CHAPTER 286
(SB 65)
Coordination of benefits for medical assistance
between the state and insurers.
ENTITLED, An Act to
revise certain provisions regarding the reimbursement for medical
assistance made by certain insurers to the state.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF SOUTH DAKOTA:
Section
1.
That
§
58-12-23
be amended to read as follows:
58-12-23.
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
2.
That
§
58-12-24
be amended to read as follows:
58-12-24.
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
for medical assistance paid by the department 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 for which reimbursement is sought, if the claim is submitted within three years from
the date the item or service was furnished and any action by the department to enforce its rights
with respect to such claim is commenced within six years of the department's submission of such
claim
.
Section
3.
That
§
58-12-26
be amended to read as follows:
58-12-26.
For the purposes of §§ 58-12-22 to 58-12-29, inclusive, the term, insurer, means:
(1)
Any commercial insurance company, employer-employee benefit plan, health
maintenance organization, professional association,
service benefit plan,
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
managed care organization, third-party administrator, pharmacy benefits manager,
or other
entity which processes claims, administers services, or otherwise manages
health benefits on behalf of any of the aforementioned insurers
; or
(5) Any other party that is by statute, contract, or agreement, legally responsible for
payment of a claim for a health care item or service including workers' compensation,
automobile insurance, and liability insurance plans
.
Section
4.
That
§
58-12-29
be repealed.
Signed February 23, 2007