(a) Medical assistance paid to, or on behalf of, any recipient cannot be recovered from a beneficiary unless such assistance has been incorrectly paid, or, unless the recipient or beneficiary recovers or is entitled to recover from a third party reimbursement for all or part of the costs of care or treatment for the injury or illness for which the medical assistance is paid. To the extent of payments of medical assistance, the state shall be subrogated to all rights of recovery, for the cost of care or treatment for the injury or illness for which medical assistance is provided, contractual or otherwise, of the recipients against any person. Medicaid payments to the provider of the medical services shall not be withdrawn or reduced to recover funds obtained by the recipient from third parties for medical services rendered by the provider if these funds were obtained without the knowledge or direct assistance of the provider of medical assistance. When the state asserts its right to subrogation, the state shall notify the recipients in language understandable to all recipients, of recipient’s rights of recovery against third parties and that recipient should seek the advice of an attorney regarding those rights of recovery to which recipient may be entitled. If, while receiving assistance, the recipient becomes possessed of any resource or income in excess of the amount stated in the application provided for in this part, it shall be the duty of the recipient immediately to notify the agency designated to determine eligibility under this part of the receipt or possession of such resource or income. When it is found that any person has failed to so notify the agency that such person is or was possessed of any resource or income in excess of the amount allowed or when it is found that, within five (5) years prior to the date of recipient’s application, a recipient made an assignment or transfer of property for the purpose of rendering the recipient eligible for assistance under this part, any amount of assistance paid in excess of the amount to which the recipient was entitled shall constitute benefits incorrectly paid. Any benefits incorrectly paid shall be recoverable from the recipient, while living, as a debt due to the state and, upon the recipient’s death, as a claim classified with taxes having preference under the laws of this state.
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Terms Used In Tennessee Code 71-5-117

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Contract: A legal written agreement that becomes binding when signed.
  • Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
  • Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
  • Department: means the department of health. See Tennessee Code 71-5-103
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Lawsuit: A legal action started by a plaintiff against a defendant based on a complaint that the defendant failed to perform a legal duty, resulting in harm to the plaintiff.
  • Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
  • Medical assistance: means payment of the cost of care, services and supplies necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with the person's capacity for normal activity, or threaten some significant handicap and that are furnished an eligible person in accordance with this part and the rules and regulations of the department. See Tennessee Code 71-5-103
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Person: includes a corporation, firm, company or association. See Tennessee Code 1-3-105
  • Plaintiff: The person who files the complaint in a civil lawsuit.
  • Property: includes both personal and real property. See Tennessee Code 1-3-105
  • Recipient: means any person who has been determined eligible to receive benefits under this part and who has received such benefits. See Tennessee Code 71-5-103
  • Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. Source: FDIC
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
  • State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
  • Statute: A law passed by a legislature.
  • Title XIX: means Title XIX of the Social Security Act as amended (P. See Tennessee Code 71-5-103
  • Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b) Upon accepting medical assistance, the recipient shall be deemed to have made an assignment to the state of the right of third party insurance benefits to which the recipient may be entitled. Failure of the recipient to reimburse the state for medical assistance received from any third party insurance benefits received as a result of the illness or injury from which the medical assistance was paid may be grounds for removing the recipient from future participation in the benefits available under this part; provided, that any removal from participation shall be after appropriate advance notice to the recipient and that the provider of service shall not be prevented from receiving payment from the state for medical assistance services previously furnished the recipient, and that nothing in this subsection (b) shall require an insurer to pay benefits to the state that have already been paid to the recipient.
(c)

(1) For purposes of this subsection (c), “third party for medical services” or “third parties” includes, but is not limited to, a health and liability insurer, an administrator of an ERISA plan, an employee welfare benefit plan, a workers’ compensation plan, CHAMPUS, medicare, and other parties that are by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
(2)

