Page:United States Statutes at Large Volume 100 Part 1.djvu/241

 PUBLIC LAW 99-272—APR. 7, 1986 (7)

100 STAT. 205

COORDINATED SERVICES AND SUBSTITUTION OF PARTICI-

PANTS.—The amendments made by subsections (h) and (i) shall become effective on the date of the enactment of this Act. SEC. 9503. THIRD-PARTY LIABILITY. (a)

AMENDMENTS TO STATE PLAN REQUIREMENTS.—(1)

Section

1902{a)(25) of the Social Security Act (42 U.S.C. 1396a(a)(25)) is amended to read as follows: "(25) provide— "(A) that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties (including health insurers) to pay for care and services available under the plan, including— "(i) the collection of sufficient information (as speci- Claims. fied by the Secretary in regulations) to enable the State to pursue claims against such third parties, with such information being collected at the time of any determination or redetermination of eligibility for medical assistance, and "(ii) the submission to the Secretary of a plan (subject to approval by the Secretary) for pursuing claims against such third parties, which plan shall— "(I) be integrated with, and be monitored as a part of the Secretary's review of, the State's mechanized claims processing and information retrieval system under section 1903(r), and 42 USC 1396b. "(II) be subject to the provisions of section 1903(r)(4) relating to reductions in Federal payments for failure to meet conditions of approval, but shall not be subject to any other financial penalty as a result of any other monitoring, quality control, or auditing requirements; "(B) that in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual and where the amount of reimbursement the State can reasonably expect to recover exceeds the costs of such recovery, the State or local agency will seek reimbursement for such assistance to the extent of such legal liability; "(C) that in the case of an individual who is entitled to medical assistance under the State plan with respect to a service for which a third party is liable for payment, the person furnishing the service may not seek to collect from the individual (or any financially responsible relative or representative of that individual) payment of an amount for that service (i) if the total of the amount of the liabilities of third parties for that service is at least equal to the amount payable for that service under the plan (disregarding section 1916), or (ii) in an amount which exceeds the lesser of 42 USC l396o. (I) the amount which may be collected under section 1916, or (II) the amount by which the amount payable for that service under the plan (disregarding section 1916) exceeds the total of the amount of the liabilities of third parties for that service; "(D) that a person who furnishes services and is participating under the plan may not refuse to furnish services to

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