HB 1092: RELATING TO MEDICAID THIRD PARTY LIABILITY.

A BILL FOR AN ACT

RELATING TO MEDICAID THIRD PARTY LIABILITY.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

     SECTION 1.  The legislature finds that section 202 of the Consolidated Appropriations Act, 2022 amended section 1902(a)(25)(I) of the Social Security Act to require state medicaid programs to have state laws in place that bar responsible third party payers, other than medicare plans, from refusing payment for an item or service solely on the basis that the item or service did not receive prior authorization under the third party payer's rules.  It also modified the requirement for a third party payer to respond to a state inquiry regarding a health claim that is submitted not later than three years after the provision of the item or service to specify that the third party must respond within sixty days of receiving the inquiry.

     The purpose of this Act is to amend state law to comply with the amended federal requirements of section 202 of the Consolidated Appropriations Act, 2022.

     SECTION 2.  Section 431L-2.5, Hawaii Revised Statutes, is amended to read as follows:

     "§431L-2.5  Insurer requirements.  Any health insurer as identified in section 431L-1 shall:

     (1)  Provide upon the request of the State, information for all of its members to determine during what period the individual or the individual's spouse or dependents may be or may have been covered by a health insurer and the nature of the coverage that is or was provided by the health insurer, including the name, address, and identifying number of the plan in a manner prescribed by the State;

     (2)  Beginning in 2014, provide to an independent, third party entity, no more than quarterly, a report listing its members.  The third party entity shall match this report with one provided by the department of human services and provide the department of human services with third party liability information for medical assistance recipients.  The department of human services shall determine the minimum data required to ensure the validity of matches, which may include name, date of birth, and social security number, as available.  The information provided by the health insurers to the third party entity shall not be used for any purpose other than that specified in this chapter.  The department of human services shall provide for representation by private health insurers in evaluating the qualifications of potential third party entities and determining the minimum data fields for matching;

     (3)  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 party for a health care item or service for which payment has been made for medical assistance under title 42 United States Code section 1396a (section 1902 of the Social Security Act);

     (4)  Respond to any inquiry by the State within sixty calendar days regarding a health care 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 health care item or service; [and]

     (5)  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, or a failure to obtain a prior authorization for the item or service for which the claim is being submitted, in the case of a responsible third party, if:

          (A)  The claim is submitted by the State within the three-year period beginning on the date on which the health care item or service was furnished; and

          (B)  Any action by the State to enforce its rights with respect to the claim is commenced within six years of the State's submission of the claim[.]; and

     (6)  Agree, when a responsible third party requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance under the state medical assistance program, to accept authorization provided by the state medical assistance program that the item or service is covered under the state medical assistance program for that individual, as if the authorization were the prior authorization made by the third party for the item or service."

     SECTION 3.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 4.  This Act shall take effect on July 1, 3000.

Report Title:

Medicaid; Third Party Liability; State Medical Assistance Program Claims

Description:

Amends third party liability provisions for Medicaid program claims for payment as required under the federal Consolidated Appropriations Act, 2022.  Effective 7/1/3000.  (HD1)

The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.

A BILL FOR AN ACT

RELATING TO MEDICAID THIRD PARTY LIABILITY.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

     SECTION 1.  The legislature finds that section 202 of the Consolidated Appropriations Act, 2022 amended section 1902(a)(25)(I) of the Social Security Act to require state medicaid programs to have state laws in place that bar responsible third party payers, other than Medicare plans, from refusing payment for an item or service solely on the basis that such item or service did not receive prior authorization under the third party payer's rules.  It also modified the requirement for a third party payer to respond to a state inquiry regarding a health claim that is submitted not later than three years after the provision of such item or service to specify that the third party must respond within sixty days of receiving the inquiry.

     The purpose of this Act is to amend state law to comply with the amended federal requirements of section 202.

     SECTION 2.  Section 431L-2.5, Hawaii Revised Statutes, is amended to read as follows:

     "§431L-2.5  Insurer requirements.  Any health insurer as identified in section 431L-1 shall:

     (1)  Provide upon the request of the State, information for all of its members to determine during what period the individual or the individual's spouse or dependents may be or may have been covered by a health insurer and the nature of the coverage that is or was provided by the health insurer, including the name, address, and identifying number of the plan in a manner prescribed by the State;

     (2)  Beginning in 2014, provide to an independent, third party entity, no more than quarterly, a report listing its members.  The third party entity shall match this report with one provided by the department of human services and provide the department of human services with third party liability information for medical assistance recipients.  The department of human services shall determine the minimum data required to ensure the validity of matches, which may include name, date of birth, and social security number, as available.  The information provided by the health insurers to the third party entity shall not be used for any purpose other than that specified in this chapter.  The department of human services shall provide for representation by private health insurers in evaluating the qualifications of potential third party entities and determining the minimum data fields for matching;

     (3)  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 party for a health care item or service for which payment has been made for medical assistance under title 42 United States Code section 1396a (section 1902 of the Social Security Act);

     (4)  Respond to any inquiry by the State within sixty calendar days regarding a health care 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 health care item or service; [and]

     (5)  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, or a failure to obtain a prior authorization for the item or service for which the claim is being submitted, in the case of a responsible third party, if:

          (A)  The claim is submitted by the State within the three-year period beginning on the date on which the health care item or service was furnished; and

          (B)  Any action by the State to enforce its rights with respect to the claim is commenced within six years of the State's submission of the claim[.]; and

     (6)  Agree, when a responsible third party requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance under the state medical assistance program, to accept authorization provided by the state medical assistance program that the item or service is covered under the state medical assistance program for that individual, as if the authorization were the prior authorization made by the third party for the item or service."

     SECTION 3.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 4.  This Act shall take effect upon its approval.

Report Title:

Medicaid; Third Party Liability

Description:

Amends third party liability provisions for medical assistance program claims for payment as required under the Consolidated Appropriations Act, 2022.

The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.

STAND. COM. REP. NO.  446

Honolulu, Hawaii

                , 2025

RE:   H.B. No. 1092

      H.D. 1

Honorable Nadine K. Nakamura

Speaker, House of Representatives

Thirty-Third State Legislature

Regular Session of 2025

State of Hawaii

Madame:

     Your Committee on Health, to which was referred H.B. No. 1092 entitled:

"A BILL FOR AN ACT RELATING TO MEDICAID THIRD PARTY LIABILITY,"

begs leave to report as follows:

     The purpose of this measure is to amend third party liability provisions for Medicaid programs for payment as required under the federal Consolidated Appropriations Act, 2022.  

     Your Committee received testimony in support of this measure from the Department of Human Services.

     Your Committee finds that updates to state law are necessary to conform to new third party liability requirements included in the federal Consolidated Appropriations Act, 2022.  This measure requires liable third-party payers to be responsible for reimbursing Medicaid providers based on the standards of the Medicaid program and prohibits providers from denying payment based on other standards.

     Your Committee has amended this measure by:

     (1)  Changing the effective date to July 1, 3000, to encourage further discussion; and

     (2)  Making technical, nonsubstantive amendments for clarity, consistency, and style.

     As affirmed by the record of votes of the members of your Committee on Health that is attached to this report, your Committee is in accord with the intent and purpose of H.B. No. 1092, as amended herein, and recommends that it pass Second Reading in the form attached hereto as H.B. No. 1092, H.D. 1, and be referred to your Committee on Consumer Protection & Commerce.

Respectfully submitted on behalf of the members of the Committee on Health,