PRIA, Government Policy, Made Personal

Summary

Allows the United States, an Indian tribe, or a tribal organization to get back the cost of health care they paid from insurance companies, HMOs, employer benefit plans, people who caused the injury, or other responsible third parties (including local governments). They can recover the reasonable bills they charged, or if higher, the biggest amount the third party would pay for the same care from non-government providers. Recovery is allowed only to the same extent that the patient or a private provider could get money for those same costs if the care had been given by a non-government provider and the patient had paid. There are limits and rules. Recovery from a State is allowed only when the injury is covered by workers’ compensation or a no-fault auto plan. No State law or contract made or renewed after November 23, 1988, can stop this right. The federal government, tribes, or tribal organizations may join or start lawsuits to collect and must try to notify the patient when they start a separate suit. For care given on or after March 23, 2010, tribes may recover from tortfeasors under the Federal Medical Care Recovery Act, and that recovery is separate from the patient’s own claims. The United States cannot recover from a tribe-funded self-insurance plan unless the tribe’s governing body gives written permission for a period of no more than 1 year (which can be revoked). A winning party gets reasonable lawyer fees and costs. Plans cannot deny claims based on claim format if they follow Medicare claim rules. Urban Indian organizations are covered the same way. Time limits in 28 U.S.C. 2415 apply, and this section does not cut off any other recovery rights.

Title 25, §1621e

Indians, Source: USLM XML via OLRC

(a)Right of recovery

Except as provided in subsection (f), the United States, an Indian tribe, or tribal organization shall have the right to recover from an insurance company, health maintenance organization, employee benefit plan, third-party tortfeasor, or any other responsible or liable third party (including a political subdivision or local governmental entity of a State) the reasonable charges billed by the Secretary, an Indian tribe, or tribal organization in providing health services through the Service, an Indian tribe, or tribal organization, or, if higher, the highest amount the third party would pay for care and services furnished by providers other than governmental entities, to any individual to the same extent that such individual, or any nongovernmental provider of such services, would be eligible to receive damages, reimbursement, or indemnification for such charges or expenses if—

(1)such services had been provided by a nongovernmental provider; and

(2)such individual had been required to pay such charges or expenses and did pay such charges or expenses.

(b)Limitations on recoveries from States

Subsection (a) shall provide a right of recovery against any State, only if the injury, illness, or disability for which health services were provided is covered under—

(1)workers’ compensation laws; or

(2)a no-fault automobile accident insurance plan or program.

(c)Nonapplicability of other laws

No law of any State, or of any political subdivision of a State and no provision of any contract, insurance or health maintenance organization policy, employee benefit plan, self-insurance plan, managed care plan, or other health care plan or program entered into or renewed after November 23, 1988, shall prevent or hinder the right of recovery of the United States, an Indian tribe, or tribal organization under subsection (a).

(d)No effect on private rights of action

No action taken by the United States, an Indian tribe, or tribal organization to enforce the right of recovery provided under this section shall operate to deny to the injured person the recovery for that portion of the person’s damage not covered hereunder.

(e)Enforcement

(1)In general

The United States, an Indian tribe, or tribal organization may enforce the right of recovery provided under subsection (a) by—

(A)intervening or joining in any civil action or proceeding brought—

(i)by the individual for whom health services were provided by the Secretary, an Indian tribe, or tribal organization; or

(ii)by any representative or heirs of such individual, or

(B)instituting a separate civil action, including a civil action for injunctive relief and other relief and including, with respect to a political subdivision or local governmental entity of a State, such an action against an official thereof.

(2)Notice

All reasonable efforts shall be made to provide notice of action instituted under paragraph (1)(B) to the individual to whom health services were provided, either before or during the pendency of such action.

(3)Recovery from tortfeasors

(A)In general

In any case in which an Indian tribe or tribal organization that is authorized or required under a compact or contract issued pursuant to the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) to furnish or pay for health services to a person who is injured or suffers a disease on or after March 23, 2010, under circumstances that establish grounds for a claim of liability against the tortfeasor with respect to the injury or disease, the Indian tribe or tribal organization shall have a right to recover from the tortfeasor (or an insurer of the tortfeasor) the reasonable value of the health services so furnished, paid for, or to be paid for, in accordance with the Federal Medical Care Recovery Act (42 U.S.C. 2651 et seq.), to the same extent and under the same circumstances as the United States may recover under that Act.

