New Mexico 2018 Regular Session Status: To Executive

SB 2 — MEDICAID CHANGES

Last action — Pocket Veto

  1. ✓
    Introduced
  2. ✓
    In Committee
  3. ✓
    Passed Senate
  4. ✓
    Passed House
  5. 5
    To Executive
  6. 6
    Enacted

This bill died with 2018 Regular Session. It reached “To Executive” and never advanced before the session ended, so it can no longer move — a new version would have to be reintroduced in the current session.

This bill is no longer active — its legislative session has ended, so there is no live prognosis. It would have to be reintroduced in the current session to move again.

Bill Text

What changed in the latest version

672 added · 1006 removed

Plain-language change summary

The amendments to Bill SB 2 clarified the title of the act, changing it to "Medicaid Provider and Managed Care Act," and included specific definitions regarding claims for payment. This change is important because it helps ensure a better understanding of the terms and processes related to Medicaid services, aiming to protect providers and streamline the handling of payment requests. By clearly defining terms, the bill seeks to facilitate smoother operations within the Medicaid system and ensure that all parties know their rights and obligations.

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SENATE FLOOR SUBSTITUTE FOR SENATE BILL 2 53RD LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION , 2018 4 6 8 10 AN ACT RELATING TO MEDICAID;
AN ACT RELATING TO MEDICAID;
e t 17 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
9 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
w l n d 18 SECTION 1.
SECTION 1.
Section 27-11-1 NMSA 1978 (being Laws 1998, = = 19 Chapter 30, Section 1) is amended to read:
Section 27-11-1 NMSA 1978 (being Laws 1998, Chapter 30, Section 1) is amended to read:
a l i a e r 20 "27-11-1.
"27-11-1.
SHORT TITLE.--[This act ] Chapter 27, Article 11 a t m m 21 NMSA 1978 may be cited as the "Medicaid Provider and Managed d r e 22 Care Act"." c e s k 23 SECTION 2.
SHORT TITLE.--Chapter 27, Article 11 NMSA 1978 may be cited as the "Medicaid Provider and Managed Care Act"." SECTION 2.
Section 27-11-2 NMSA 1978 (being Laws 1998, e a n b 24 Chapter 30, Section 2) is amended to read:
Section 27-11-2 NMSA 1978 (being Laws 1998, Chapter 30, Section 2) is amended to read:
u [ "27-11-2.
"27-11-2.
DEFINITIONS.--As used in the Medicaid Provider .209163.8 SFl/SB 2 and Managed Care Act:
DEFINITIONS.--As used in the Medicaid Provider and Managed Care Act:
(1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor;
(1) contains substantially all the required data elements necessary for accurate adjudication of the SFL/SB 2 claim without the need for additional information from the Page 1 medicaid provider or subcontractor;
"credible" means having indicia of reliability e e 17 after the state has reviewed all allegations, facts and e e n d 18 evidence carefully and acted judiciously on a case-by-case = = l ] 19 basis;
"credible" means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis;
a l r i 20 D.
D.
"credible allegation of fraud" means an t e a t allegation that has been verified by the state from any source, m m 21 e d including fraud hotline complaints, claims data mining and r e 22 c e r c 23 provider audits;
"credible allegation of fraud" means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits;
e a n b 24 [A.] E.
E.
"department" means the human services u [ department;
"department" means the human services department;
.209163.8 - 2 - SFl/SB 2 F.
F.
[B.] G.
G.
[C.] H.
H.
"medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act;
"medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social SFL/SB 2 Page 2 Security Act and regulations issued pursuant to that act;
[D.] I.
I.
"medicaid provider" means a person [including a managed care organization, operating under contract with the department to provide] who provides medicaid- related services to recipients;
"medicaid provider" means a person who provides medicaid-related services to recipients;
"overpayment" means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid e e 17 provider or subcontractor is not entitled;
"overpayment" means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled;
e e n d 18 [E.] K.
K.
"person" means an individual or other legal = = l ] 19 entity;
"person" means an individual or other legal entity;
a l r i 20 [F.] L.
L.
"recipient" means a person whom the t e a t department has determined to be eligible to receive medicaid- m m 21 e d related services;
"recipient" means a person whom the department has determined to be eligible to receive medicaid-related services;
r e 22 c e r c 23 [G.] M.
M.
"secretary" means the secretary of human e a n b 24 services;
"secretary" means the secretary of human services;
and u [ [H.] N.
and N.
"subcontractor" means a person who .209163.8 - 3 - SFl/SB 2 contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients." SECTION 3.
"subcontractor" means a person who contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients." SECTION 3.
REVIEW OF MEDICAID [PROVIDERS ] PROVIDER OR MANAGED CARE ORGANIZATION--CONTRACT REMEDIES--PENALTIES.-- A.
REVIEW OF MEDICAID PROVIDER OR MANAGED CARE ORGANIZATION--CONTRACT REMEDIES--PENALTIES.-- A.
Consistent with the terms of any contract between the department and a medicaid provider or managed care organization, the secretary shall have the right to be afforded access to such of the medicaid provider's or managed care organization's records and personnel, as well as its subcontracts and that subcontractor's records and personnel, as may be necessary to ensure that the medicaid provider or managed care organization is complying with the terms of its contract with the department.
Consistent with the terms of any contract between the department and a medicaid provider or managed care organization, the secretary shall have the right to be afforded access to such of the medicaid provider's or managed SFL/SB 2 Page 3 care organization's records and personnel, as well as its subcontracts and that subcontractor's records and personnel, as may be necessary to ensure that the medicaid provider or managed care organization is complying with the terms of its contract with the department.
e e 17 B.
B.
Upon not less than two days' written notice to a e e n d 18 medicaid provider or managed care organization , the secretary = = l ] 19 may, consistent with the provisions of the Medicaid Provider a l r i 20 and Managed Care Act and rules issued pursuant to that act, t e a t carry out an administrative investigation or conduct m m 21 e d administrative proceedings to determine whether a medicaid r e 22 c e r c 23 provider or managed care organization has:
