AN ACT
RELATING TO HEALTH CARE FOR INDIGENTS; REVISING
REIMBURSEMENT CRITERIA; AMENDING SECTIONS OF THE NMSA 1978.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. Section 27-5-3 NMSA 1978 (being Laws 1965,
Chapter 234, Section 3, as amended) is amended to read:
"27-5-3. PUBLIC ASSISTANCE PROVISIONS.--
A. A hospital shall not be paid from the fund
under the Indigent Hospital and County Health Care Act for costs of an indigent
patient for services that have been determined by the department to be eligible
for medicaid reimbursement. However,
nothing in the Indigent Hospital and County Health Care Act shall be construed
to prevent the board from transferring money from the fund to the sole
community provider fund or the county-supported medicaid fund for support of
the state medicaid program.
B. No action for collection of claims under the
Indigent Hospital and County Health Care Act shall be allowed against an
indigent patient who is medicaid eligible for medicaid covered services, nor
shall action be allowed against the person who is legally responsible for the
care of the indigent patient during the time that person is medicaid
eligible."
Section 2. Section 27-5-4 NMSA 1978 (being Laws 1965,
Chapter 234, Section 4, as amended by Laws 2001, Chapter 30, Section 1, Laws
2001, Chapter 272, Section 1 and also by Laws 2001, Chapter 280, Section 1) is
amended to read:
"27-5-4. DEFINITIONS.--As used in the Indigent
Hospital and County Health Care Act:
A. "ambulance provider" or
"ambulance service" means a specialized carrier based within the
state authorized under provisions and subject to limitations as provided in
individual carrier certificates issued by the public regulation commission to
transport persons alive, dead or dying en route by means of ambulance
service. The rates and charges
established by public regulation commission tariff shall govern as to allowable
cost. Also included are air ambulance
services approved by the board. The air
ambulance service charges shall be filed and approved pursuant to Subsection D
of Section 27‑5‑6 NMSA 1978 and Section 27-5-11 NMSA 1978;
B. "board" means a county indigent
hospital and county health care board;
C. "indigent patient" means a person to
whom an ambulance service, a hospital or a health care provider has provided
medical care, ambulance transportation or health care services and who can
normally support himself and his dependents on present income and liquid assets
available to him but, taking into consideration this income and those assets
and his requirement for other necessities of life for himself and his
dependents, is unable to pay the cost of the ambulance transportation or
medical care administered or both. If
provided by resolution of a board, it shall not include any person whose annual
income together with his spouse's annual income totals an amount that is fifty
percent greater than the per capita personal income for New Mexico as shown for
the most recent year available in the survey of current business published by
the United States department of commerce.
Every board that has a balance remaining in the fund at the end of a
given fiscal year shall consider and may adopt at the first meeting of the
succeeding fiscal year a resolution increasing the standard for indigency. The term "indigent patient"
includes a minor who has received ambulance transportation or medical care or
both and whose parent or the person having custody of that minor would qualify
as an indigent patient if transported by ambulance, admitted to a hospital for
care or treated by a health care provider;
D. "hospital" means a general or
limited hospital licensed by the department of health, whether nonprofit or
owned by a political subdivision, and may include by resolution of a board the
following health facilities if licensed or, in the case of out-of-state
hospitals, approved, by the department of health:
(1) for-profit hospitals;
(2) state-owned hospitals; or
(3) licensed out-of-state hospitals where
treatment provided is necessary for the proper care of an indigent patient when
that care is not available in an in-state hospital;
E. "cost" means all allowable costs of
providing health care services, to the extent determined by resolution of a
board, for an indigent patient.
