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EXPLANATION-Matter enclosed in bold-faced brackets [thus] in this bill is not enacted
and is intended to be omitted in the law.
SECOND REGULAR SESSION
SENATE BILL NO. 1687
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR MCCREERY .
6990S.01I KRISTINA MARTIN, Secretary
AN ACT
To repeal section 208.215, RSMo, and to enact in lieu thereof one new section relating to MO
HealthNet third party liability.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Section 208.215, RSMo, is repealed and one new 1
section enacted in lieu thereof, to be known as section 208.215, 2
to read as follows:3
208.215. 1. MO HealthNet is payer of last resort 1
unless otherwise specified by law. When any person, 2
corporation, institution, public agency or private agency is 3
liable, either pursuant to contract or otherwise, to a 4
participant receiving public assistance on account of 5
personal injury to or disability or disease or benefits 6
arising from a health insurance plan to which the 7
participant may be entitled, payments made by the department 8
of social services or MO HealthNet division shall be a debt 9
due the state and recoverable from the liable party or 10
participant for all payments made on behalf of the 11
participant and the debt due the state shall not exceed the 12
payments made from MO HealthNet benefits provided under 13
sections 208.151 to 208.158 and section 208.162 and section 14
208.204 on behalf of the participant, minor or estate for 15
payments on account of the injury, disease, or disability or 16
benefits arising from a health insurance program to which 17
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the participant may be entitled. Any health benefit plan as 18
defined in section 376.1350, third-party administrator, 19
administrative service organization, and pharmacy benefits 20
manager shall process and pay all properly submitted medical 21
assistance subrogation claims or MO HealthNet subrogation 22
claims using standard electronic transactions or paper claim 23
forms: 24
(1) For a period of three years from the date services 25
were provided or rendered; however, an entity: 26
(a) Shall respond to any inquiry by the state 27
regarding a claim for payment for any health care item or 28
service not later than sixty days after receiving any such 29
inquiry; 30
(b) Shall not be required to reimburse for items or 31
services which are not covered under MO HealthNet; 32
[(b)] (c) Shall not deny a claim submitted by the 33
state solely on the basis of the date of submission of the 34
claim, the type or format of the claim form, failure to 35
present proper documentation of coverage at the point of 36
sale, or failure to provide prior authorization for the item 37
or service for which the claim is being submitted, except 38
that such shall not apply to the original Medicare fee-for- 39
service program under Parts A and B of Subchapter XVIII of 40
42 U.S.C. Chapter 7, a Medicare Advantage plan offered by a 41
Medicare Advantage organization under Part C of such 42
subchapter, a reasonable cost reimbursement plan under 42 43
U.S.C. 1395mm, a health care prepayment plan under 42 U.S.C. 44
1395l, or a prescription drug plan offered by a PDP sponsor 45
under Part D of Subchapter XVIII of 42 U.S.C. Chapter 7 with 46
regards to prior authorizations; 47
[(c)] (d) Shall not be required to reimburse for items 48
or services for which a claim was previously submitted to 49
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the health benefit plan, third-party administrator, 50
administrative service organization, or pharmacy benefits 51
manager by the health care provider or the participant and 52
the claim was properly denied by the health benefit plan, 53
third-party administrator, administrative service 54
organization, or pharmacy benefits manager for procedural 55
reasons, except for timely filing, type or format of the 56
claim form, failure to present proper documentation of 57
coverage at the point of sale, or failure to obtain prior 58
authorization; 59
(e) Shall accept authorization provided by the state 60
that the item or service is covered under the state plan or 61
waiver of such plan for such individual, as if such 62
authorization were the prior authorization made by the third 63
party for such item or service, except that such shall not 64
apply to the original Medicare fee-for-service program under 65
Parts A and B of Subchapter XVIII of 42 U.S.C. Chapter 7, a 66
Medicare Advantage plan offered by a Medicare Advantage 67
organization under Part C of such subchapter, a reasonable 68
cost reimbursement plan under 42 U.S.C. 1395mm, a health 69
care prepayment plan under 42 U.S.C. 1395l, or a 70
prescription drug plan offered by a PDP sponsor under Part D 71
of Subchapter XVIII of 42 U.S.C. Chapter 7; 72
[(d)] (f) Shall not be required to reimburse for items 73
or services which are not covered under or were not covered 74
under the plan offered by the entity against which a claim 75
for subrogation has been filed; and 76
[(e)] (g) Shall reimburse for items or services to the 77
same extent that the entity would have been liable as if it 78
had been properly billed at the point of sale, and the 79
amount due is limited to what the entity would have paid as 80
