CHAPTER 263
(SB 58)
Insurers to cooperate with the Department of Social Services
to coordinate medical benefits.
ENTITLED, An Act to
require insurers to cooperate with the Department of Social Services in the
coordination of medical benefits.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF SOUTH DAKOTA:
Section
1.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
Within sixty days of a request from the Department of Social Services, the department and an
insurer shall negotiate an acceptable format for the transmission of information from the insurer's
database of policy holders, sponsors, subscribers, covered individuals in South Dakota, and
coverage dates. The format shall include the data elements, medium, frequency of reporting, any
costs of the insurer to be reimbursed, and procedures that will be followed when a data match is
found. The Department of Social Services shall match the name, address, date of birth, and social
security number if available, of the insured's policyholders, sponsors, subscribers, and covered
individuals against the medicaid eligible recipients and recipients of support enforcement services
as defined in subdivision 25-7A-1(19).
Upon discovery of a match, the department may incorporate the following information into its
recipient database:
(1) The name, address, date of birth, social security number if available, and the unique
health care identification number of the covered individual;
(2) The name, address, date of birth, social security number if available, policy number, and
group identification number of the policyholder, sponsor, or subscriber;
(3) The name and address of the employer if it is an employer-employee benefit plan;
(4) Types of covered services under the plan or policy;
(5) Coverage effective date and termination of coverage date for each covered individual;
and
(6) The name and address of the claim administrator for the policy or plan.
The department may not use or disclose any information provided by the insurer other than as
permitted or required by law. The insurer may not be held liable for the release of insurance
coverage information to the department or the director by any party when done so under the
authority of this Act.
Section
2.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
Notwithstanding any other provision of a health benefit plan, health insurance policy, plan,
contract, or certificate, an insurer shall recognize that an application for medical assistance or
acceptance of medical assistance, paid by the Department of Social Services operates as a release
of any information kept by the insurer and readily available, that would facilitate efficient
coordination of benefits between the department and the insurer, which may include:
(1) The name, address, date of birth, social security number if available, and unique health
care identification number of the covered individual;
(2) The name, address, date of birth, social security number if available, policy number,
group identification number of the policyholder, sponsor, or subscriber;
(3) The name and address of the employer if it is an employer-employee benefit plan; types
of services covered under the plan or policy; and the name and address of the claims
administrator for the policy or plan;
(4) Previously paid benefits including the name and address of the payee; and
(5) The name and address of claims processing or administration centers, or both.
Upon written request by the department, the insurer shall provide the requested information
in writing within thirty calendar days of receipt of the request.
Section
3.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
Notwithstanding any other provision of a health benefit plan, health insurance policy, plan,
contract, or certificate, that is issued, entered into, or renewed after July 1, 2005, no insurer may
refuse to reimburse the Department of Social Services because of the manner, form, or date of a
claim for reimbursement, if within one year after the date the claim has been paid by medicaid, for
which reimbursement is sought, the department provides the insurer evidence of the insurer's
liability.
Section
4.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
If the Department of Social Services notifies an insurer that the department has paid for
services on behalf of an individual who is covered under an individual, group, or blanket health
insurance policy or contract that the insurer issued, delivered, entered into, or renewed in the state,
to the extent that the insurer is legally liable, it shall reimburse the department for the cost of the
services, regardless of any provision in the health insurance policy or contract that requires
payment to the policy holder, subscriber, or another payee. If the insurer, after notice from the
department, issues payment to any payee other than the department, the insurer remains liable to
the department for the amount of benefits paid to the other party.
Section
5.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
For the purposes of this Act, the term, insurer, means:
(1) Any commercial insurance company, employer-employee benefit plan, health
maintenance organization, professional association, public self-funded employer or
pool, union, or fraternal group selling or otherwise offering individual or group health
insurance coverage including self-insured and self-funded plans;
(2) Any profit or nonprofit prepaid plan offering either medical services of full or partial
payment for services included in the department's medicaid plan;
(3) Any other entity offering health benefits for which a medicaid recipient may be eligible
in addition to public medical assistance; or
(4) Any entity which processes claims, administers services, or otherwise manages health
benefits on behalf of any of the aforementioned insurers.
Section
6.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
For the purposes of this Act, the term, department, means the Department of Social Services,
or an entity under contract with the Department of Social Services to carry out the functions of this
Act.
Section
7.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
The provisions of chapter 1-27 do not apply to any records the insurer is required to provide
to the department.
Section
8.
That chapter
58-12
be amended by adding thereto a NEW SECTION to read as
follows:
This Act does not apply to any coverages under a personal lines property and casualty policy.
Signed March 7, 2005