Upon not less than two days' written notice to a medicaid provider or managed care organization, the secretary may, consistent with the provisions of the Medicaid Provider and Managed Care Act and rules issued pursuant to that act, carry out an administrative investigation or conduct administrative proceedings to determine whether a medicaid provider or managed care organization has:
e a n b 24 (1) materially breached its obligation to u [ furnish medicaid-related services to recipients, or any other .209163.8 - 4 - SFl/SB 2 duty specified in its contract with the department;
(1) materially breached its obligation to furnish medicaid-related services to recipients, or any other duty specified in its contract with the department;
(4) intentionally or with reckless disregard advertised or marketed, or attempted to advertise or market, its services to recipients in a manner as to misrepresent its services or capacity for services, or engaged in any deceptive, misleading or unfair practice with respect to advertising or marketing;
(4) intentionally or with reckless disregard advertised or marketed, or attempted to advertise or market, SFL/SB 2 Page 4 its services to recipients in a manner as to misrepresent its services or capacity for services, or engaged in any deceptive, misleading or unfair practice with respect to advertising or marketing;
(5) hindered or prevented the secretary from e e 17 performing any duty imposed by the Public Assistance Act, the e e n d 18 Human Services Department Act or the Medicaid Provider and = = l ] 19 Managed Care Act or any rules issued pursuant to those acts;
(5) hindered or prevented the secretary from performing any duty imposed by the Public Assistance Act, the Human Services Department Act or the Medicaid Provider and Managed Care Act or any rules issued pursuant to those acts;
or a l r i 20 (6) fraudulently procured or attempted to t e a t procure any benefit from medicaid.
or (6) fraudulently procured or attempted to procure any benefit from medicaid.
m m 21 e d C.
C.
Subject to the provisions of Subsection D of r e 22 c e r c 23 this section, after affording a medicaid provider or managed e a n b 24 care organization written notice of hearing not less than ten u [ days before the hearing date and an opportunity to be heard, .209163.8 - 5 - SFl/SB 2 and upon making appropriate administrative findings, the secretary may take any or any combination of the following actions against the medicaid provider or managed care organization:
Subject to the provisions of Subsection D of this section, after affording a medicaid provider or managed care organization written notice of hearing not less than ten days before the hearing date and an opportunity to be heard, and upon making appropriate administrative findings, the secretary may take any or any combination of the following actions against the medicaid provider or managed care organization:
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(1) impose an administrative penalty of not more than five thousand dollars ($5,000) for engaging in any practice described in [Paragraphs (1) through (6) of ] Subsection B of this section;
(1) impose an administrative penalty of not more than five thousand dollars ($5,000) for engaging in any practice described in Subsection B of this section;
(2) issue an administrative order requiring the medicaid provider or managed care organization to:
(2) issue an administrative order requiring SFL/SB 2 Page 5 the medicaid provider or managed care organization to:
(b) fulfill its contractual obligations e e 17 in the manner specified in the order;
(b) fulfill its contractual obligations in the manner specified in the order;
e e n d 18 (c) provide any service that has been = = l ] 19 denied;
(c) provide any service that has been denied;
a l r i 20 (d) take steps to provide or arrange for t e a t any service that it has agreed or is otherwise obligated to m m 21 e d make available;
(d) take steps to provide or arrange for any service that it has agreed or is otherwise obligated to make available;
or r e 22 c e r c 23 (e) enter into and abide by the terms of e a n b 24 a binding or nonbinding arbitration proceeding, if agreed to by u [ any opposing party, including the secretary;
or (e) enter into and abide by the terms of a binding or nonbinding arbitration proceeding, if agreed to by any opposing party, including the secretary;
or .209163.8 - 6 - SFl/SB 2 (3) suspend or revoke the contract between the medicaid provider or managed care organization and the department pursuant to the terms of that contract.
or (3) suspend or revoke the contract between the medicaid provider or managed care organization and the department pursuant to the terms of that contract.
If a medicaid provider's or managed care organization's contract so specifies, the medicaid provider or managed care organization shall have the right to seek de novo review in district court of any decision by the secretary regarding a contractual dispute." SECTION 4.
If a medicaid provider's or managed care SFL/SB 2 Page 6 organization's contract so specifies, the medicaid provider or managed care organization shall have the right to seek de novo review in district court of any decision by the secretary regarding a contractual dispute." SECTION 4.
Section 27-11-4 NMSA 1978 (being Laws 1998, e e 17 Chapter 30, Section 4, as amended) is amended to read:
Section 27-11-4 NMSA 1978 (being Laws 1998, Chapter 30, Section 4, as amended) is amended to read:
e e n d 18 "27-11-4.
"27-11-4.
RETENTION AND PRODUCTION OF RECORDS.-- = = l ] 19 A.
RETENTION AND PRODUCTION OF RECORDS.-- A.
Medicaid providers, managed care organizations a l r i 20 and their subcontractors shall retain, for a period of at least t e a t six years from the date of creation, all medical and business m m 21 e d records that are necessary to verify the:
Medicaid providers, managed care organizations and their subcontractors shall retain, for a period of at least six years from the date of creation, all medical and business records that are necessary to verify the:
r e 22 c e r c 23 (1) treatment or care of any recipient for e a n b 24 which the medicaid provider, managed care organization or u [ subcontractor received payment from the department to provide .209163.8 - 7 - SFl/SB 2 that benefit or service;