if it had been properly billed at the point of sale; and 81
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(2) If any action by the state to enforce its rights 82
with respect to such claim is commenced within six years of 83
the state's submission of such claim. 84
2. The department of social services, MO HealthNet 85
division, or its contractor may maintain an appropriate 86
action to recover funds paid by the department of social 87
services or MO HealthNet division or its contractor that are 88
due under this section in the name of the state of Missouri 89
against the person, corporation, institution, public agency, 90
or private agency liable to the participant, minor or estate. 91
3. Any participant, minor, guardian, conservator, 92
personal representative, estate, including persons entitled 93
under section 537.080 to bring an action for wrongful death 94
who pursues legal rights against a person, corporation, 95
institution, public agency, or private agency liable to that 96
participant or minor for injuries, disease or disability or 97
benefits arising from a health insurance plan to which the 98
participant may be entitled as outlined in subsection 1 of 99
this section shall upon actual knowledge that the department 100
of social services or MO HealthNet division has paid MO 101
HealthNet benefits as defined by this chapter promptly 102
notify the MO HealthNet division as to the pursuit of such 103
legal rights. 104
4. Every applicant or participant by application 105
assigns his right to the department of social services or MO 106
HealthNet division of any funds recovered or expected to be 107
recovered to the extent provided for in this section. All 108
applicants and participants, including a person authorized 109
by the probate code, shall cooperate with the department of 110
social services, MO HealthNet division in identifying and 111
providing information to assist the state in pursuing any 112
third party who may be liable to pay for care and services 113
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available under the state's plan for MO HealthNet benefits 114
as provided in sections 208.151 to 208.159 and sections 115
208.162 and 208.204. All applicants and participants shall 116
cooperate with the agency in obtaining third-party resources 117
due to the applicant, participant, or child for whom 118
assistance is claimed. Failure to cooperate without good 119
cause as determined by the department of social services, MO 120
HealthNet division in accordance with federally prescribed 121
standards shall render the applicant or participant 122
ineligible for MO HealthNet benefits under sections 208.151 123
to 208.159 and sections 208.162 and 208.204. A participant 124
who has notice or who has actual knowledge of the 125
department's rights to third-party benefits who receives any 126
third-party benefit or proceeds for a covered illness or 127
injury is either required to pay the division within sixty 128
days after receipt of settlement proceeds the full amount of 129
the third-party benefits up to the total MO HealthNet 130
benefits provided or to place the full amount of the third- 131
party benefits in a trust account for the benefit of the 132
division pending judicial or administrative determination of 133
the division's right to third-party benefits. 134
5. Every person, corporation or partnership who acts 135
for or on behalf of a person who is or was eligible for MO 136
HealthNet benefits under sections 208.151 to 208.159 and 137
sections 208.162 and 208.204 for purposes of pursuing the 138
applicant's or participant's claim which accrued as a result 139
of a nonoccupational or nonwork-related incident or 140
occurrence resulting in the payment of MO HealthNet benefits 141
shall notify the MO HealthNet division upon agreeing to 142
assist such person and further shall notify the MO HealthNet 143
division of any institution of a proceeding, settlement or 144
the results of the pursuit of the claim and give thirty 145
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days' notice before any judgment, award, or settlement may 146
be satisfied in any action or any claim by the applicant or 147
participant to recover damages for such injuries, disease, 148
or disability, or benefits arising from a health insurance 149
program to which the participant may be entitled. 150
6. Every participant, minor, guardian, conservator, 151
personal representative, estate, including persons entitled 152
under section 537.080 to bring an action for wrongful death, 153
or his attorney or legal representative shall promptly 154
notify the MO HealthNet division of any recovery from a 155
third party and shall immediately reimburse the department 156
of social services, MO HealthNet division, or its contractor 157
from the proceeds of any settlement, judgment, or other 158
recovery in any action or claim initiated against any such 159
third party. A judgment, award, or settlement in an action 160
by a participant to recover damages for injuries or other 161
third-party benefits in which the division has an interest 162
may not be satisfied without first giving the division 163
notice and a reasonable opportunity to file and satisfy the 164
claim or proceed with any action as otherwise permitted by 165
