405 Ind. Admin. Code 1-1-15

Current through November 6, 2024

Section 405 IAC 1-1-15 - Third party liability; definitions

Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2

Affected: IC 12-13-7-3; IC 12-15

Sec. 15.

(a) The following definitions are intended to apply only to this section:

(1) "Certification" means a statement authenticated by the seal of the office.

(2) "Coordination of benefits" means all activities by which an insurer notifies or is notified by other insurers or Medicaid, or both, that a claim has been received, for the purpose of establishing primary liability, if previous payment has been made on all or part of the claim.

(3) "Final settlement" means payment of money from a third party liable for the injury, illness, or disease of a member whether by compromise, judgment, court order, or restitution, which payment is intended as the total compensation for the injury, illness, or disease caused by the liable third party.

(4) "Notice" means a written statement of the office's claim bearing:

(A) a certification that the person named in the notice is a member of Medicaid; and

(B) the signature of an authorized Medicaid employee.

(5) "Office's claim" means a statement of Medicaid payments made by the office for any Medicaid member that has been certified by an authorized Medicaid employee.

(b) The office has a lien upon any money or fund payable by any third party who is or may be liable for the medical expenses of a Medicaid member when the office provides Medicaid. Circumstances under which the office may assert its lien include, but are not limited to, cases where Medicaid has made payment because:

(1) payment from a third party was not immediately available;

(2) there are disputes and delays in the coordination of benefits;

(3) the third party was not identified;

(4) the office erroneously made payment before the third party or all other parties had made payment;

(5) a court order has been issued; or

(6) the member asserts a claim against a third party who is or may be liable for the injury, illness, or disease of a Medicaid applicant or member.

(c) The office, acting in behalf of the Medicaid member, may initiate an action against a third party that is or may be liable for the injury, illness, or disease of a Medicaid member because:

(1) the member has not done so; and

(2) the time remaining under the statute of limitations for the action is six (6) months or less.

(d) In perfecting its lien, the office shall take the following action before the third party makes final settlement to the Medicaid member as total compensation for the member's injury, illness, or disease:

(1) Serve notice:

(A) to third parties in the manner described in subsection (e); or

(B) to insurers in the manner described in either subsection (e)(3)(C) or (f) as deemed appropriate by the office.

(2) File a claim that:

(A) shows the amount of payment made at the time notice is served;

(B) is updated at not less than yearly intervals and shows the total of all identified expenditures and average daily cost of the individual's care;

(C) is prepared by the office's staff or is a hard copy of computer generated claims payment records; and

(D) is certified by an authorized Medicaid employee.

(e) The office may perfect its lien by serving notice to third parties in the following manner:

(1) Filing a written notice in the Marion County Court stating the following:

(A) The name and address of the member.

(B) That the individual is eligible for Medicaid.

(C) The name of the person or third party alleged to be liable to the injured, ill, or diseased member.

(2) Sending a copy of the notice filed in the Marion County Court by certified mail to the third party.

(3) Sending a copy of the notice to the following persons or entities if the appropriate names and addresses are determined:

(A) The member.

(B) The member's attorney.

(C) The insurer or other third parties.

(f) The office may serve notice to insurers or initiate the coordination of benefits by mailing a notice to the insurer that:

(1) is on state letterhead;

(2) is sent by certified mail; and

(3) includes, if reasonably available to the office, the following information pertaining to the Medicaid member:

(A) Name of employer.

(B) Name of policyholder.

(C) Employee identification number.

(D) Claim certificate number.

(g) When an insurer has received the notice specified in subsection (e)(3)(C) or (f) prior to making payment on a claim, and the insurer is liable for part or all of a Medicaid member's medical expenses, the insurer shall coordinate the benefits with the office and:

(1) pay the provider of service for bills submitted by the provider unless the office certifies that it has already paid the bill;

(2) reimburse the office for claims submitted by the office; or

(3) reimburse the office if the provider and the office submit claims for the same services.

(h) An insurer that is put on notice of a claim by the office under either subsection (g)(1), (g)(2), or (g)(3) and proceeds to pay the claim to a person or entity other than the office is not discharged from payment of the office's claim.

(i) Once Medicaid has been reimbursed for the office's claim by the insurer, the insurer has discharged its responsibility for that claim. Neither the insurer nor the member shall be held liable for any remaining balance. For any provider seeking adjustments in payment, recourse is limited to an administrative appeal as provided by 405 IAC 1-1.4.

(j) The rules set forth in subsection (g) shall also apply when the member notifies the insurer that the member has received Medicaid from the office. In this case, the insurer is required to initiate coordination of benefits with the office.

(k) Any clause in any insurance contract that excludes payment when the contract beneficiary is eligible for Medicaid is void and the insurer shall make payments described in subsection (g).

(l) The office may waive its lien, at its discretion.

405 IAC 1-1-15

Office of the Secretary of Family and Social Services; 405 IAC 1-115; filed Sep 29, 1982, 3:09 pm: 5 IR 2322; filed May 22, 1987, 12:45 pm: 10 IR 2282, eff Jul 1, 1987; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA

Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA

Errata filed 10/6/2016, 2:59 p.m.: 20161019-IR-405160452ACA

Filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA

Transferred from the Division of Family and Children (470 IAC 5-1-13) to the Office of the Secretary of Family and Social Services (405 IAC 1-1-15) by P.L. 9-1991, SECTION 131, effective January 1, 1992.