(1) treatment or care of any recipient for which the medicaid provider, managed care organization or subcontractor received payment from the department to provide that benefit or service;
B.
SFL/SB 2 Page 7 B.
Upon written request by the department to a medicaid provider, managed care organization or any subcontractor for copies or inspection of records pursuant to the Public Assistance Act, the medicaid provider, managed care organization or subcontractor shall provide the copies or e e 17 permit the inspection, as applicable within two business days e e n d 18 after the date of the request unless the records are held by a = = l ] 19 subcontractor, agent or satellite office, in which case the a l r i 20 records shall be made available within ten business days after t e a t the date of the request.
Upon written request by the department to a medicaid provider, managed care organization or any subcontractor for copies or inspection of records pursuant to the Public Assistance Act, the medicaid provider, managed care organization or subcontractor shall provide the copies or permit the inspection, as applicable within two business days after the date of the request unless the records are held by a subcontractor, agent or satellite office, in which case the records shall be made available within ten business days after the date of the request.
m m 21 e d C.
C.
Failure to provide copies or to permit r e 22 c e r c 23 inspection of records requested pursuant to this section shall e a n b 24 constitute a violation of the Medicaid Provider and Managed u [ Care Act within the meaning of Paragraph (3) of Subsection B of .209163.8 - 8 - SFl/SB 2 Section 27-11-3 NMSA 1978." SECTION 5.
Failure to provide copies or to permit inspection of records requested pursuant to this section shall constitute a violation of the Medicaid Provider and Managed Care Act within the meaning of Paragraph (3) of Subsection B of Section 27-11-3 NMSA 1978." SECTION 5.
"[NEW MATERIAL] DETERMINATION OF OVERPAYMENTS OR CREDIBLE ALLEGATION OF FRAUD--AUDIT FINDINGS--SAMPLING--EXTRAPOLATION LIMITED--NOTICE OF RIGHT TO INFORMAL CONFERENCE AND EXPEDITED ADJUDICATORY PROCEEDING.-- A.
"DETERMINATION OF OVERPAYMENTS OR CREDIBLE ALLEGATION OF FRAUD--AUDIT FINDINGS--SAMPLING--EXTRAPOLATION LIMITED-- NOTICE OF RIGHT TO INFORMAL CONFERENCE AND EXPEDITED ADJUDICATORY PROCEEDING.-- A.
If the department contracts for the audit, the department shall contract only with an independent auditor approved by the state auditor.
If the department contracts for the audit, the department shall contract only with an independent SFL/SB 2 Page 8 auditor approved by the state auditor.
The department shall not extrapolate audit e e 17 findings unless a medicaid provider's or subcontractor's error e e n d 18 rate exceeds ten percent based upon an appropriate sampling and = = l ] 19 a representative sample of claims computed by valid statistical a l r i 20 methods in accordance with the most recently published medicare t e a t program integrity manual and using statistical software m m 21 e d approved by the United States department of health and human r e 22 c e r c 23 services.
The department shall not extrapolate audit findings unless a medicaid provider's or subcontractor's error rate exceeds ten percent based upon an appropriate sampling and a representative sample of claims computed by valid statistical methods in accordance with the most recently published medicare program integrity manual and using statistical software approved by the United States department of health and human services.
e a n b 24 C.
C.
Prior to reaching either a final determination u [ of overpayment or a credible allegation of fraud, the .209163.8 - 9 - SFl/SB 2 department shall serve the medicaid provider or subcontractor with a written preliminary finding of overpayment.
Prior to reaching either a final determination of overpayment or a credible allegation of fraud, the department shall serve the medicaid provider or subcontractor with a written preliminary finding of overpayment.
and (3) notify the medicaid provider or subcontractor that is the subject of a preliminary finding of overpayment of its right to request, within thirty calendar days of service of the preliminary finding of overpayment, an informal conference with a representative of the department who is knowledgeable about the department's preliminary finding of overpayment and with a member of the audit team, if an audit formed the basis of any alleged overpayment, to informally e e 17 address, resolve or dispute the department's preliminary e e n d 18 finding of overpayment.
and (3) notify the medicaid provider or subcontractor that is the subject of a preliminary finding of SFL/SB 2 Page 9 overpayment of its right to request, within thirty calendar days of service of the preliminary finding of overpayment, an informal conference with a representative of the department who is knowledgeable about the department's preliminary finding of overpayment and with a member of the audit team, if an audit formed the basis of any alleged overpayment, to informally address, resolve or dispute the department's preliminary finding of overpayment.
= = l ] 19 E.
E.
Prior to making either a final determination of a l r i 20 overpayment or a determination of credible allegation of fraud, t e a t the department may impose corrective action upon the medicaid m m 21 e d provider or subcontractor to address systemic conditions r e 22 c e r c 23 contributing to errors in the submission of claims for payment e a n b 24 to which a medicaid provider or subcontractor is not entitled." u [ SECTION 6.
Prior to making either a final determination of overpayment or a determination of credible allegation of fraud, the department may impose corrective action upon the medicaid provider or subcontractor to address systemic conditions contributing to errors in the submission of claims for payment to which a medicaid provider or subcontractor is not entitled." SECTION 6.
A new section of the Medicaid Provider and .209163.8 - 10 - SFl/SB 2 Managed Care Act is enacted to read:
A new section of the Medicaid Provider and Managed Care Act is enacted to read:
"[NEW MATERIAL] INFORMAL CONFERENCE--CORRECTIVE ACTION-- REQUIREMENTS.-- A.
"INFORMAL CONFERENCE--CORRECTIVE ACTION--REQUIREMENTS.-- A.
Upon receipt of a request for an informal conference, the department shall set a date for the conference to occur no later than fourteen business days following receipt of the request.