(A) The commissioner of finance and administration, the director of the bureau of TennCare, and individual managed care organizations under contract with the state are authorized to require certain information identifying persons covered by third parties for medical services. As a condition of doing business in the state or providing coverage to residents of this state, and subject to subdivision (c)(3), a third party for medical services shall, upon request from the commissioner, the director, or a managed care organization, but no less frequently than monthly, electronically provide full eligibility files that contain information to determine the period that the recipient, the recipient’s spouse, or the recipient’s dependents may be or may have been covered by the third party. The eligibility files shall also include the nature of the coverage that is or was provided by the third party, the name, address, date of birth, social security number, group number, identifying number of the plan, and effective and termination dates.
(B) No third party shall be liable to a policyholder for proper release of this information to the commissioner, the director, or managed care organization.
(C) The information shall be provided pursuant to a written request from the commissioner, the director, or managed care organization, with each third party establishing confidentiality requirements.
(3)

(A) A third party for medical services shall, consistent with 42 U.S.C. § 1396a(25)(l):

(i) Accept the state’s right of recovery and the assignment to the state of the 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 state plan or under a waiver of such plan;
(ii) In the case of a responsible third party, other than Medicare plans, that requires prior authorization for an item or service furnished to an individual eligible to receive medical assistance under this chapter, accept authorization provided by the state that the item or service is covered under the state plan or under a waiver of such plan for such individual, as if such authorization were the prior authorization made by the third party for such item or service; and
(iii) 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, a failure to present proper documentation at the point of sale that is the basis of the claim, or in the case of a responsible third party, other than Medicare plans, a failure to obtain a prior authorization for the item or service for which the claim is being submitted, if:

(a) The claim is submitted by the state within the three-year period beginning on the date the item or service was furnished; and
(b) Any action by the state to enforce its rights with respect to such claim is commenced within six (6) years of the state’s submission of such claim.
(B) Third parties shall respond to any inquiry by the state regarding a claim for payment for any health care item or service that is submitted not later than three (3) years after the date of the provision of such health care item or service.
(4) Third parties shall agree to respond to the request for payment, by providing payment on the claim, written request for additional information with which to process the claim, or written reason for denial of the claim, within sixty (60) working days after receipt of written proof of loss or claim for payment for health care services provided to a recipient of medical assistance who is covered by the entity. Notwithstanding title 56, a failure to pay or deny a claim within one hundred forty (140) days after receipt of the claim constitutes a waiver of any objection to the claim and an obligation to pay the claim.
(5) A payment made by a third party to the bureau or managed care organization under contract with the state shall be considered final thirty (30) months after payment is made. After that date, the amount of the payment is not subject to adjustment.
(6) A third party shall treat a managed care organization as the bureau, for the purposes of providing the managed care organization with access to third-party eligibility and claims data authorized under subdivision (c)(2); complying with the assignment to the managed care organization of a TennCare beneficiary’s right to payment; and refraining from denying reimbursement to the managed care organization, for a claim in which both of the following apply:

(A) The beneficiary who is the subject of the claim received a medical item or service through a managed care organization that has entered into a contract with the bureau; and
(B) The bureau has delegated third party responsibilities to the managed care organization.
(d)

(1) To the extent necessary to reimburse the department for expenditures for its costs for services provided for any child eligible for medical services under Title XIX of the federal Social Security Act, the department shall have a right of action against, and shall be permitted to garnish the wages, salary, or other employment income of, any person who:

