HOUSE BILL 402
53rd legislature - STATE OF NEW MEXICO - first session, 2017
INTRODUCED BY
Elizabeth "Liz" Thomson
AN ACT
RELATING TO HEALTH COVERAGE; REGULATING REIMBURSEMENT FOR AIR AMBULANCE SERVICES BY HEALTH CARRIERS; HOLDING CONSUMERS HARMLESS FOR BALANCE BILLING FOR AIR AMBULANCE SERVICES UNDER HEALTH CARE PLAN CONTRACTS; ESTABLISHING PENALTIES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] SHORT TITLE.--This act may be cited as the "Air Ambulance Reimbursement Act"."
SECTION 2. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] DEFINITIONS.--As used in the Air Ambulance Reimbursement Act:
A. "air ambulance provider" means any government or private transportation entity designated and used or intended to be used for the transportation of sick or injured persons by air;
B. "air ambulance services" means ambulance services provided by aircraft;
C. "balance billing" means the practice of an air ambulance provider billing a covered person for the difference between the air ambulance provider's charge for air ambulance services and the amount the covered person's health benefits policy allows to be billed for those air ambulance services;
D. "claim" means a request from an air ambulance provider for payment for services;
E. "coinsurance" means the percentage of costs of a covered health care service that a covered person pays after the covered person pays the covered person's deductible;
F. "copayment" means a fixed amount a covered person pays for a health care service either before or after the deductible is paid;
G. "cost-sharing" means a copayment, coinsurance, deductible or any other form of financial obligation of a covered person other than premium or share of premium, or any combination of any of these financial obligations as defined by the terms of a health benefits policy;
H. "covered benefits" means the specific health services provided under a health benefits policy;
I. "covered person" means a policyholder, subscriber, enrollee or any individual who, as a principal or dependent under the terms of a health benefits policy, is entitled to have health care expense payments made on the individual's behalf or to the individual according to the terms of a health benefits policy;
J. "covered service" means a health care service reimbursable by a health carrier pursuant to a health benefits policy;
K. "deductible" means a fixed dollar amount that the covered person may be required to pay during the benefit period before a health carrier begins payment for covered benefits in accordance with the terms of a health benefits policy; provided that a health benefits policy may:
(1) require payment both of an individual and a family deductible or a separate deductible for specific services; and
(2) offer first-dollar items or services without requiring a covered person to meet a deductible before the health benefits policy covers the covered benefit;
L. "health benefits policy" means a policy, contract, certificate or agreement entered into, offered or issued in the state by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services. "Health benefits policy" does not include any of the following:
(1) a credit-only policy;
(2) a medicare supplement policy;
(3) a TRICARE policy, including a civilian health and medical program of the uniformed services supplement policy;
(4) a fixed indemnity policy;
(5) a dental-only policy;
(6) a vision-only policy;
(7) an automobile medical payment policy; or
(8) any other policy specified in rules of the superintendent;
M. "health carrier" means a person that has a valid certificate of authority in good standing issued pursuant to the New Mexico Insurance Code to act as an insurer, including a health insurance company, fraternal benefit society, vision plan or pre-paid dental plan, a health maintenance organization, a hospital and health service corporation, a provider service network, a nonprofit health care plan, a third party or any other entity that contracts or offers to contract, or enters into agreements to provide, deliver, arrange for, pay for or reimburse any costs of health care services or that provides, offers or administers health benefit policies and managed health benefits plans in the state;
N. "medicare" means health care coverage pursuant to Part A or Part B of Title 18 of the federal Social Security Act, as amended;
O. "nonparticipating provider" means an air ambulance services provider that is not a participating provider;
P. "participating provider" means an air ambulance provider that, under express contract with a health carrier or with its contractor or subcontractor, has agreed to provide air ambulance services to covered persons with an expectation of receiving payment directly or indirectly from the health carrier, subject to copayments, coinsurance, deductibles or other cost-sharing provisions;
Q. "prior authorization" or "pre-certification" means a pre-service determination made by a health carrier regarding a covered person's eligibility for services, medical necessity, benefit coverage, location and appropriateness of services, pursuant to the terms of a health benefits policy; and
R. "superintendent" means the superintendent of insurance or the office of superintendent of insurance."
SECTION 3. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] AIR AMBULANCE SERVICES--CAPPED REIMBURSEMENT--OVERPAYMENT.--
A. A health benefits policy that is delivered, issued for delivery or renewed in this state that covers air ambulance services shall cap reimbursement for air ambulance services at two hundred fifty percent of the rate at which medicare makes reimbursement for the same air ambulance services. This capped reimbursement amount shall include any deductible, coinsurance or copayment paid by the covered person under the terms of the covered person's health benefits policy.