Upon receipt of a request for an informal conference, the department shall set SFL/SB 2 Page 10 a date for the conference to occur no later than fourteen business days following receipt of the request.
Within seven days following the informal conference, a medicaid provider or subcontractor may submit a proposed corrective action plan to the department to correct clerical, typographical, scrivener's and computer errors or to e e 17 provide requested credentialing, licensure or training records e e n d 18 identified in audit findings.
Within seven days following the informal conference, a medicaid provider or subcontractor may submit a proposed corrective action plan to the department to correct clerical, typographical, scrivener's and computer errors or to provide requested credentialing, licensure or training records identified in audit findings.
The department shall not = = l ] 19 unreasonably withhold approval of the proposed corrective a l r i 20 action plan.
The department shall not unreasonably withhold approval of the proposed corrective action plan.
A medicaid provider or subcontractor shall have t e a t no less than thirty days from the date of approval of its m m 21 e d corrective action plan to provide additional information or r e 22 c e r c 23 documentation to the department to attempt to address or e a n b 24 resolve a disputed preliminary finding of overpayment." u [ SECTION 7.
A medicaid provider or subcontractor shall have no less than thirty days from the date of approval of its corrective action plan to provide additional information or documentation to the department to attempt to address or resolve a disputed preliminary finding of overpayment." SECTION 7.
A new section of the Medicaid Provider and .209163.8 - 11 - SFl/SB 2 Managed Care Act is enacted to read:
A new section of the Medicaid Provider and Managed Care Act is enacted to read:
"[NEW MATERIAL] EXPEDITED ADJUDICATORY PROCEEDINGS-- REQUIREMENTS.-- A.
"EXPEDITED ADJUDICATORY PROCEEDINGS--REQUIREMENTS.-- A.
The chief hearing officer of the administrative hearings office shall appoint or contract with a hearing officer qualified pursuant to Section 8 of the this 2018 act no later than thirty calendar days after service upon the administrative hearings office of a request for an expedited adjudicatory proceeding pursuant to the Medicaid Provider and e e 17 Managed Care Act by a medicaid provider or subcontractor.
The chief hearing officer of the administrative SFL/SB 2 Page 11 hearings office shall appoint or contract with a hearing officer qualified pursuant to Section 8 of the 2018 act no later than thirty calendar days after service upon the administrative hearings office of a request for an expedited adjudicatory proceeding pursuant to the Medicaid Provider and Managed Care Act by a medicaid provider or subcontractor.
e e n d 18 C.
C.
The expedited adjudicatory proceeding requested = = l ] 19 by a medicaid provider or subcontractor in accordance with the a l r i 20 Medicaid Provider and Managed Care Act shall commence no later t e a t than thirty calendar days following the appointment of the m m 21 e d hearing officer or as stipulated by the parties or as otherwise r e 22 c e r c 23 ordered by the hearing officer upon a showing of good cause.
The expedited adjudicatory proceeding requested by a medicaid provider or subcontractor in accordance with the Medicaid Provider and Managed Care Act shall commence no later than thirty calendar days following the appointment of the hearing officer or as stipulated by the parties or as otherwise ordered by the hearing officer upon a showing of good cause.
e a n b 24 The evidentiary hearing of an expedited adjudicatory proceeding u [ pursuant to this section shall not exceed ten business days in .209163.8 - 12 - SFl/SB 2 length and shall be conducted in accordance with Section 12-8-11 NMSA 1978.
The evidentiary hearing of an expedited adjudicatory proceeding pursuant to this section shall not exceed ten business days in length and shall be conducted in accordance with Section 12-8-11 NMSA 1978.
In addition, the hearing officer shall determine the amount of overpayment with respect to each disputed claim submitted for payment, if any.
In addition, the hearing officer shall determine the amount of overpayment with respect to each disputed claim submitted for payment, if SFL/SB 2 Page 12 any.
The hearing officer's findings of fact and e e 17 conclusions of law shall be binding on the department and e e n d 18 constitute a final agency decision, which may be appealed = = l ] 19 pursuant to Section 39-3-1.1 NMSA 1978." a l r i 20 SECTION 8.
The hearing officer's findings of fact and conclusions of law shall be binding on the department and constitute a final agency decision, which may be appealed pursuant to Section 39-3-1.1 NMSA 1978." SECTION 8.
A new section of the Medicaid Provider and t e a t Managed Care Act is enacted to read:
A new section of the Medicaid Provider and Managed Care Act is enacted to read:
m m 21 e d "[NEW MATERIAL] QUALIFICATIONS AND SELECTION OF HEARING r e 22 c e r c 23 OFFICER FOR EXPEDITED ADJUDICATORY PROCEEDINGS.-- e a n b 24 A.
"QUALIFICATIONS AND SELECTION OF HEARING OFFICER FOR EXPEDITED ADJUDICATORY PROCEEDINGS.-- A.
The hearing officer presiding over the expedited u [ adjudicatory proceeding held pursuant to the Medicaid Provider .209163.8 - 13 - SFl/SB 2 and Managed Care Act shall:
The hearing officer presiding over the expedited adjudicatory proceeding held pursuant to the Medicaid Provider and Managed Care Act shall:
(3) have at least five years' experience in commercial litigation demonstrating the ability to make a record in an adjudicatory proceeding suitable for judicial review;
(3) have at least five years' experience in commercial litigation demonstrating the ability to make a record in an adjudicatory proceeding suitable for judicial SFL/SB 2 Page 13 review;
and e e 17 (5) not be related within the third degree of e e n d 18 consanguinity to a person currently employed by an executive = = l ] 19 agency of the state, currently doing business with the state or a l r i 20 currently employed by an organization doing business with the t e a t state.
and (5) not be related within the third degree of consanguinity to a person currently employed by an executive agency of the state, currently doing business with the state or currently employed by an organization doing business with the state.
m m 21 e d B.
B.
