made within 36 months after the item or service is provided. Further, third parties must agree not to deny a DHFS claim on the basis of certain circumstances, if submitted less than 36 months after the health care item or service is provided and if action by DHFS to enforce its rights is commenced less than 72 months after DHFS submits the claim.
Under current law, DHFS may request from health insurers information to enable DHFS to identify Medical Assistance recipients who are eligible, or who would be eligible as dependents, for health insurance coverage. An insurer that receives a request must provide the information within a certain period of time. Under the bill, DHFS must provide any information that it receives from a health insurer, self-insured plan, service benefit plan, and pharmacy benefits manager to DWD for purposes of DWD's program related to child and spousal support, paternity establishment, and medical support liability. DWD may allow county and tribal child support agencies access to the information, subject to use and disclosure restrictions under current law, and must consult with DHFS regarding procedures to safeguard the confidentiality of the information.
For further information see the state and local fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
SECTION 1. 20.435 (4) (pa) of the statutes is amended to read:
20.435 (4) (pa) Federal aid; Medical Assistance and food stamp contracts administration. All federal moneys received for the federal share of the cost of contracting for payment and services administration and reporting, other than moneys received under par. (nn), to reimburse insurers 3rd parties for their costs under s. 49.475, for administrative contract costs for the food stamp program under s. 49.79, and for services of resource centers under s. 46.283.
SECTION 2. 46.286 (3m) of the statutes is repealed and recreated to read:
46.286 (3m) INFORMATION ABOUT ENROLLEES. The department shall obtain and share information about family care enrollees as provided in s. 49.475.
SECTION 3. 49.475 (1) (a) of the statutes is renumbered 49.475 (1) (ar).
SECTION 4. 49.475 (1) (ag) of the statutes is created to read:
49.475 (1) (ag) "Covered entity" means any of the following that is not an insurer:
1. A nonprofit hospital, as defined in s. 46.21 (2) (m).
2. An employer, as defined in s. 101.01 (4), labor union, or other group of persons organized in this state if the employer, labor union, or other group provides prescription drug coverage to covered individuals who reside or are employed in this state.
3. A comprehensive or limited health care benefits program administered by the state that provides prescription drug coverage.
SECTION 5. 49.475 (1) (am) of the statutes is created to read:
49.475 (1) (am) "Covered individual" means an individual who is a member, participant, enrollee, policyholder, certificate holder, contract holder, or beneficiary of a covered entity, or a dependent of the individual, and who receives prescription drug coverage from or through the covered entity.
SECTION 6. 49.475 (1) (c) of the statutes is created to read:
49.475 (1) (c) "Pharmacy benefits management" means the procurement of prescription drugs at a negotiated rate for dispensation in this state to covered individuals; the administration or management of prescription drug benefits provided by a covered entity for the benefit of covered individuals; or any of the following services provided in the administration of pharmacy benefits:
1. Dispensation of prescription drugs by mail.
2. Claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals.
3. Clinical formulary development and management services.
4. Rebate contracting and administration.
5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.
SECTION 7. 49.475 (1) (d) of the statutes is created to read:
49.475 (1) (d) "Pharmacy benefits manager" means a person that performs pharmacy benefits management functions.
SECTION 8. 49.475 (1) (e) of the statutes is created to read:
49.475 (1) (e) "Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:
1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.
2. An enrollee of family care.
3. A recipient of the Badger Care health care program.
4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.
5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.
6. A woman who receives services that are reimbursed under s. 255.06.
SECTION 9. 49.475 (1) (f) of the statutes is created to read:
49.475 (1) (f) "Third party" means an entity that by statute, rule, or contract is responsible for payment of a claim for a health care item or service. "Third party" includes all of the following:
1. An insurer.
2. An employee benefit plan described in 29 USC 1003 (a) that is not exempt under 29 USC 1003 (b) and is not a multiple employer welfare arrangement.
