210-RICR-10-00-5. Interception of Insurance Payments (version Technical Revision, 09/04/2012 to 03/20/2018)

Medicaid Section 0311 INTERCEPTION OF INSURANCE PAYMENTS September 4, 2012 EOHHS 9/4/2012 1 Medicaid - Interception of Insurance Payments 0311 INTERCEPTION OF INSURANCE PAYMENTS 0311.05 LEGAL BASIS EFF:09/2012 In accordance with state law and applicable administrative rules, when applying for Medicaid, an applicant automatically assigns his/her rights to the Executive Office of Health and Human Services, the RI Medicaid state agency, any third party payments from insurers. Nothing in these sections shall limit the Executive Office of Health and Human services from recovery of any other monies allowed, to the extent of the distribution, in accordance with all state and federal laws. 0311.10 PROCESS EFF:09/2012 Every domestic insurer or insurance company authorized to issue policies of liability insurance and any worker's compensation insurer, shall review information provided by the Executive Office of Health and Human Services, pursuant to R.I.G.L. chapter 27-57.1, indicating whether or not the claimant has received Medicaid funded services as a result of an accident or loss which is the basis of the claim. Said review shall occur within thirty (30) days prior to making any payment equal to or in excess of five hundred dollars ($500.00) to any claimant who is a resident of this state, for personal injury or workers' compensation benefits under a contract of insurance The Executive Office of Health and Human Services shall electronically furnish these insurers and insurance companies with a database data match option report of names of individuals with last known addresses, as of the date of the report, who have received Medicaid in excess of five hundred dollars ($500). To facilitate the efficient and prompt reporting of those Medicaid beneficiaries in one centralized location, the duty and responsibility of the insurance companies doing business is as follows: o Utilize one centralized database, to which the Executive Office of Health and Human Services shall report and administer. o Any insurer receiving information identifying a Medicaid beneficiary shall maintain the confidentiality of that information to the full extent required under federal and state law. Minimal data elements, including, but not limited to, the date of injury and other necessary identifying information, shall be shared with an agency contracted by the Executive Office of Health and Human Services which maintains a centralized database of insurance claims. o The contracted centralized database is required to keep confidential: any personal and personnel information; records sufficient to identify a person applying for or receiving Medicaid; preliminary drafts, notes, impressions, memoranda, working papers, and work products; as well as any other records, reports, opinions, information, and statements deemed confidential pursuant to state or federal law or regulation, or rule of EOHHS 9/4/2012 2 Medicaid - Interception of Insurance Payments court. Any such confidential data shall not be disclosed to the insurer. o Matched results indicating that a beneficiary is a claimant of an insurer are returned to the Executive Office of Health and Human Services through its contracted agency. Proper quality assurance shall be performed by the contracted agency to insure the claim is open. The contracted agency may also collect additional information from the insurer including but not limited to contact information. If the insurer determines from the information provided by the Executive Office of Health and Human Services, pursuant to R.I.G.L. 27-57.1-4, that the claimant or payee has received Medicaid funded services, as a result of an accident or loss which is the basis of the claim, the insurer shall, except to the extent that payments are subject to liens or interests (i.e. health care providers, attorney fees, holders of security interests, or the assignment of rights under R.I.G.L. 40-6-9 and 40-6-10), withhold from payment the amount to the extent of the distribution for Medicaid as a result of an accident or loss, dating back to the date if the incident. The insurer shall pay such amount to the Executive Office of Health and Human Service and shall pay the balance to the claimant or other entitled person. Workers’ compensation claimants who receive Medicaid, provided in accordance with chapter 40-8, shall be subject to the provisions of R.I.G.L. 27-57.1. The workers’ compensation reimbursement payments made to the Executive Office of Health and Human Services in accordance shall be limited to that set forth in chapter 28-33 and section 40-6-10. 0311.15 NOTICE EFF:09/2012 The Executive Office and Health and Human Services shall provide written notice to the insurer, claimant and his/her attorney, if any, which shall include the date, name, social security number, case number, total amount of the payment proposed to be withheld to reimburse the state for Medicaid funded services and a list of the items and services, including dates of service for which reimbursement is sought. The notice shall explain the right to request a hearing pursuant to section 0311.20. 0311.20 REQUEST FOR HEARING EFF:09/2012 Any payments made by an insurer pursuant to this chapter, shall be made to the Executive Office of Health and Human Services, unless there is a request for an administrative hearing by the claimant. Any claimant aggrieved by any action taken under these procedures may, within thirty (30) days of the date of the notice to the claimant, request an administrative hearing from the Executive Office of Health and Human Services. If there is an administrative hearing, the insurer must remit payment within ten (10) business days of and in accordance with the hearing decision. EOHHS 9/4/2012 3 Medicaid - Interception of Insurance Payments 0311.25 PAYMENT BY INSURER EFF:09/2012 The insurer shall make any payments required, pursuant to this chapter, to the Executive Office of Health and Human Services, thirty (30) days after the date of notification to the claimant or his/her attorney. Provided, however, that if the claimant has requested a hearing, payment shall not be made until ten (10) days after the hearing decision and in accordance with the hearing decision.