law. 166
7. The department of social services, MO HealthNet 167
division or its contractor shall have a right to recover the 168
amount of payments made to a provider under this chapter 169
because of an injury, disease, or disability, or benefits 170
arising from a health insurance plan to which the 171
participant may be entitled for which a third party is or 172
may be liable in contract, tort or otherwise under law or 173
equity. Upon request by the MO HealthNet division, all 174
third-party payers shall provide the MO HealthNet division 175
with information contained in a 270/271 Health Care 176
Eligibility Benefits Inquiry and Response standard 177
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transaction mandated under the federal Health Insurance 178
Portability and Accountability Act, except that third-party 179
payers shall not include accident-only, specified disease, 180
disability income, hospital indemnity, or other fixed 181
indemnity insurance policies. 182
8. The department of social services or MO HealthNet 183
division shall have a lien upon any moneys to be paid by any 184
insurance company or similar business enterprise, person, 185
corporation, institution, public agency or private agency in 186
settlement or satisfaction of a judgment on any claim for 187
injuries or disability or disease benefits arising from a 188
health insurance program to which the participant may be 189
entitled which resulted in medical expenses for which the 190
department or MO HealthNet division made payment. This lien 191
shall also be applicable to any moneys which may come into 192
the possession of any attorney who is handling the claim for 193
injuries, or disability or disease or benefits arising from 194
a health insurance plan to which the participant may be 195
entitled which resulted in payments made by the department 196
or MO HealthNet division. In each case, a lien notice shall 197
be served by certified mail or registered mail, upon the 198
party or parties against whom the applicant or participant 199
has a claim, demand or cause of action. The lien shall 200
claim the charge and describe the interest the department or 201
MO HealthNet division has in the claim, demand or cause of 202
action. The lien shall attach to any verdict or judgment 203
entered and to any money or property which may be recovered 204
on account of such claim, demand, cause of action or suit 205
from and after the time of the service of the notice. 206
9. On petition filed by the department, or by the 207
participant, or by the defendant, the court, on written 208
notice of all interested parties, may adjudicate the rights 209
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of the parties and enforce the charge. The court may 210
approve the settlement of any claim, demand or cause of 211
action either before or after a verdict, and nothing in this 212
section shall be construed as requiring the actual trial or 213
final adjudication of any claim, demand or cause of action 214
upon which the department has charge. The court may 215
determine what portion of the recovery shall be paid to the 216
department against the recovery. In making this 217
determination the court shall conduct an evidentiary hearing 218
and shall consider competent evidence pertaining to the 219
following matters: 220
(1) The amount of the charge sought to be enforced 221
against the recovery when expressed as a percentage of the 222
gross amount of the recovery; the amount of the charge 223
sought to be enforced against the recovery when expressed as 224
a percentage of the amount obtained by subtracting from the 225
gross amount of the recovery the total attorney's fees and 226
other costs incurred by the participant incident to the 227
recovery; and whether the department should, as a matter of 228
fairness and equity, bear its proportionate share of the 229
fees and costs incurred to generate the recovery from which 230
the charge is sought to be satisfied; 231
(2) The amount, if any, of the attorney's fees and 232
other costs incurred by the participant incident to the 233
recovery and paid by the participant up to the time of 234
recovery, and the amount of such fees and costs remaining 235
unpaid at the time of recovery; 236
(3) The total hospital, doctor and other medical 237
expenses incurred for care and treatment of the injury to 238
the date of recovery therefor, the portion of such expenses 239
theretofore paid by the participant, by insurance provided 240
by the participant, and by the department, and the amount of 241
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such previously incurred expenses which remain unpaid at the 242
time of recovery and by whom such incurred, unpaid expenses 243
are to be paid; 244
(4) Whether the recovery represents less than 245
substantially full recompense for the injury and the 246
hospital, doctor and other medical expenses incurred to the 247
date of recovery for the care and treatment of the injury, 248
so that reduction of the charge sought to be enforced 249
against the recovery would not likely result in a double 250
recovery or unjust enrichment to the participant; 251
(5) The age of the participant and of persons 252
dependent for support upon the participant, the nature and 253