Allowable costs shall be based on medicaid fee-for-service reimbursement
rates for hospitals, licensed medical doctors and osteopathic physicians;
F. "fund" means a county indigent
hospital claims fund;
G. "medicaid eligible" means a person
who is eligible for medical assistance from the department;
H. "county" means a county except a
class A county with a county hospital operated and maintained pursuant to a
lease with a state educational institution named in Article 12, Section 11 of
the constitution of New Mexico;
I. "department" means the human
services department;
J. "sole community provider hospital"
means:
(1) a hospital that is a sole community provider
hospital under the provisions of the federal medicare guidelines; or
(2) an acute care general hospital licensed by
the department of health that is qualified, pursuant to rules adopted by the
state agency primarily responsible for the medicaid program, to receive
distributions from the sole community provider fund;
K. "drug rehabilitation center" means
an agency of local government, a state agency, a private nonprofit entity or
combination thereof that operates drug abuse rehabilitation programs that meet
the standards and requirements set by the department of health;
L. "alcohol rehabilitation center"
means an agency of local government, a state agency, a private nonprofit entity
or combination thereof that operates alcohol abuse rehabilitation programs that
meet the standards set by the department of health;
M. "mental health center" means a
not-for-profit center that provides outpatient mental health services that meet
the standards set by the department of health;
N. "health care provider" means:
(1) a nursing home;
(2) an in-state home health agency;
(3) an in-state licensed hospice;
(4) a community-based health program operated by
a political subdivision of the state or other nonprofit health organization
that provides prenatal care delivered by New Mexico licensed, certified or
registered health care practitioners;
(5) a community-based health program operated by
a political subdivision of the state or other nonprofit health care
organization that provides primary care delivered by New Mexico licensed,
certified or registered health care practitioners;
(6) a drug rehabilitation center;
(7) an alcohol rehabilitation center;
(8) a mental health center; or
(9) a licensed medical doctor, osteopathic
physician, dentist, optometrist or expanded practice nurse when providing
emergency services, as determined by the board, in a hospital to an indigent
patient;
O. "health care services" means
treatment and services designed to promote improved health in the county
indigent population, including primary care, prenatal care, dental care,
provision of prescription drugs, preventive care or health outreach services,
to the extent determined by resolution of the board;
P. "planning" means the development of
a countywide or multicounty health plan to improve and fund health services in
the county based on the county's needs assessment and inventory of existing
services and resources and that demonstrates coordination between the county
and state and local health planning efforts; and
Q. "commission" means the New Mexico
health policy
commission."
Section 3. Section 27-5-6 NMSA 1978 (being Laws 1965,
Chapter 234, Section 6, as amended) is amended to read:
"27-5-6. POWERS AND DUTIES OF THE BOARD.--The board:
A. shall administer claims pursuant to the
provisions of the Indigent Hospital and County Health Care Act;
B. shall prepare and submit a budget to the
board of county commissioners for the amount needed to defray claims made upon
the fund and to pay costs of administration of the Indigent Hospital and County
Health Care Act and costs of development of a countywide or multicounty health
plan. The combined costs of administration
and planning shall not exceed the following percentages of revenues based on
the previous fiscal year revenues for a fund that has existed for at least one
fiscal year or based on projected revenues for the year being budgeted for a
fund that has existed for less than one fiscal year. The percentage of the revenues in the fund
that may be used for such combined administrative and planning costs is equal
to the sum of the following:
(1) ten percent of the amount of the revenues in
the fund not over five hundred thousand dollars ($500,000);
(2) eight percent of the amount of the revenues
in the fund over five hundred thousand dollars ($500,000) but not over one
million dollars ($1,000,000); and
(3) four and one-half percent of the amount of
the revenues in the fund over one million dollars ($1,000,000);
C. shall make rules necessary to carry out the
provisions of the Indigent Hospital and County Health Care Act; provided that
the standards for eligibility and allowable costs for county indigent patients
shall be no more restrictive than the standards for eligibility and allowable
costs prior to December 31, 1992;
D. shall set criteria and cost limitations for
medical care furnished by licensed out-of-state hospitals, ambulance services
or health care providers;
E. shall cooperate with appropriate state
agencies to use available funds efficiently and to make health care more
available;
F. shall cooperate with the department in making
an investigation to determine the validity of claims made upon the fund for an
indigent patient;
G. may accept contributions or other county
revenues, which shall be deposited in the fund;
H. may hire personnel to carry out the
provisions of the Indigent Hospital and County Health Care Act;
I. shall review all claims presented by a
hospital, ambulance service or health care provider to determine compliance
with the rules adopted by the board or with the provisions of the Indigent
Hospital and County Health Care Act; determine whether the patient for whom the
claim is made is an indigent patient; and determine the allowable medical,
ambulance service or health care services costs; provided that the burden of
proof of any claim shall be upon the hospital, ambulance service or health care
provider;
J. shall state in writing the reason for
rejecting or disapproving any claim and shall notify the submitting hospital,
ambulance service or health care provider of the decision within sixty days
after eligibility for claim payment has been determined;
K. shall pay all claims that are not matched
with federal funds under the state medicaid program and that have been approved
by the board from the fund and shall make payment within thirty days after
approval of a claim by the board;
L. shall determine by county ordinance the types
of health care providers that will be eligible to submit claims under the
Indigent Hospital and County Health Care Act;
M. shall review, verify and approve all medicaid
sole community provider hospital payment requests in accordance with rules
adopted by the board prior to their submittal by the hospital to the department
for payment but no later than January 1 of each year;
N. shall transfer to the state by the last day
of March, June, September and December of each year an amount equal to
one-fourth of the county's payment for support of sole community provider
payments as calculated by the department for that county for the current fiscal
year. This money shall be deposited in
the sole community provider fund;
O. shall, in carrying out the provisions of the
Indigent Hospital and County Health Care Act, comply with the standards of the
federal Health Insurance Portability and Accountability Act of 1996;
P. may provide for the transfer of money from
the fund to the county-supported medicaid fund to meet the requirements of the
Statewide Health Care Act; and
Q. may contract with ambulance providers,
hospitals or health care providers for the provision of health care services."
