The correction was published in the Federal Register on December 14, 2012. In it CMS clarified that states must reimburse providers the lower or the provider’s charge or the applicable Medicare rate.

The Affordable Care Act envisions and directs that there be a coordinated system for making eligibility determinations between Medicaid, CHIP and the Exchange to avoid gaps in coverage as individuals' income fluctuates. Smooth eligibility transitions will not necessarily prevent people from having to select a new plan and/or provider when they lose eligibility for one insurance affordability program and gain eligibility for another.

State laws determine what information is required of the health plans. A health plan's disclosure and use of information that is required to be submitted under state law - such as, information from insurer eligibility files sufficient to determine during what period any individual may be, or have been, covered by a health insurer and the nature of the coverage that is or was provided by the health insurer — is consistent with the HIPAA privacy provisions.

State Medicaid agencies and their business associates can use the data obtained pursuant to the process established under section 1902(a)(25)(I) of the Social Security Act and applicable state laws, as permitted or required by law. This should include the coordination of payments for services covered under the Medicaid state plan and actions to ensure that correct payment amounts are made under the Medicaid program and that mistaken payments are recovered.

The Deficit Reduction Act of 2005 (DRA) requires states to have laws in effect that require health insurers to honor claims submitted by the Medicaid agency within three years of the date of service.

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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.

Section Eligibility and Enrollment Systems5(b) of the Deficit Reduction Act of 2005 (DRA) created a new subparagraph (I) in section 1902(a)(25) of the Social Security Act (the Act), that requires states to establish laws that require the production of the information necessary for each state Medicaid agency to determine third party liability for services rendered to Medicaid beneficiaries.

Yes. PBMs and TPAs are considered to be ""third parties,"" as clarified in section Eligibility and Enrollment Systems5(a) of the Deficit Reduction Act of 2005 (DRA)'s amendment of section 1902(a)(25)(A) of the Social Security Act.

Section 1902(a)(25)(A) of the Act requires states to take all reasonable measures to ascertain the legal liability of "third parties" for health care items and services provided to Medicaid beneficiaries. The DRA did not change the definition of "third parties," but rather clarified the entities subject to the provisions of section 1902(a) (25) (A) and (G) of the Act.