permanency of the participant's injuries as they affect not 254
only the future employability and education of the 255
participant but also the reasonably necessary and 256
foreseeable future material, maintenance, medical 257
rehabilitative and training needs of the participant, the 258
cost of such reasonably necessary and foreseeable future 259
needs, and the resources available to meet such needs and 260
pay such costs; 261
(6) The realistic ability of the participant to repay 262
in whole or in part the charge sought to be enforced against 263
the recovery when judged in light of the factors enumerated 264
above. 265
10. The burden of producing evidence sufficient to 266
support the exercise by the court of its discretion to 267
reduce the amount of a proven charge sought to be enforced 268
against the recovery shall rest with the party seeking such 269
reduction. The computerized records of the MO HealthNet 270
division, certified by the director or his or her designee, 271
shall be prima facie evidence of proof of moneys expended 272
and the amount of the debt due the state. 273
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11. The court may reduce and apportion the 274
department's or MO HealthNet division's lien proportionate 275
to the recovery of the claimant. The court may consider the 276
nature and extent of the injury, economic and noneconomic 277
loss, settlement offers, comparative negligence as it 278
applies to the case at hand, hospital costs, physician 279
costs, and all other appropriate costs. The department or 280
MO HealthNet division shall pay its pro rata share of the 281
attorney's fees based on the department's or MO HealthNet 282
division's lien as it compares to the total settlement 283
agreed upon. This section shall not affect the priority of 284
an attorney's lien under section 484.140. The charges of 285
the department or MO HealthNet division or contractor 286
described in this section, however, shall take priority over 287
all other liens and charges existing under the laws of the 288
state of Missouri with the exception of the attorney's lien 289
under such statute. 290
12. Whenever the department of social services or MO 291
HealthNet division has a statutory charge under this section 292
against a recovery for damages incurred by a participant 293
because of its advancement of any assistance, such charge 294
shall not be satisfied out of any recovery until the 295
attorney's claim for fees is satisfied, regardless of 296
whether an action based on participant's claim has been 297
filed in court. Nothing herein shall prohibit the director 298
from entering into a compromise agreement with any 299
participant, after consideration of the factors in 300
subsections 9 to 13 of this section. 301
13. This section shall be inapplicable to any claim, 302
demand or cause of action arising under the workers' 303
compensation act, chapter 287. From funds recovered 304
pursuant to this section the federal government shall be 305
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paid a portion thereof equal to the proportionate part 306
originally provided by the federal government to pay for MO 307
HealthNet benefits to the participant or minor involved. 308
The department or MO HealthNet division shall enforce TEFRA 309
liens, 42 U.S.C. Section 1396p, as authorized by federal law 310
and regulation on permanently institutionalized 311
individuals. The department or MO HealthNet division shall 312
have the right to enforce TEFRA liens, 42 U.S.C. Section 313
1396p, as authorized by federal law and regulation on all 314
other institutionalized individuals. For the purposes of 315
this subsection, "permanently institutionalized individuals" 316
includes those people who the department or MO HealthNet 317
division determines cannot reasonably be expected to be 318
discharged and return home, and "property" includes the 319
homestead and all other personal and real property in which 320
the participant has sole legal interest or a legal interest 321
based upon co-ownership of the property which is the result 322
of a transfer of property for less than the fair market 323
value within thirty months prior to the participant's 324
entering the nursing facility. The following provisions 325
shall apply to such liens: 326
(1) The lien shall be for the debt due the state for 327
MO HealthNet benefits paid or to be paid on behalf of a 328
participant. The amount of the lien shall be for the full 329
amount due the state at the time the lien is enforced; 330
(2) The MO HealthNet division shall file for record, 331
with the recorder of deeds of the county in which any real 332
property of the participant is situated, a written notice of 333
the lien. The notice of lien shall contain the name of the 334
participant and a description of the real estate. The 335
recorder shall note the time of receiving such notice, and 336
shall record and index the notice of lien in the same manner 337
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as deeds of real estate are required to be recorded and 338
indexed. The director or the director's designee may 339
release or discharge all or part of the lien and notice of 340
the release shall also be filed with the recorder. The 341
