0001| HOUSE BILL 287 | 0002| 43RD LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION, 1998 | 0003| INTRODUCED BY | 0004| TERRY T. MARQUARDT | 0005| | 0006| | 0007| | 0008| FOR THE HEALTH AND WELFARE REFORM COMMITTEE | 0009| | 0010| AN ACT | 0011| RELATING TO PUBLIC ASSISTANCE; PROVIDING FOR REVIEW AND | 0012| REGULATION OF MEDICAID PROVIDERS; PROVIDING ADMINISTRATIVE | 0013| PENALTIES. | 0014| | 0015| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0016| Section 1. SHORT TITLE.--This act may be cited as the | 0017| "Medicaid Provider Act". | 0018| Section 2. DEFINITIONS.--As used in the Medicaid | 0019| Provider Act: | 0020| A. "department" means the human services | 0021| department; | 0022| B. "managed care organization" means a person | 0023| eligible to enter into risk-based prepaid capitation | 0024| agreements with the department to provide health care and | 0025| related services; | - 1 - 0001| C. "medicaid" means the medical assistance program | 0002| established pursuant to Title 19 of the federal Social | 0003| Security Act and regulations issued pursuant to that act; | 0004| D. "medicaid provider" means a person, including a | 0005| managed care organization, operating under contract with the | 0006| department to provide medicaid-related services to recipients; | 0007| E. "person" means an individual or other legal | 0008| entity; | 0009| F. "recipient" means a person whom the department | 0010| has determined to be eligible to receive medicaid-related | 0011| services; | 0012| G. "secretary" means the secretary of human | 0013| services; and | 0014| H. "subcontractor" means a person who contracts | 0015| with a medicaid provider to provide medicaid-related services | 0016| to recipients. | 0017| Section 3. REVIEW OF MEDICAID PROVIDERS--CONTRACT | 0018| REMEDIES--PENALTIES.-- | 0019| A. The secretary may review the operations of a | 0020| medicaid provider, and shall have the right and be afforded | 0021| full access to the medicaid provider's records, personnel and | 0022| facilities for that purpose at all times. | 0023| B. The secretary may, consistent with the | 0024| provisions of the Medicaid Provider Act and rules issued | 0025| pursuant to that act, carry out an administrative | - 2 - 0001| investigation or conduct administrative proceedings to | 0002| determine whether a medicaid provider has: | 0003| (1) operated in a manner that materially | 0004| violates its organizational documents; | 0005| (2) materially breached its obligation to | 0006| furnish medicaid-related services to recipients, or any other | 0007| duty specified in its contract with the department; | 0008| (3) violated any provision of the Public | 0009| Assistance Act or the Medicaid Provider Act or any rules | 0010| issued pursuant to those acts; | 0011| (4) made any false statement with respect to | 0012| any report or statement required by the Public Assistance Act, | 0013| or the Medicaid Provider Act, rules issued pursuant to either | 0014| of those acts or a contract with the department; | 0015| (5) advertised or marketed, or attempted to | 0016| advertise or market, its services to recipients in a manner as | 0017| to misrepresent its services or capacity for services, or | 0018| engaged in any deceptive, misleading or unfair practice with | 0019| respect to advertising or marketing; | 0020| (6) hindered or prevented the secretary from | 0021| performing any duty imposed by the Public Assistance Act, the | 0022| Human Services Department Act or the Medicaid Provider Act or | 0023| any rules issued pursuant to those acts; or | 0024| (7) fraudulently procured or attempted to | 0025| procure any benefit from medicaid. | - 3 - 0001| C. After affording a medicaid provider written | 0002| notice of hearing not less than ten days before the hearing | 0003| date and an opportunity to be heard, and upon making | 0004| appropriate administrative findings, the secretary may take | 0005| any or any combination of the following actions against the | 0006| provider: | 0007| (1) impose an administrative penalty of not | 0008| more than ten thousand dollars ($10,000) for engaging in any | 0009| practice described in Paragraphs (1) through (7) of Subsection | 0010| B of this section; provided that each occurrence of each | 0011| practice shall constitute a separate offense; | 0012| (2) issue an administrative order requiring | 0013| the provider to: | 0014| (a) cease or modify any specified | 0015| conduct or practices engaged in by it or its employees, | 0016| subcontractors or agents; | 0017| (b) fulfill its contractual obligations | 0018| in the manner specified in the order; | 0019| (c) provide any service that has been | 0020| denied; | 0021| (d) take steps to provide or arrange | 0022| for any service that it has agreed or is otherwise obligated | 0023| to make available; or | 0024| (e) enter into and abide by the terms | 0025| of a binding or nonbinding arbitration proceeding, if agreed | - 4 - 0001| to by any opposing party, including the secretary; or | 0002| (3) suspend or revoke the contract between | 0003| the provider and the department, in which case the provider: | 0004| (a) during the period of any | 0005| suspension, shall not enroll or treat additional recipients, | 0006| except newborn children or other newly acquired dependents of | 0007| existing enrolled recipients, and shall not engage in any | 0008| advertising, marketing or solicitation for enrollment or | 0009| treatment of additional recipients; and | 0010| (b) immediately following the effective | 0011| date of any revocation, shall proceed expeditiously to wind up | 0012| its affairs under its contract with the department, and shall | 0013| not conduct further business except as may be essential to the | 0014| orderly conclusion of its medicaid-related affairs and | 0015| transfer to other medicaid providers of its recipients and | 0016| their records; provided that the secretary may, by written | 0017| order, permit further operation of the medicaid provider's | 0018| medicaid-related services as the secretary finds to be in the | 0019| best interest of recipients, to the end that they will be | 0020| afforded the greatest practical opportunity to obtain | 0021| continuous medicaid-related coverage. | 0022| Section 4. RETENTION AND PRODUCTION OF RECORDS.-- | 0023| A. Medicaid providers and their subcontractors | 0024| shall retain, for a period of at least five years from the | 0025| date of creation, all medical and business records relating | - 5 - 0001| to: | 0002| (1) treatment or care of any recipient; | 0003| (2) services or goods provided to any | 0004| recipient; | 0005| (3) amounts paid by medicaid or the medicaid | 0006| provider on behalf of any recipient; and | 0007| (4) records required by medicaid or used for | 0008| its administration. | 0009| B. Upon written request by medicaid or the | 0010| department to a medicaid provider or any subcontractor for | 0011| copies or inspection of records pursuant to the Public | 0012| Assistance Act, the medicaid provider or subcontractor shall | 0013| provide the copies or permit the inspection, as applicable, | 0014| within five business days after the date of the request. | 0015| C. Failure to provide copies or to permit | 0016| inspection of records requested pursuant to this section shall | 0017| constitute a violation of the Medicaid Provider Act within the | 0018| meaning of Paragraph (3) of Subsection B of Section 3 of that | 0019| act. | 0020| Section 5. RULES.--The secretary shall adopt and | 0021| promulgate rules appropriate to administer, carry out and | 0022| enforce the provisions of the Medicaid Provider Act. | 0023| |