B. The cap for reimbursement for air ambulance services applies to both participating and nonparticipating providers.
C. If a covered person pays an air ambulance provider more than the capped reimbursement amount, the air ambulance provider shall refund to the covered person within one hundred business days of receipt any amount paid in excess of the in-network cost-sharing amount.
D. If an air ambulance provider has not made a full refund of any amount paid in excess of the in-network cost- sharing amount to the covered person within thirty business days of receipt, the air ambulance provider shall owe the covered person the amount paid in excess plus interest. Interest shall accrue at the rate of ten percent per year beginning with the first calendar day after the thirty- business-day period."
SECTION 4. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] AIR AMBULANCE SERVICES--COVERED PERSONS--HOLD HARMLESS--CREDIT AGAINST MAXIMUM OUT-OF-POCKET COST-SHARING AMOUNT.--
A. A health carrier shall make reimbursement for air ambulance services provided to a covered person if the air ambulance provider agrees:
(1) to hold the covered person harmless for any balance billing; or
(2) not to advance to collections any charges above the capped reimbursement amount for which the air ambulance provider has billed a covered person.
B. A health carrier shall count toward a covered person's in-network deductible and maximum out-of-pocket cost-sharing amount each payment that a covered person makes to satisfy a nonparticipating provider claim subject to the Air Ambulance Reimbursement Act."
SECTION 5. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] REBATES AND INDUCEMENTS PROHIBITED.--A nonparticipating provider may not, either directly or indirectly, knowingly waive, rebate, give, pay or offer to waive, rebate, give or pay all or part of a cost-sharing amount owed by a covered person pursuant to the terms of the covered person's health benefits policy as an inducement for the covered person to seek a health care service from that nonparticipating provider."
SECTION 6. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] LIMITATIONS.--Nothing in the Air Ambulance Reimbursement Act shall be construed to prohibit a health carrier from:
A. using reasonable medical management techniques, including prior authorization or pre-certification, of air ambulance services; or
B. excluding coverage of air ambulance services under the terms of a health benefits policy."
SECTION 7. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] ENFORCEMENT.--
A. The superintendent shall ensure compliance with the provisions of the Air Ambulance Reimbursement Act. In order to ensure compliance with the provisions of that act, the superintendent may investigate potential violations of that act based upon information received from covered persons, health carriers, providers and other sources.
B. Upon satisfactory evidence that a health carrier has violated a provision of the Air Ambulance Reimbursement Act, the superintendent may, at the superintendent's discretion, pursue any one of the following courses of action:
(1) enter a cease and desist order against the health carrier;
(2) impose a civil penalty of not more than five thousand dollars ($5,000) for each action in violation of the Air Ambulance Reimbursement Act; provided that any action taken to impose a civil penalty shall comply with applicable state and federal law;
(3) impose a civil penalty of not more than ten thousand dollars ($10,000) for each action in willful violation of the Air Ambulance Reimbursement Act; or
(4) impose any other penalty or remedy, including restitution, that the superintendent deems appropriate.
C. A fine that the superintendent imposes against any individual health carrier pursuant to the Air Ambulance Reimbursement Act shall not exceed three hundred thousand dollars ($300,000) in the aggregate during a single calendar year.
D. The enforcement remedies under this section are in addition to any other remedies or penalties that may be imposed under any other applicable statute."
SECTION 8. A new section of the New Mexico Insurance Code is enacted to read:
"[NEW MATERIAL] NO PRIVATE CAUSE OF ACTION.--Nothing in the Air Ambulance Reimbursement Act shall be construed to create or imply a private cause of action for a violation of that act."
SECTION 9. SEVERABILITY.--If any part or application of the Air Ambulance Reimbursement Act is held invalid, the remainder or its application to other situations or persons shall not be affected.
SECTION 10. APPLICABILITY.--The provisions of the Air Ambulance Reimbursement Act apply to following health coverage delivered or issued for delivery in this state:
A. group health coverage governed by the provisions of the Health Care Purchasing Act;
B. individual health insurance policies, health benefits policies and certificates of insurance governed by the provisions of Chapter 59A, Article 22 NMSA 1978;
C. group and blanket health insurance policies, health benefits policies and certificates of insurance governed by the provisions of Chapter 59A, Article 23 NMSA 1978;
D. individual and group health maintenance organization plan contracts governed by the provisions of the Health Maintenance Organization Law; and
E. individual and group nonprofit health care plan contracts governed by the provisions of the Nonprofit Health Care Plan Law.
- 10 -