department of social services, MO HealthNet division, shall 342
provide payment to the recorder of deeds the fees set for 343
similar filings in connection with the filing of a lien and 344
any other necessary documents; 345
(3) No such lien may be imposed against the property 346
of any individual prior to the individual's death on account 347
of MO HealthNet benefits paid except: 348
(a) In the case of the real property of an individual: 349
a. Who is an inpatient in a nursing facility, 350
intermediate care facility for the intellectually disabled, 351
or other medical institution, if such individual is 352
required, as a condition of receiving services in such 353
institution, to spend for costs of medical care all but a 354
minimal amount of his or her income required for personal 355
needs; and 356
b. With respect to whom the director of the MO 357
HealthNet division or the director's designee determines, 358
after notice and opportunity for hearing, that he cannot 359
reasonably be expected to be discharged from the medical 360
institution and to return home. The hearing, if requested, 361
shall proceed under the provisions of chapter 536 before a 362
hearing officer designated by the director of the MO 363
HealthNet division; or 364
(b) Pursuant to the judgment of a court on account of 365
benefits incorrectly paid on behalf of such individual; 366
(4) No lien may be imposed under paragraph (b) of 367
subdivision (3) of this subsection on such individual's home 368
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if one or more of the following persons is lawfully residing 369
in such home: 370
(a) The spouse of such individual; 371
(b) Such individual's child who is under twenty-one 372
years of age, or is blind or permanently and totally 373
disabled; or 374
(c) A sibling of such individual who has an equity 375
interest in such home and who was residing in such 376
individual's home for a period of at least one year 377
immediately before the date of the individual's admission to 378
the medical institution; 379
(5) Any lien imposed with respect to an individual 380
pursuant to subparagraph b. of paragraph (a) of subdivision 381
(3) of this subsection shall dissolve upon that individual's 382
discharge from the medical institution and return home. 383
14. The debt due the state provided by this section is 384
subordinate to the lien provided by section 484.130 or 385
section 484.140, relating to an attorney's lien and to the 386
participant's expenses of the claim against the third party. 387
15. Application for and acceptance of MO HealthNet 388
benefits under this chapter shall constitute an assignment 389
to the department of social services or MO HealthNet 390
division of any rights to support for the purpose of medical 391
care as determined by a court or administrative order and of 392
any other rights to payment for medical care. 393
16. All participants receiving benefits as defined in 394
this chapter shall cooperate with the state by reporting to 395
the family support division or the MO HealthNet division, 396
within thirty days, any occurrences where an injury to their 397
persons or to a member of a household who receives MO 398
HealthNet benefits is sustained, on such form or forms as 399
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provided by the family support division or MO HealthNet 400
division. 401
17. If a person fails to comply with the provision of 402
any judicial or administrative decree or temporary order 403
requiring that person to maintain medical insurance on or be 404
responsible for medical expenses for a dependent child, 405
spouse, or ex-spouse, in addition to other remedies 406
available, that person shall be liable to the state for the 407
entire cost of the medical care provided pursuant to 408
eligibility under any public assistance program on behalf of 409
that dependent child, spouse, or ex-spouse during the period 410
for which the required medical care was provided. Where a 411
duty of support exists and no judicial or administrative 412
decree or temporary order for support has been entered, the 413
person owing the duty of support shall be liable to the 414
state for the entire cost of the medical care provided on 415
behalf of the dependent child or spouse to whom the duty of 416
support is owed. 417
18. The department director or the director's designee 418
may compromise, settle or waive any such claim in whole or 419
in part in the interest of the MO HealthNet program. 420
Notwithstanding any provision in this section to the 421
contrary, the department of social services, MO HealthNet 422
division is not required to seek reimbursement from a liable 423
third party on claims for which the amount it reasonably 424
expects to recover will be less than the cost of recovery or 425
for which recovery efforts will not be cost-effective. Cost- 426
effectiveness is determined based on the following: 427
(1) Actual and legal issues of liability as may exist 428
between the participant and the liable party; 429
(2) Total funds available for settlement; and 430
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(3) An estimate of the cost to the division of 431
pursuing its claim. 432
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