Section 4. Section 27-5-11 NMSA 1978 (being Laws 1965,
Chapter 234, Section 12, as amended) is amended to read:
"27-5-11. HOSPITALS AND AMBULANCE SERVICES--HEALTH CARE
PROVIDERS--REQUIRED TO FILE DATA--SOLE COMMUNITY PROVIDER HOSPITAL DUTIES.--
A. An ambulance service, hospital or health care
provider in New Mexico or licensed out-of-state hospital, prior to the filing
of a claim with the board, shall have placed on file with the board:
(1) current data, statistics, schedules and
information deemed necessary by the board to determine the cost for all
patients in that hospital or cared for by that health care provider or tariff
rates or charges of an ambulance service;
(2) proof that the hospital, ambulance service or
health care provider is licensed under the laws of this state or the state in
which the hospital operates; and
(3) other information or data deemed necessary by
the board.
B. A sole community provider hospital requesting
or receiving medicaid sole community provider hospital payments shall:
(1) accept indigent patients and request
reimbursement for those patients through the appropriate county indigent
fund. The responsible county shall
approve requests meeting its eligibility standards and notify the hospital of
such approval;
(2) confirm the amount of payment authorized by
each county for indigent patients, to that county for the previous fiscal year,
by September 30 of each calendar year;
(3) negotiate with each county the amount of
indigent hospital payments anticipated for the following fiscal year by
December 31 of each year; and
(4) provide to the department prior to January 15
of each year the amount of the authorized indigent hospital payments
anticipated for the following fiscal year after an agreement has been reached
on the amount with each responsible county and such other related information
as the department may request."
Section 5. Section 27-5-12.2 NMSA 1978 (being Laws 1993,
Chapter 321, Section 15) is amended to read:
"27-5-12.2. DUTIES OF THE COUNTY--SOLE COMMUNITY PROVIDER
HOSPITAL PAYMENTS.--A county that authorizes payment for services to a sole
community provider hospital shall:
A. determine eligibility for benefits and
determine an amount payable on each claim for services to indigent patients
from sole community provider hospitals;
B. notify the sole community provider hospital
of its decision on each request for payment while not actually reimbursing the
hospital for the services that are reimbursed with federal funds under the
state medicaid program;
C. confirm the amount of the sole community
provider hospital payments authorized for each hospital for the past fiscal
year by September 30 of the current fiscal year based on a report prepared by
the hospital using a format jointly prescribed by the counties and hospitals
that provides aggregate data, including the number of indigent patients served
and the total cost of uncompensated care provided by the hospital;
D. negotiate agreements with each sole community
provider hospital providing services for county residents on the anticipated
amount of the payments for the following fiscal year; provided that the
agreements shall be in compliance with federal regulations regarding
intergovernmental transfers and provider contributions and shall not include provisions
for reimbursements to counties of matching and sole community provider fund
allocations; and
E. provide the department by January 15 of each
year with the budgeted amount of sole community provider
hospital payments, by hospital,
for the following fiscal
year."