BILL REQ. #:  Z-0427.1 

Read first time 01/29/2007.   Referred to Committee on Health & Long-Term Care.

     AN ACT Relating to medical benefits; amending RCW 74.09A.005, 74.09A.010, and 74.09A.020; and adding a new section to chapter 74.09A RCW.

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

Sec. 1   RCW 74.09A.005 and 1993 c 10 s 1 are each amended to read as follows:
     The legislature finds that:
     (1) Simplification in the administration of payment of health benefits is important for the state, providers, and ((private)) health insurers;
     (2) The state, providers, and ((private)) health insurers should take advantage of all opportunities to streamline operations through automation and the use of common computer standards; ((and))
     (3) It is in the best interests of the state, providers, and ((private)) health insurers to identify all third parties that are obligated to cover the cost of health care coverage of joint beneficiaries; and
     (4) Health insurers, including private insurers, group health plans, service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, as a condition of doing business in Washington, must increase their effort to share information with the department and accept the department's timely claims consistent with 42 U.S.C. 1396a(a)(25).
     Therefore, the legislature declares that to improve the coordination of benefits between the department of social and health services and ((private)) health insurers to ensure that medical insurance benefits are properly utilized, a transfer of ((uniform information from the department of social and health services to Washington state private insurers should be instituted)) information between the department of social and health services and health insurers should be instituted, and the process for submitting requests for information and claims should be simplified.

Sec. 2   RCW 74.09A.010 and 1993 c 10 s 2 are each amended to read as follows:
     For the purposes of this chapter:
     (1) "Health insurance coverage" includes any coverage under which medical services are provided by ((an employer or a union whether that coverage is provided through a self-insurance program, under the employee retirement income security act of 1974, a commercial insurer pursuant to chapters 48.20 and 48.21 RCW, a health care service contractor pursuant to chapter 48.44 RCW, or a health maintenance organization pursuant to chapter 48.46 RCW,)) health insurers and the medical assistance administration under chapter 74.09 RCW((, and the state through this chapter)).
     (2) "Health insurer" means a commercial insurance company providing disability insurance under chapter 48.20 or 48.21 RCW, a health care service contractor providing health care coverage under chapter 48.44 RCW, a health maintenance organization providing comprehensive health care services under chapter 48.46 RCW, and shall also include any employer or union that is providing health insurance coverage on a self-insured basis, as well as any private insurers, group health plans, service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
     (3) "Medical assistance administration" means the division within the department of social and health services authorized under chapter 74.09 RCW.
     (4) "Computerized" means on-line or batch processing with standardized format via magnetic tape output.
     (5) (("Insurance coverage" means subscriber and beneficiary eligibility and benefit coverage data.
     (6))) "Joint beneficiary" is ((a resident of Washington state)) an individual who has ((private)) health insurance coverage and is a recipient of public assistance benefits under chapter 74.09 RCW.

Sec. 3   RCW 74.09A.020 and 2005 c 274 s 350 are each amended to read as follows:
     (1) The medical assistance administration shall provide routine and periodic computerized information to ((private)) health insurers regarding client eligibility and coverage information. ((Private)) Health insurers shall use this information to identify joint beneficiaries. Identification of joint beneficiaries shall be transmitted to the medical assistance administration. The medical assistance administration shall use this information to improve accuracy and currency of health insurance coverage and promote improved coordination of benefits.
     (2) To the maximum extent possible, necessary data elements and a compatible data base shall be developed by affected health insurers and the medical assistance administration. The medical assistance administration shall establish a representative group of insurers and state agency representatives to develop necessary technical and file specifications to promote a standardized data base. The data base shall include elements essential to the medical assistance administration and its population's insurance coverage information.
     (3) If the state and ((private)) health insurers enter into other agreements regarding the use of common computer standards, the data base identified in this section shall be replaced by the new common computer standards.
     (4) The information provided will be of sufficient detail to promote reliable and accurate benefit coordination and identification of individuals who are also eligible for medical assistance administration programs.
     (5) The frequency of updates will be mutually agreed to by each health insurer and the medical assistance administration based on frequency of change and operational limitations. In no event shall the computerized data be provided less than semiannually.
     (6) The health insurers and the medical assistance administration shall safeguard and properly use the information to protect records as provided by law, including but not limited to chapters 42.48, 74.09, 74.04, 70.02, and 42.56 RCW, and 42 U.S.C. Sec. 1396a and 42 C.F.R. Sec. 43 et seq. The purpose of this exchange of information is to improve coordination and administration of benefits and ensure that medical insurance benefits are properly utilized.
     (7) The medical assistance administration shall target implementation of this ((chapter)) section to those ((private)) health insurers with the highest probability of joint beneficiaries.

NEW SECTION.  Sec. 4   A new section is added to chapter 74.09A RCW to read as follows:
     Health insurers, as a condition of doing business in Washington, must:
     (1) Provide, with respect to individuals who are eligible for, or are provided, medical assistance under chapter 74.09 RCW, upon the request of the medical assistance administration, information to determine during what period the individual or their spouses or their dependants may be, or may have been, covered by a health insurer and the nature of 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 medical assistance administration;
     (2) Accept the medical assistance administration's right to recovery and the assignment to the medical assistance administration of any right of an individual or other entity to payment from the party for an item or service for which payment has been made under chapter 74.09 RCW;
     (3) Respond to any inquiry by the medical assistance administration regarding a 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 such health care item or service;
     (4) Agree not to deny a claim submitted by the medical assistance administration 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, if:
     (a) The claim is submitted by the medical assistance administration within the three-year period beginning on the date the item or service was furnished; and
     (b) Any action by the medical assistance administration to enforce its rights with respect to such claim is commenced within six years of the medical assistance administration's submission of such claim; and
     (5) Agree that the prevailing party in any legal action to enforce these sections receives attorneys' fees as well as related collection fees and costs incurred in the enforcement of these sections.