BILL REQ. #:  H-1856.4 

     AN ACT Relating to enforcing primacy of insurance coverage when third-party liability exists regarding claims under state-purchased health care programs; adding new sections to chapter 48.05 RCW; adding a new section to chapter 41.05 RCW; and creating a new section.

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

NEW SECTION.  Sec. 1   The legislature finds that the citizens of the state of Washington benefit from the efficient and effective resolution of claims for benefits under health plans administered, in whole or in part, by the state. The legislature recognizes a public interest in injured citizens' certainty in determining whether and to what extent their treatment is covered by various insurers. The legislature further recognizes the public's interest in the state's administration of programs that is as efficient as possible, in light of technological advances.

NEW SECTION.  Sec. 2   A new section is added to chapter 48.05 RCW to read as follows:
     (1)(a) For the purpose of determining the eligibility of persons claiming benefits under medicaid, the department of social and health services or its agent shall send automated eligibility inquiry messages to insurers providing health insurance or health care coverage, workers compensation, auto insurance, or homeowner's insurance to persons residing in the state.
     (b) The department of social and health services or its agent is authorized to transmit, and shall transmit, automated eligibility inquiries to insurers to resolve the primacy of claims for benefits under health plans administered, in whole or in part, by the state. The eligibility inquiries may include the minimum human identifiers in ANSI X.12 270, such as the name, gender, and date of birth of a person.
     (2) In addition to their obligations under RCW 74.09A.030, insurers must respond within twenty-four hours to the department's eligibility inquiry messages or upload to a centralized database information on coverage and benefits, as required by the state of Washington.
     (3) Before January 1, 2010, the department of social and health services shall:
     (a) Examine all medicaid claims paid after January 1, 2004, and before July 1, 2009;
     (b) Determine which of those claims were eligible for payment by a third party other than medicaid; and
     (c) Recover the costs associated with the claims that were eligible for payment by a third party other than medicaid.
     (4) The department of social and health services is authorized to enforce this section against an insurer that fails to comply with the requirements of this section.
     (a) In a case in which an insurer fails to comply with the requirements of this section, the attorney general shall:
     (i) Subpoena the enrollment data of the insurer;
     (ii) Commence a complaint under 42 U.S.C. Sec. 1320(d) for administrative sanctions under the health insurance portability and accountability act;
     (iii) Commence a prosecution under 18 U.S.C. Sec. 1035; or
     (iv) Commence an action in state court to enjoin the insurer from nonperformance of its duty under this section.
     (b)(i) A court may order injunctive relief and costs, including attorney fees; or
     (ii) A court may order damages, including penalties of up to one thousand dollars for each eligibility inquiry message to which the insurer has failed or refused to respond. An attempt to impose data elements or other burdens not expressly authorized by this statute upon the content, terms, or execution of the response must be construed as a failure or refusal to comply.
     (c) The insurance commissioner may suspend, revoke, or refuse to renew an insurer's certificate of authority, based upon failure or refusal to comply with this section.
     (5) For purposes of this section, "insurer" has the same meaning as in RCW 48.01.050.

NEW SECTION.  Sec. 3   A new section is added to chapter 41.05 RCW to read as follows:
     (1)(a) For the purpose of determining the eligibility of persons claiming benefits under the public employees' benefits board, the basic health plan, or the health insurance partnership, the administrator of the Washington state health care authority or his or her agent may send automated eligibility inquiry messages to insurers providing health insurance or health care coverage, workers compensation, auto insurance, or homeowner's insurance to persons residing in the state.
     (b) The administrator or his or her agent is authorized to transmit automated eligibility inquiries to insurers to resolve the primacy of claims for benefits under health plans administered, in whole or in part, by the state. The eligibility inquiries may include the minimum human identifiers in ANSI X.12 270, such as the name, gender, and date of birth of a person.
     (2) In addition to their obligations under RCW 74.09A.030, insurers must respond within twenty-four hours to the administrator's eligibility inquiry messages or upload to a centralized database information on coverage and benefits, as required by the state of Washington.
     (3) The administrator may:
     (a) Examine any claims paid;
     (b) Determine which of those claims were eligible for payment by a third party other than those programs administered by the administrator; and
     (c) Recover the costs associated with the claims that were eligible for payment by a third party other than those programs administered by the administrator.
     (4) The administrator is authorized to enforce this section against an insurer that fails to comply with the requirements of this section.
     (a) In a case in which an insurer fails to comply with the requirements of this section, the attorney general shall:
     (i) Subpoena the enrollment data of the insurer;
     (ii) Commence a complaint under 42 U.S.C. Sec. 1320(d) for administrative sanctions under the health insurance portability and accountability act;
     (iii) Commence a prosecution under applicable law; or
     (iv) Commence an action in state court to enjoin the insurer from nonperformance of its duty under this section.
     (b)(i) A court may order injunctive relief and costs, including attorney fees; or
     (ii) A court may order damages, including penalties of up to one thousand dollars for each eligibility inquiry message to which the insurer has failed or refused to respond. An attempt to impose data elements or other burdens not expressly authorized by this statute upon the content, terms, or execution of the response must be construed as a failure or refusal to comply.
     (c) The insurance commissioner may suspend, revoke, or refuse to renew an insurer's certificate of authority, based upon failure or refusal to comply with this section.
     (5) For purposes of this section, "insurer" has the same meaning as in RCW 48.01.050.

NEW SECTION.  Sec. 4   A new section is added to chapter 48.05 RCW to read as follows:
     Eligibility, coverage, employment, and income data that is shared under this act in the process of determining primacy must be construed as an element of data used in the process of billing for medical services rendered and is expressly exempt from the privacy and confidentiality provisions of 42 U.S.C. Sec. 1320 and state law. A person receiving data for that purpose may not use the data for any other purpose.