The chief hearing officer of the administrative r e 22 c e r c 23 hearings office shall select the hearing officer to preside e a n b 24 over an expedited adjudicatory proceeding held pursuant to the u [ Medicaid Provider and Managed Care Act and the Administrative .209163.8 - 14 - SFl/SB 2 Procedures Act." SECTION 9.
The chief hearing officer of the administrative hearings office shall select the hearing officer to preside over an expedited adjudicatory proceeding held pursuant to the Medicaid Provider and Managed Care Act and the Administrative Procedures Act." SECTION 9.
"[NEW MATERIAL] COSTS OF EXPEDITED ADJUDICATORY PROCEEDING.-- A.
"COSTS OF EXPEDITED ADJUDICATORY PROCEEDING.-- A.
B.
SFL/SB 2 Page 14 B.
The department shall reimburse the administrative hearings office for the costs of a contract hearing officer." e e 17 SECTION 10.
The department shall reimburse the administrative hearings office for the costs of a contract hearing officer." SECTION 10.
A new section of the Medicaid Provider and e e n d 18 Managed Care Act is enacted to read:
A new section of the Medicaid Provider and Managed Care Act is enacted to read:
= = l ] 19 "[NEW MATERIAL] RIGHTS OF MEDICAID PROVIDER OR a l r i 20 SUBCONTRACTOR--PRELIMINARY OR FINAL DETERMINATION OF t e a t OVERPAYMENT.-- m m 21 e d A.
"RIGHTS OF MEDICAID PROVIDER OR SUBCONTRACTOR-- PRELIMINARY OR FINAL DETERMINATION OF OVERPAYMENT.-- A.
A medicaid provider or subcontractor may r e 22 c e r c 23 challenge:
A medicaid provider or subcontractor may challenge:
e a n b 24 (1) the department's preliminary or final u [ determination of overpayment as:
(1) the department's preliminary or final determination of overpayment as:
.209163.8 - 15 - SFl/SB 2 (a) exceeding statutory authority;
(a) exceeding statutory authority;
A medicaid provider or subcontractor may, but shall not be required to, conduct its own audit or sampling to challenge a preliminary or final determination of overpayment." SECTION 11.
A medicaid provider or subcontractor may, but shall not be required to, conduct its own audit or sampling SFL/SB 2 Page 15 to challenge a preliminary or final determination of overpayment." SECTION 11.
"[NEW MATERIAL] RELEASE OF SUSPENDED PAYMENT FOR SERVICES e e 17 PREVIOUSLY RENDERED--PREPAYMENT REVIEW--REMEDIAL TRAINING AND e e n d 18 EDUCATION--TEMPORARY ASSISTANCE.-- = = l ] 19 A.
"RELEASE OF SUSPENDED PAYMENT FOR SERVICES PREVIOUSLY RENDERED--PREPAYMENT REVIEW--REMEDIAL TRAINING AND EDUCATION--TEMPORARY ASSISTANCE.-- A.
The department shall direct the release of a a l r i 20 suspended payment to a medicaid provider or subcontractor that t e a t is the subject of a referral based upon a determination of a m m 21 e d credible allegation of fraud for services previously rendered r e 22 c e r c 23 if the medicaid provider or subcontractor posts a surety bond e a n b 24 in the amount of the suspended payment, which posting shall be u [ deemed good cause not to suspend payment.
The department shall direct the release of a suspended payment to a medicaid provider or subcontractor that is the subject of a referral based upon a determination of a credible allegation of fraud for services previously rendered if the medicaid provider or subcontractor posts a surety bond in the amount of the suspended payment, which posting shall be deemed good cause not to suspend payment.
.209163.8 - 16 - SFl/SB 2 B.
B.
or (3) requiring the medicaid provider or subcontractor to engage an independent third party approved by the department to temporarily manage or provide technical assistance to the medicaid provider or subcontractor.
or (3) requiring the medicaid provider or SFL/SB 2 Page 16 subcontractor to engage an independent third party approved by the department to temporarily manage or provide technical assistance to the medicaid provider or subcontractor.
The department shall direct that the release of a suspended payment occur no later than ten business days e e 17 following the earlier of:
The department shall direct that the release of a suspended payment occur no later than ten business days following the earlier of:
e e n d 18 (1) the posting of a surety bond by the = = l ] 19 medicaid provider or subcontractor in the amount of the a l r i 20 suspended payment;
(1) the posting of a surety bond by the medicaid provider or subcontractor in the amount of the suspended payment;
t e a t (2) notice from the attorney general that the m m 21 e d attorney general will not pursue legal action against the r e 22 c e r c 23 medicaid provider or subcontractor arising out of the referral e a n b 24 of the medicaid provider or subcontractor based on a u [ determination of a credible allegation of fraud;
(2) notice from the attorney general that the attorney general will not pursue legal action against the medicaid provider or subcontractor arising out of the referral of the medicaid provider or subcontractor based on a determination of a credible allegation of fraud;
.209163.8 - 17 - SFl/SB 2 (3) the date on which an administrative decision as to the basis for suspending such payments, or portion of such payments, in favor of the medicaid provider or subcontractor becomes final;
(3) the date on which an administrative decision as to the basis for suspending such payments, or portion of such payments, in favor of the medicaid provider or subcontractor becomes final;
"[NEW MATERIAL] MAINTENANCE OF SERVICES--PAYMENT FOR ONGOING SERVICES.-- A.
"MAINTENANCE OF SERVICES--PAYMENT FOR ONGOING SFL/SB 2 Page 17 SERVICES.-- A.
Following the referral of a medicaid provider or subcontractor based on a determination of a credible allegation of fraud, and during the pendency of a dispute between the department and a medicaid provider or subcontractor regarding e e 17 an alleged overpayment, including an overpayment based in whole e e n d 18 or in part on a credible allegation of fraud, the department = = l ] 19 shall not terminate or deny the medicaid provider's or a l r i 20 subcontractor's continued participation in the state's medicaid t e a t program if the medicaid provider or subcontractor:
Following the referral of a medicaid provider or subcontractor based on a determination of a credible allegation of fraud, and during the pendency of a dispute between the department and a medicaid provider or subcontractor regarding an alleged overpayment, including an overpayment based in whole or in part on a credible allegation of fraud, the department shall not terminate or deny the medicaid provider's or subcontractor's continued participation in the state's medicaid program if the medicaid provider or subcontractor:
m m 21 e d (1) submits to a prepayment review of claims r e 22 c e r c 23 for ongoing services;
(1) submits to a prepayment review of claims for ongoing services;
e a n b 24 (2) demonstrates that its employees have u [ completed remedial training or education required by the .209163.8 - 18 - SFl/SB 2 department to prevent the submission of claims for payment to which the medicaid provider or subcontractor is not entitled;
(2) demonstrates that its employees have completed remedial training or education required by the department to prevent the submission of claims for payment to which the medicaid provider or subcontractor is not entitled;
The department shall not unreasonably withhold approval of a third party proposed by the medicaid provider or subcontractor pursuant to Paragraph (3) of Subsection A of this section.
The department shall not unreasonably withhold approval of a third party proposed by the medicaid provider SFL/SB 2 Page 18 or subcontractor pursuant to Paragraph (3) of Subsection A of this section.
A medicaid provider or subcontractor that complies with the requirements of Subsection A of this section shall be reimbursed for each clean claim for ongoing services within ten calendar days of receipt if submitted electronically or thirty calendar days if submitted manually." e e 17 SECTION 13.
A medicaid provider or subcontractor that complies with the requirements of Subsection A of this section shall be reimbursed for each clean claim for ongoing services within ten calendar days of receipt if submitted electronically or thirty calendar days if submitted manually." SECTION 13.
A new section of the Medicaid Provider and e e n d 18 Managed Care Act is enacted to read:
= = l ] 19 "[NEW MATERIAL] DISPOSITION OF RECOVERED MEDICAID FUNDS.-- a l r i 20 A.
Overpayments collected pursuant to the Medicaid t e a t Provider and Managed Care Act on behalf of the state shall be m m 21 e d remitted to the department for deposit in the general fund to r e 22 c e r c 23 be used for the state's medicaid program.
e a n b 24 B.
The department shall not enter into a contract u [ to pay any portion of funds recovered by the state from a .209163.8 - 19 - SFl/SB 2 medicaid provider, a managed care organization or a subcontractor to any other person unless expressly authorized or required to do so by state or federal law." SECTION 14.
"[NEW MATERIAL] CREDIBLE ALLEGATION OF FRAUD--JUDICIAL REVIEW--SUBSTANTIAL EVIDENCE REQUIRED.-- A.
"DISPOSITION OF RECOVERED MEDICAID FUNDS.-- A.
A credible allegation of fraud determination by the department shall be deemed a final agency decision and may be appealed pursuant to Section 39-3-1.1 NMSA 1978.
Overpayments collected pursuant to the Medicaid Provider and Managed Care Act on behalf of the state shall be remitted to the department for deposit in the general fund to be used for the state's medicaid program.
The department shall not enter into a contract to pay any portion of funds recovered by the state from a medicaid provider, a managed care organization or a subcontractor to any other person unless expressly authorized or required to do so by state or federal law." SECTION 14.
A new section of the Medicaid Provider and Managed Care Act is enacted to read:
"CREDIBLE ALLEGATION OF FRAUD--JUDICIAL REVIEW-- SUBSTANTIAL EVIDENCE REQUIRED.-- A.
A credible allegation of fraud determination by SFL/SB 2 Page 19 the department shall be deemed a final agency decision and may be appealed pursuant to Section 39-3-1.1 NMSA 1978.
B.
The department shall show by substantial evidence e e 17 that:
The department shall show by substantial evidence that:
e e n d 18 (1) it has not abused its discretion by = = l ] 19 failing to follow its own procedures;
(1) it has not abused its discretion by failing to follow its own procedures;
and a l r i 20 (2) the evidence relied upon to make its t e a t credible allegation of fraud determination was relevant, m m 21 e d credible and material to the issue of fraud.
and (2) the evidence relied upon to make its credible allegation of fraud determination was relevant, credible and material to the issue of fraud.
r e 22 c e r c 23 C.
C.
In a proceeding for judicial review under this e a n b 24 section, the reviewing court shall not consider evidence u [ acquired by the department after making its credible allegation .209163.8 - 20 - SFl/SB 2 of fraud determination." SECTION 15.
In a proceeding for judicial review under this section, the reviewing court shall not consider evidence acquired by the department after making its credible allegation of fraud determination." SECTION 15.
"[NEW MATERIAL] AWARD OF COSTS, FEES AND INTEREST.-- A.
"AWARD OF COSTS, FEES AND INTEREST.-- A.
If a medicaid provider or subcontractor is the prevailing party in any expedited adjudicatory or court proceeding brought by the medicaid provider or subcontractor pursuant to the Medicaid Provider and Managed Care Act on or after July 1, 2018 in connection with a preliminary or final determination of overpayment or a determination of credible allegation of fraud, the medicaid provider or subcontractor shall be entitled to:
If a medicaid provider or subcontractor is the prevailing party in any expedited adjudicatory or court proceeding brought by the medicaid provider or subcontractor pursuant to the Medicaid Provider and Managed Care Act on or SFL/SB 2 Page 20 after July 1, 2018 in connection with a preliminary or final determination of overpayment or a determination of credible allegation of fraud, the medicaid provider or subcontractor shall be entitled to:
(2) reasonable litigation costs incurred in e e 17 connection with a court proceeding;
(2) reasonable litigation costs incurred in connection with a court proceeding;
and e e n d 18 (3) interest pursuant to Subsection F of this = = l ] 19 section.
and (3) interest pursuant to Subsection F of this section.
a l r i 20 B.
B.
t e a t (1) "court proceeding" means any civil action m m 21 e d brought in state district court;
(1) "court proceeding" means any civil action brought in state district court;
r e 22 c e r c 23 (2) "reasonable administrative costs" means e a n b 24 actual charges for preparation for and conduct of an u [ administrative proceeding, including:
(2) "reasonable administrative costs" means actual charges for preparation for and conduct of an administrative proceeding, including:
.209163.8 - 21 - SFl/SB 2 (a) court reporter fees, service of process fees and similar expenses;