(B)Treatment

The right of an Indian tribe or tribal organization to recover under subparagraph (A) shall be independent of the rights of the injured or diseased person served by the Indian tribe or tribal organization.

(f)Limitation

Absent specific written authorization by the governing body of an Indian tribe for the period of such authorization (which may not be for a period of more than 1 year and which may be revoked at any time upon written notice by the governing body to the Service), the United States shall not have a right of recovery under this section if the injury, illness, or disability for which health services were provided is covered under a self-insurance plan funded by an Indian tribe, tribal organization, or urban Indian organization. Where such authorization is provided, the Service may receive and expend such amounts for the provision of additional health services consistent with such authorization.

(g)Costs and attorney’s fees

In any action brought to enforce the provisions of this section, a prevailing plaintiff shall be awarded its reasonable attorney’s fees and costs of litigation.

(h)Nonapplicability of claims filing requirements

An insurance company, health maintenance organization, self-insurance plan, managed care plan, or other health care plan or program (under the Social Security Act [42 U.S.C. 301 et seq.] or otherwise) may not deny a claim for benefits submitted by the Service or by an Indian tribe or tribal organization based on the format in which the claim is submitted if such format complies with the format required for submission of claims under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] or recognized under section 1175 of such Act [42 U.S.C. 1320d–4].

(i)Application to urban Indian organizations

The previous provisions of this section shall apply to urban Indian organizations with respect to populations served by such Organizations in the same manner they apply to Indian tribes and tribal organizations with respect to populations served by such Indian tribes and tribal organizations.

(j)Statute of limitations

The provisions of section 2415 of title 28 shall apply to all actions commenced under this section, and the references therein to the United States are deemed to include Indian tribes, tribal organizations, and urban Indian organizations.

(k)Savings

Nothing in this section shall be construed to limit any right of recovery available to the United States, an Indian tribe, or tribal organization under the provisions of any applicable, Federal, State, or tribal law, including medical lien laws.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), referred to in subsec. (e)(3)(A), is Pub. L. 93–638, Jan. 4, 1975, 88 Stat. 2203, which was classified principally to subchapter II (§ 450 et seq.) of chapter 14 of this title prior to editorial reclassification as chapter 46 (§ 5301 et seq.) of this title. For complete classification of this Act to the Code, see

Short Title

note set out under section 5301 of this title and Tables. The Federal Medical Care Recovery Act, referred to in subsec. (e)(3)(A), probably means Pub. L. 87–693, Sept. 25, 1962, 76 Stat. 593, which is classified generally to chapter 32 (§ 2651 et seq.) of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see Tables. The Social Security Act, referred to in subsec. (h), is act Aug. 14, 1935, ch. 531, 49 Stat. 620, which is classified generally to chapter 7 (§ 301 et seq.) of Title 42, The Public Health and Welfare. Title XVIII of the Act is classified generally to subchapter XVIII (§ 1395 et seq.) of chapter 7 of Title 42. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. Codification Amendment by Pub. L. 111–148 is based on section 125 of title I of S. 1790, One Hundred Eleventh Congress, as reported by the Committee on Indian Affairs of the Senate in Dec. 2009, which was enacted into law by section 10221(a) of Pub. L. 111–148.

Amendments

2010—Pub. L. 111–148 amended section generally. Prior to amendment, section related to right of recovery of costs of health services by the United States, an Indian tribe, or a tribal organization from certain third parties. 1992—Subsec. (a). Pub. L. 102–573, § 209(b)(1), substituted “Except as provided in subsection (f) of this section, the” for “The”. Pub. L. 102–573, § 209(a)(1)–(3), inserted “, an Indian tribe, or a tribal organization” after “United States”, after “Service”, and after “Secretary”. Subsec. (b). Pub. L. 102–573, § 209(a)(4), struck out “, or any political subdivision of a State,” after “against any State”. Subsecs. (c), (d). Pub. L. 102–573, § 209(a)(1), inserted “, an Indian tribe, or a tribal organization” after “United States”. Subsec. (e). Pub. L. 102–573, § 209(a)(1), (3), inserted “, an Indian tribe, or a tribal organization” after “United States” in two places and after “Secretary”. Subsec. (f). Pub. L. 102–573, § 209(b)(2), added subsec. (f).

§1621e Reimbursement From Certain Third Parties of Costs of Health Services