NRS695C.163. Eligibility for coverage: Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

      1.  A health maintenance organization shall not, when considering eligibility for coverage or making payments under a health care plan, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.

      2.  To the extent that payment has been made by Medicaid for health care, a health maintenance organization:

      (a) Shall treat Medicaid as having a valid and enforceable assignment of benefits due an enrollee or claimant under the enrollee regardless of any exclusion of Medicaid or the absence of a written assignment; and

      (b) May, as otherwise allowed by its plan, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid to reimbursement against any other liable party if:

             (1) It is so authorized pursuant to a contract with Medicaid for managed care; or

             (2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its enrollee.

      3.  If a state agency is assigned any rights of a person who is:

      (a) Eligible for medical assistance under Medicaid; and

      (b) Covered by a health care plan,

Ê the organization responsible for the health care plan shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the same plan.

      4.  If a state agency is assigned any rights of an enrollee who is eligible for medical assistance under Medicaid, a health maintenance organization shall:

      (a) Upon request of the state agency, provide to the state agency information regarding the enrollee to determine:

             (1) Any period during which the enrollee, the spouse or a dependent of the enrollee may be or may have been covered by the health care plan; and

             (2) The nature of the coverage that is or was provided by the organization, including, without limitation, the name and address of the enrollee and the identifying number of the health care plan;

      (b) Respond to any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service not later than 3 years after the date of the provision of the medical item or service; and

      (c) Agree not to deny a claim submitted by the state agency solely on the basis of the date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:

             (1) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and

             (2) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.

      (Added to NRS by 1995, 2435; A 2007, 2406)