(a) court reporter fees, service of process fees and similar expenses;
and (d) fees and costs paid or incurred for the services of attorneys or of certified public accountants in connection with the expedited adjudicatory proceeding;
and (d) fees and costs paid or incurred for the services of attorneys or of certified public accountants SFL/SB 2 Page 21 in connection with the expedited adjudicatory proceeding;
and 4) fees and costs paid or e e 17 incurred for the services of attorneys or certified public e e n d 18 accountants in connection with the proceeding.
and 4) fees and costs paid or incurred for the services of attorneys or certified public accountants in connection with the proceeding.
= = l ] 19 C.
C.
a l r i 20 (1) the medicaid provider or subcontractor is t e a t the prevailing party if it has:
(1) the medicaid provider or subcontractor is the prevailing party if it has:
m m 21 e d (a) substantially prevailed with respect r e 22 c e r c 23 to the amount in controversy;
(a) substantially prevailed with respect to the amount in controversy;
or e a n b 24 (b) substantially prevailed with respect u [ to most of the issues involved in the case or the most .209163.8 - 22 - SFl/SB 2 significant issue or set of issues involved in the case;
or (b) substantially prevailed with respect to most of the issues involved in the case or the most significant issue or set of issues involved in the case;
For purposes of this paragraph, the position of the department shall be presumed not to be based upon a reasonable application of the law to the facts of the case if:
For SFL/SB 2 Page 22 purposes of this paragraph, the position of the department shall be presumed not to be based upon a reasonable application of the law to the facts of the case if:
or (b) the department's preliminary finding or final determination of overpayment giving rise to the proceeding was not supported by substantial evidence at the e e 17 time such finding or determination was made;
or (b) the department's preliminary finding or final determination of overpayment giving rise to the proceeding was not supported by substantial evidence at the time such finding or determination was made;
and e e n d 18 (3) the determination of whether the medicaid = = l ] 19 provider or subcontractor is the prevailing party and the a l r i 20 amount of reasonable administrative costs or reasonable t e a t litigation costs shall be made:
and (3) the determination of whether the medicaid provider or subcontractor is the prevailing party and the amount of reasonable administrative costs or reasonable litigation costs shall be made:
m m 21 e d (a) by agreement of the parties;
(a) by agreement of the parties;
r e 22 c e r c 23 (b) in an expedited adjudicatory e a n b 24 proceeding, by the hearing officer;
(b) in an expedited adjudicatory proceeding, by the hearing officer;
or u [ (c) in a court proceeding, by the court.
or (c) in a court proceeding, by the court.
.209163.8 - 23 - SFl/SB 2 D.
D.
An order granting or denying in whole or in part an award for reasonable litigation costs pursuant to Subsection A of this section in a court proceeding may be incorporated as a part of the decision or judgment in the court proceeding and shall be subject to appeal in the same manner as the decision or judgment.
An order granting or denying in whole or in part an award for SFL/SB 2 Page 23 reasonable litigation costs pursuant to Subsection A of this section in a court proceeding may be incorporated as a part of the decision or judgment in the court proceeding and shall be subject to appeal in the same manner as the decision or judgment.
A medicaid provider or e e 17 subcontractor awarded administrative or litigation costs e e n d 18 pursuant to this section may not receive an award of attorney = = l ] 19 fees pursuant to any other statutory provision.
A medicaid provider or subcontractor awarded administrative or litigation costs pursuant to this section may not receive an award of attorney fees pursuant to any other statutory provision.
a l r i 20 F.
F.
Interest on amounts owed to a prevailing t e a t medicaid provider or subcontractor shall accrue and be paid at m m 21 e d the rate of one and one-half percent a month on the amount of r e 22 c e r c 23 a:
Interest on amounts owed to a prevailing medicaid provider or subcontractor shall accrue and be paid at the rate of one and one-half percent a month on the amount of a:
e a n b 24 (1) clean claim electronically submitted by u [ the medicaid provider or subcontractor and not paid within .209163.8 - 24 - SFl/SB 2 thirty days of receipt;
(1) clean claim electronically submitted by the medicaid provider or subcontractor and not paid within thirty days of receipt;
or (3) claim for which additional information was necessary to substantiate the claim and not paid within sixty days of receipt of such additional information." SECTION 16.
or (3) claim for which additional information SFL/SB 2 Page 24 was necessary to substantiate the claim and not paid within sixty days of receipt of such additional information." SECTION 16.
"[NEW MATERIAL] APPLICABILITY OF ADMINISTRATIVE PROCEDURES ACT.-- A.
"APPLICABILITY OF ADMINISTRATIVE PROCEDURES ACT.-- A.
Sections 12-8-2, 12-8-10 through 12-8-13, e e 17 12-8-15 and 12-8-16 NMSA 1978 apply to Sections 5, 7 through 11 e e n d 18 and 14 of this 2018 act." = = l ] 19 SECTION 17.
Sections 12-8-2, 12-8-10 through 12-8-13, 12-8-15 and 12-8-16 NMSA 1978 apply to Sections 5, 7 through 11 and 14 of this 2018 act." SECTION 17.
A new section of the Administrative Hearings a l r i 20 Office Act is enacted to read:
A new section of the Administrative Hearings Office Act is enacted to read:
t e a t "[NEW MATERIAL] APPOINTMENT OF HEARING OFFICER FOR m m 21 e d EXPEDITED ADJUDICATORY PROCEEDINGS UNDER THE MEDICAID PROVIDER r e 22 c e r c 23 AND MANAGED CARE ACT.--The chief hearing officer shall select a e a n b 24 hearing officer for expedited adjudicatory proceedings as u [ provided by the Medicaid Provider and Managed Care Act." .209163.8 - 25 - SFl/SB 2 SECTION 18.
"APPOINTMENT OF HEARING OFFICER FOR EXPEDITED ADJUDICATORY PROCEEDINGS UNDER THE MEDICAID PROVIDER AND MANAGED CARE ACT.--The chief hearing officer shall select a hearing officer for expedited adjudicatory proceedings as provided by the Medicaid Provider and Managed Care Act." SECTION 18.
- 26 - 9 11 13 15 e e 17 e e n d 18 = = l ] 19 a l r i 20 t e a t m m 21 e d r e 22 c e r c 23 e a n b 24 u [ .209163.8
SFL/SB 2 Page 25
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Action History

