HOUSE BILL 963
47th legislature - STATE OF NEW MEXICO - first session, 2005
INTRODUCED BY
Daniel R. Foley
AN ACT
RELATING TO MEDICAID; CREATING A CONSUMER-DRIVEN MEDICAID BENEFIT PACKAGE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. A new section of the Public Assistance Act is enacted to read:
"[NEW MATERIAL] MEDICAID--CONSUMER-DRIVEN BENEFIT PROGRAM.--
A. The department shall develop a consumer-driven, calendar-year-based benefit program for beneficiaries entitled to medicaid benefits pursuant to Title 19 or Title 21 of the federal Social Security Act. The program shall include:
(1) a benefit amount not to exceed the average cost for a medicaid beneficiary, not including beneficiaries enrolled in a medicaid waiver program, two years prior to the year in which the benefit amount is made effective; provided that the benefit amount may be adjusted for inflation, economic and geographic factors;
(2) a prorated benefit amount for a beneficiary that becomes eligible after January 1 of any year;
(3) an annual patient cost-sharing amount, applied through any combination of deductible, copayment, coinsurance or other patient cost-share, not to exceed twenty percent of the benefit amount pursuant to Paragraphs (1) and (2) of Subsection A of this section; provided, however, that the cost-sharing amount may be lower than twenty percent as determined by the department based on a sliding schedule that takes the beneficiary's household income into consideration;
(4) an eligibility card that is electronically readable and provides the beneficiary, upon enrollment, with the amount determined in Paragraph (1) or Paragraph (2) of this subsection;
(5) an exemption from the patient cost-sharing amounts, except for a nominal copayment, for preventive care services as determined by department rule;
(6) a benefit package that is equal to the benefits mandated by federal law; provided, however, that additional benefits may be provided if the department can demonstrate that the additional benefits will provide a cost-benefit to the state and that the program is and will continue to be actuarially sound with the additional benefits; and
(7) an exemption for medicaid beneficiaries that are covered under a waiver program for disabled and elderly, developmentally disabled, medically fragile or human immunodeficiency virus or acquired immunodeficiency syndrome patients.
B. The general services department shall provide administrative support similar to that provided for state employees through contracts with a third party administrator for enrollment, claims payment, customer service, provider networks, case or disease management and related activities.
C. Any balance remaining on an eligibility card at the end of a calendar year shall roll over to the next calendar year if the beneficiary remains eligible; provided, however, that the beneficiary shall not accumulate a balance greater than five times the benefit amount for the current calendar year and the eligibility card shall not contain a balance greater than two times the benefit amount for the current calendar year; and provided further that the beneficiary may access the accumulated balance upon verification of eligibility and service.
D. A beneficiary who has exhausted the current year's and any accumulated balance and has met the annual cost-sharing amount but continues to meet eligibility criteria shall continue to be enrolled in the medicaid program under a benefits-exhausted status for that year; provided that, if the patient receives services from a medicaid-participating provider, the provider shall not collect from the patient an amount greater than the medicaid-allowable amount.
E. The department may, by rule, provide for exceptions to benefit limits or cost-sharing provisions for beneficiaries that experience catastrophic illnesses or financial hardship.
F. The department shall provide educational materials, regional workshops, customer service, online information and ongoing health care consumer training that provides information on health care services, cost-sharing requirements, benefit limitations, planning, preventive care, financial implications and other health care considerations to ensure that medicaid beneficiaries make the most appropriate use of health care services and financing."
Section 2. TEMPORARY PROVISION.--By October 1, 2005, the human services department shall, for implementation of this 2005 act:
A. request a waiver from and submit a state medicaid plan to the centers for medicare and medicaid services of the federal department of health and human services;
B. provide its policy and legislative recommendations to the interim legislative health and human services committee; and
C. provide its financing and budget findings, implications and recommendations to the legislative finance committee.
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