(A) Is required by a court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under Title XIX of the federal Social Security Act;
(B) Has received payment from a third party for the costs of such services provided to such child; and
(C) Has not used such payments from the third party to reimburse, as appropriate, either the other parent or guardian of such child or the provider of such services.
(2) The claims by the department for the costs of such services shall be subordinate to any claims for current or past-due child support.
(e) The state’s right of action under this section shall be authorized as part of the contractual functions of the individual managed care organization or organizations that incurred the medical expenses on behalf of a TennCare recipient where the TennCare program deems appropriate. The bureau of TennCare shall maintain an easily accessible and clearly identified internet web page, updated at least bi-annually, that identifies the individual managed care organization or organizations having authorization to pursue the state’s right of action under this section and such internet web page, at the minimum, shall provide the appropriate manner, method and form for contacting the managed care organization or organizations. The form made accessible through such internet web page shall be consistent with the requirements of subsection (f).
(f) Before the entry of the judgment or settlement in a personal injury case, the plaintiff‘s attorney shall notify and contact in writing by facsimile or certified mail return receipt requested any entity acting pursuant to and identified in accordance with subsection (e), in order to determine if the state or managed care organization or organizations have a subrogation interest. Notice by the plaintiff’s attorney, at the minimum, shall provide the following information: the full name of the plaintiff’s client; the client’s date of birth; the client’s social security number, if known; the client’s TennCare or managed care organization identification number; and the date the client’s claim arose. Notice by the plaintiff’s attorney shall be consistent with the foregoing in order to be considered valid. Within sixty (60) days of receipt of the above-referenced notice, the entities having a subrogation interest shall respond to the plaintiff’s attorney in writing via facsimile or certified mail return receipt requested with either the amount of the subrogation interest or advise the plaintiff’s attorney that additional time is necessary in order to determine the amount of the subrogation interest, but in no event shall a response containing the amount of the subrogation interest exceed one hundred twenty (120) days. The plaintiff’s attorney shall then inform the court regarding the results of such attorney’s notice, if any. Should no specific number be claimed within the period specified herein, the subrogation shall be extinguished and disbursements may be made without recourse upon the plaintiff or the plaintiff’s attorney. If the plaintiff’s attorney received a timely response from the entities acting pursuant to subsection (e), but the amount of the subrogation interest remains in disagreement, then the trial judge may hold a hearing in accordance with subsection (i). After trial and at the time of the entry of the judgment or settlement in a case in which the state or any entity acting pursuant to subsection (e) has a subrogation interest under this section, it is the responsibility of the trial judge to calculate the amount of the subrogation interest and incorporate the court’s findings concerning the subrogation interest in the final judgment or settlement. The gross amount of the subrogation interest shall be based upon the findings of the jury concerning medical expenses and evidence introduced after the trial about the total sum of moneys paid by the state or any entity acting pursuant to subsection (e) for medical expenses for injuries arising from the incident that is the basis of the action. The gross amount of the subrogation interest shall be reduced by one (1) or more of the following factors, as applicable:

(1) To the extent that the plaintiff is partially at fault in the incident giving rise to the litigation, the subrogation interest is reduced by the percentage of fault assessed against the plaintiff;
(2) To the extent that the finder of fact allocated fault to a person who was immune from suit, the subrogation interest is reduced by the percentage of fault assessed against the immune person;
(3) To the extent that the finder of fact allocates fault to a governmental entity that has its liability limited under state law and the fault of the entity, when multiplied by the total dollar value of the damages found by the finder of fact, exceeds the amount of judgment that can be awarded against the entity, the subrogation interest is reduced proportionately by a percentage derived by dividing the uncollectable portion of the judgment against the governmental entity by the total damages awarded; or
(4) To the extent that the finder of fact allocated fault to a person that the plaintiff did not sue, the subrogation interest is reduced by the percentage of fault assessed against the nonparty.
(g) After these calculations are performed, the judge should further reduce the subrogation interest pro rata by the amount of reasonable attorneys’ fees and litigation costs incurred by the plaintiff in obtaining the recovery as required in former subsection (c) [repealed].
(h) The amount determined after performance of the calculations in subsections (f) and (g) is the net subrogation interest. If the plaintiff or plaintiff’s attorney collects the judgment, each has the obligation to promptly remit the net subrogation interest, and attorneys’ fees and costs to any counsel employed by the state or its assignee, as required by the final judgment. In the event that the plaintiff and such plaintiff’s attorney collect only a portion of the final judgment, each has the obligation to promptly remit a pro rata share of the net subrogation interest, and attorneys’ fees and costs to any counsel employed by the state or its assignee, as required by the final judgment. In the event that plaintiff or plaintiff’s attorney later collect additional moneys against the judgment, there is a continuing obligation on both of them to remit a pro rata share of the moneys collected as required by the final judgment.
(i) In the event that the case between the plaintiff and the defendant is settled before trial but after a lawsuit is filed and the parties and the state or its assignee are unable to reach an agreement on the amount of the subrogation interest, the trial judge shall hold a hearing to determine the gross and net subrogation interests, taking into account the criteria listed in subsections (f) and (g) and the likelihood of collecting any judgment against parties determined to be at fault. Any aggrieved party may appeal the court’s decision.
(j) It is the intention of the general assembly that subsections (f) through (i) be used in lieu of application of the “made whole” doctrine for any recovery authorized under this section. Subsections (f) through (i), inclusive, shall also apply to cases that have been settled when no lawsuit has been filed.
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