  1. Pocket Veto

  2. passed House

  3. DO PASS committee report adopted

  4. Sent to House Health and Human Services Committee

  5. passed Senate

  6. floor substitute adopted

  7. withdrawn from committee

  8. DO PASS committee report adopted

  9. germane

  10. Sent to Senate Committees' Committee & Senate Judiciary Committee & Senate Finance Committee

  11. Sent to Senate Pre-file

Sponsors

  • Mary Kay Papen · Primary

Sponsorship breakdown

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1 sponsors · 0 co-sponsors · 111 not signed on

Sponsors (1)

  • Papen, Mary Kay

Co-sponsors (0)

None.

Not signed on (111)

111 members have not signed on to this bill.

Show all 111 →

"Not signed on" means a member has not sponsored or co-sponsored this bill — it does not imply opposition. Members flagged Voted No have a recorded No vote on this bill.

Whip count is in markup. Polling the chamber and every recorded vote this session. Only the first open is slow. It’s instant for you after this. Calling the roll · Tallying · Engrossing

Subjects

healthcare health-insurance
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Frequently asked questions

Who sponsors SB 2?
SB 2 is sponsored by Papen, Mary Kay.
What is the current status of SB 2?
This bill died with 2018 Regular Session. It reached “To Executive” and never advanced before the session ended, so it can no longer move — a new version would have to be reintroduced in the current session.
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