CHAPTER 190

FORMERLY

HOUSE BILL NO. 101

AS AMENDED BY

HOUSE AMENDMENT NO. 2

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO THE INSURANCE CODE.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE :

WHEREAS, the costs to the State of Delaware for Medicaid continue to increase; and

WHEREAS, some individuals who are eligible for Medicaid are covered in part by private or other government-funded health insurance; and

WHEREAS, electronic data matching between Delaware Health and Social Services and health insurers licensed to conduct business in this State is technologically feasible; and

WHEREAS, the Federal government has mandated that states participating in the Medicaid program provide satisfactory assurances that health insurers are required by State law to share information with the State agency responsible for administering the Medicaid program.

NOW THEREFORE:

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE:

Section 1. Amend § 520(b), Title 18 of the Delaware Code by adding thereto the following new subsections (5) through (8), which shall read as follows:

“(5) As defined in Chapter 40 of this Title, has failed to comply with § 4006 of Title 18;

(6) As defined in Chapter 40 of this Title, has failed to 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 an item or service for which payment has been made under the State Medicaid Plan;

(7) As defined in Chapter 40 of this Title, has failed to respond to any inquiry by the State regarding a claim for payment for any health care item or service that is submitted within three (3) years of the date of the provision of such health care item or service;

(8) As defined in Chapter 40 of this Title, has denied a claim submitted by the State on the basis of lack of prior authorization; has denied a claim submitted by the State based solely on the date of submission of the claim, the type or format of the claim, or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:

(a) the claim submitted by the State is made within three (3) years of the date when the item or service was furnished; and

(b) any action by the State to enforce its rights with respect to such claim is commenced within six (6) years of the State’s submission of such claim.”.

Section 2. Amend § 4001(5), Title 18 of the Delaware Code by adding the phrase “or a pharmacy benefit manager” after the word “plan”.

Section 3. Amend § 4001, Title 18 of the Delaware Code by adding a new subsection (8), which shall read as follows:

“(8) Any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.”.

Section 4. Amend § 4004, Title 18 of the Delaware Code by adding the phrase:

“a pharmacy benefit manager; any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service,”

after the phrase “a self-funded entity or group providing health care coverage;” as it appears therein.

Section 5. Further Amend § 4004, Title 18 of the Delaware Code by designating the current paragraph as subsection (a), and by adding thereto the following new subsection (b), which shall read as follows:

“(b) ‘Department’ means the Delaware Department of Health and Social Services.”.

Section 6. Amend Chapter 40, Title 18 of the Delaware Code by adding thereto a new Section designated as

§ 4006. which shall read as follows:

Ҥ 4006. Data Sharing.

The Department is authorized to require any health insurer to provide, upon the request of the Department, eligibility and coverage information (including, but not limited to the name, address, date of birth, social security number, policy number, group identification number, types of covered services under the policy, effective dates of coverage, and termination date for each client) that will enable the Department to determine during what period Medicaid recipients may be or may have been covered by the health insurer and the nature of the coverage that is or was provided. This information shall be referred to as the Plan Eligibility Data Elements. The Department may enter into agreements with the health insurers for the purpose of carrying out the provisions of this Section. The agreement shall provide for the electronic exchange of data between the parties at a mutually agreed upon frequency and in a format specified by the Department designed to verify that an individual has coverage, but no less frequently than once every two (2) months. The agreement shall specify the data elements that shall be included on the electronic file from the health insurer. No health insurer that provides data required by the Department, whether confidential or not, shall be held liable for the provision of such data to the Department or for any use made thereof. The Department shall have procedures in place to ensure compliance with the requirements of the Health Insurance Portability and Accountability Act of 1996 relating to the privacy and security of individually identifiable health information, as applicable.”.

Section 7. This Act becomes effective upon enactment.

Approved February 4, 2008