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. Section Eligibility and Enrollment Systems5(a) of the DRA amended section 1902(a)(25)(A) of the Act to clarify that the "third parties" subject to the provisions of 1902(a)(25) include: (1) selfinsured plans, (2) pharmacy benefits managers (PBM), and (3) other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service, including workers compensation, automobile insurance, and liability insurance plans. The DRA also replaced reference to "a health maintenance organization" with "a managed care organization" (MCO) in identifying the types of third parties to which the provisions of section 1902(a) (25) apply.
Section 1902(a) (25) (G) of the Act prohibits health insurers from taking an individual's Medicaid status into account in enrollment or payment decisions.
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