1738-S2 AMH CODY BLAC 064
2SHB 1738 - H AMD 530
By Representative Cody
ADOPTED 04/06/2011
On page 25, line 27, after "services" strike all material through "appropriate" on line 28 and insert "subject to rules adopted by the authority or department"
On page 44, line 30, after "department))"
strike "Subject to available funds, the" and insert "The"
On page 47, line 32, after "act" strike "and subject to available funds"
On page 119, after line 30, insert the following:
"Sec. 118. RCW 74.09A.005 and 2007 c 179 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 health insurers;
(2) The state, providers, and health insurers should take advantage of all opportunities to streamline operations through automation and the use of common computer standards;
(3) It is in the best interests of the state, providers, and 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, as a condition of doing business in
Washington, must increase their effort to share information with the ((department))
authority and accept the ((department's)) authority'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)) health care authority and health insurers to ensure that
medical insurance benefits are properly utilized, a transfer of information
between the ((department)) authority and health insurers should
be instituted, and the process for submitting requests for information and
claims should be simplified.
Sec. 119. RCW 74.09A.010 and 2007 c 179 s 2 are each amended to read as follows:
For the purposes of this chapter:
(1) (("Department")) "Authority"
means the ((department of social and health services)) Washington
state health care authority.
(2) "Health insurance coverage" includes any policy, contract, or agreement under which health care items or services are provided, arranged, reimbursed, or paid for by a health insurer.
(3) "Health insurer" means any party that is, by statute, policy, contract, or agreement, legally responsible for payment of a claim for a health care item or service, including, but not limited to, 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, an employer or union self-insured plan, any private insurer, a group health plan, a service benefit plan, a managed care organization, a pharmacy benefit manager, and a third party administrator.
(4) "Computerized" means online or batch processing with standardized format via magnetic tape output.
(5) "Joint beneficiary" is an individual who has health insurance coverage and is a recipient of public assistance benefits under chapter 74.09 RCW.
Sec. 120. RCW 74.09A.020 and 2007 c 179 s 3 are each amended to read as follows:
(1) The ((department)) authority shall
provide routine and periodic computerized information to health insurers
regarding client eligibility and coverage information. Health insurers shall
use this information to identify joint beneficiaries. Identification of joint
beneficiaries shall be transmitted to the ((department)) authority.
The ((department)) authority 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 database shall be developed by affected health
insurers and the ((department)) authority. The ((department))
authority shall establish a representative group of health insurers and
state agency representatives to develop necessary technical and file
specifications to promote a standardized database. The database shall include
elements essential to the ((department)) authority and its
population's health insurance coverage information.
(3) If the state and health insurers enter into other agreements regarding the use of common computer standards, the database 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 ((department)) authority
programs.
(5) The frequency of updates will be mutually agreed to
by each health insurer and the ((department)) authority 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 ((department)) authority
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 ((department)) authority shall
target implementation of this section to those health insurers with the highest
probability of joint beneficiaries.
Sec. 121. RCW 74.09A.030 and 2007 c 179 s 4 are each amended 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 ((department)) authority, 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 ((department))
authority;
(2) Accept the ((department's)) authority's
right to recovery and the assignment to the ((department)) authority
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 ((department)) authority
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 ((department))
authority 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,
if:
(a) The claim is submitted by the ((department)) authority
within the three‑year period beginning on the date the item or service
was furnished; and
(b) Any action by the ((department)) authority
to enforce its rights with respect to such claim is commenced within six years
of the ((department's)) authority's submission of such claim; and
(5) Agree that the prevailing party in any legal action to enforce this section receives reasonable attorneys' fees as well as related collection fees and costs incurred in the enforcement of this section."
Renumber the remaining sections consecutively and correct any internal references accordingly. Correct the title.
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EFFECT: Eliminates the conditioning of care and services under Department of Social and Health Services (DSHS) medical services programs to the availability of funds. Eliminates the conditioning of prostate cancer screenings and the maternity care access program to the availability of funds.
Transfers existing DSHS responsibilities to coordinate with health insurers regarding health benefits for recipients of medical services provided by the DSHS to the Health Care Authority (HCA). Changes references from DSHS to the HCA with respect to provisions that condition business operations for health insurers in Washington upon agreeing to allow the state to recover payments for insured individuals who are also enrolled in medical services programs.
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