Section 27-14-11.1 Contents of Policies - Denial or Reduction of Benefits Due to Medicaid Eligibility Void.
AI-assisted research summary: Private insurers are defined for this section, and they cannot deny or reduce benefits, or deny enrollment, because of Medicaid eligibility. They must also provide certain coverage information, accept recovery/assignment rights, answer state inquiries within the stated timeframe, and follow limits on denying state claims.
(a) For purposes of this section, “private insurer” is defined as any of the following: (1) Any commercial insurance company offering health or casualty insurance to individuals or groups, including both experience-rated contracts and indemnity contracts. (2) Any profit or nonprofit prepaid plan offering either medical services or full or partial payment for the diagnosis or treatment of an injury, disease, or disability. (3) Any organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments or services, including self-insured and self-funded plans. (4) Any health insurer, including group health plans, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, self-insured plans, service benefit plans, managed care organizations, pharmacy benefit managers, or other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. (b) Any provision in an insurance contract issued or renewed after March 25, 1980, by a private insurer which denies or reduces benefits due to the eligibility of the insured to receive assistance under the Medicaid program is null and void. (c) A private insurer may not deny enrollment to an individual because of Medicaid eligibility. (d) As a condition of doing business in Alabama, a private insurer shall do all of the following: (1) Provide, with respect to individuals who are eligible for, or are provided, medical assistance under the Alabama Title XIX plan, upon the request of the state, information to determine during what period the individuals or their spouses or their dependents may be, or may have been, covered by a health insurer and the nature of the 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 state Medicaid Agency. (2) 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 Alabama Medicaid program. (3) Respond to an inquiry by the state 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 state 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 both of the following apply: a. The claim is submitted by the state within the three-year period beginning on the date on which the item or service was furnished. b. Any action by the state to enforce its rights with respect to the claim is commenced within six years of the state’s submission of the claim. (e) The provisions of this section shall not be effective if they are found by a court of competent jurisdiction to contravene federal laws or federal regulations applicable to the Medicaid program.