3. A service benefit plan, as specified in 42 USC 1396a (25) (I).
4. A pharmacy benefits manager.
SECTION 10. 49.475 (2) of the statutes is repealed and recreated to read:
49.475 (2) REQUIREMENTS OF 3RD PARTIES. As a condition of doing business in this state, a 3rd party shall do all of the following:
(a) Upon the department's request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:
1. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.
2. If subd. 1. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.
(b) Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department's right to recover any 3rd-party payment made for which assignment has not been accepted.
(c) Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.
(d) If all of the following apply, agree not to deny a claim submitted by the department under par. (b) solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:
1. The department submits the claim less than 36 months after the date on which the health care item or service was provided.
2. Action by the department to enforce the department's rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.
SECTION 11. 49.475 (3) (intro.) of the statutes is amended to read:
49.475 (3) WRITTEN AGREEMENT. (intro.) Upon requesting an insurer a 3rd party to provide the information under sub. (2) (a), the department and the 3rd party shall enter into a written agreement with the insurer that satisfies all of the following:
SECTION 12. 49.475 (3) (a) of the statutes is amended to read:
49.475 (3) (a) Identifies in detail the detailed format of the information to be disclosed provided to the department.
SECTION 13. 49.475 (3) (c) of the statutes is amended to read:
49.475 (3) (c) Specifies how the insurer's 3rd party's reimbursable costs under sub. (5) will be determined and specifies the manner of payment.
SECTION 14. 49.475 (4) (a) of the statutes is amended to read:
49.475 (4) (a) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer 3rd party to disclose information under this section.
SECTION 15. 49.475 (4) (b) of the statutes is amended to read:
49.475 (4) (b) An insurer A 3rd party shall provide the information requested under sub. (2) (a) within 30 days after receiving the department's request if the department has previously requested the insurer 3rd party to disclose information under this section.
SECTION 16. 49.475 (4) (d) of the statutes is created to read:
49.475 (4) (d) If a 3rd party other than an insurer fails to comply with par. (a) or (b), the department may so notify the attorney general.
SECTION 17. 49.475 (5) of the statutes is amended to read:
49.475 (5) From the appropriations under s. 20.435 (4) (bm) and (pa), the department shall reimburse an insurer A 3rd party that provides information under this section sub. (2) (a) for the insurer's 3rd party's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of the information under this section.
SECTION 18. 49.475 (6) of the statutes is created to read:
49.475 (6) SHARING INFORMATION. The department of health and family services shall provide to the department of workforce development, for purposes of the medical support liability program under s. 49.22, any information that the department of health and family services receives under this section. The department of workforce development may allow a county child support agency under s. 59.53 (5) or a tribal child support agency access to the information, subject to the use and disclosure restrictions under s. 49.83, and shall consult with the department of health and family services regarding procedures and methods to adequately safeguard the confidentiality of the information provided under this subsection.
SECTION 19. 49.665 (5m) of the statutes is repealed and recreated to read:
49.665 (5m) INFORMATION ABOUT BADGER CARE RECIPIENTS. The department shall obtain and share information about Badger Care health care program recipients as provided in s. 49.475.
SECTION 20. 49.687 (6) of the statutes is created to read:
49.687 (6) The department shall obtain and share information about individuals who receive benefits under s. 49.68, 49.683, or 49.685 as provided in s. 49.475.
SECTION 21. 49.688 (8m) of the statutes is repealed and recreated to read:
49.688 (8m) The department shall obtain and share information about participants in the program under this section as provided in s. 49.475.
SECTION 22. 255.06 (4) of the statutes is created to read:
255.06 (4) INFORMATION ABOUT WOMEN WHO RECEIVE SERVICES. The department shall obtain and share information about women who receive services that are reimbursed under this section as provided in s. 49.475.
(End)
LRB-0249LRB-0249/2
DAK:kjf:rs
2007 - 2008 LEGISLATURE
DOA:......Pink, BB0014 - Medical Assistance contractor collections
For 2007-09 Budget -- Not Ready For Introduction
2007 BILL
AN ACT ...; relating to: the budget.
Analysis by the Legislative Reference Bureau
