States enact laws to comply with section 1902(a) (25) (I)(i) of the Social Security Act and must require health insurers to provide, upon the request of the state, information to determine during what period Medicaid beneficiaries may be (or may have been) covered by the health insurer and the nature of the coverage that is or was provided.
This information includes, at a minimum, four (4) data elements: the insured’s name, address, group or member ID number, and periods of coverage. State laws determine exactly what information is required to be submitted by the health plans. Health plans are to provide these files to state Medicaid programs so that these programs can determine whether any third party payers are liable for the medical items and services that were, or will be, delivered to a Medicaid beneficiary. In essence, the point of the information gathering is to ensure that Medicaid benefits are paid correctly.
In the case of health insurers who contract with a pharmacy benefit manager (PBM) or other third party administrator (TPA) to administer the plan, states also will need to require that such insurers provide the PBM or TPA with such information as may be necessary to enable that entity to furnish the state with the prescribed data, or deal with such inquiries directly without the aid of their PBM or TPA.
(FAQ10536)
