SB 337 — SURPRISE BILLING PROTECTION ACT

h (5) coverage provided pursuant to Title 18 of g o the federal Social Security Act, as amended;

t hr g e i k (6) coverage provided pursuant to Title 19 of h r i s the federal Social Security Act and the Public Assistance Act;

h , t, (7) a federal TRICARE policy, including a e u g e b l federal civilian health and medical program of the uniformed e e h n d d i = = o h services supplement;

l ] b ,d i a º e (8) a fixed or hospital indemnity policy;

r i = r t e w d (9) a dental-only policy;

m(10) a nvision-only opolicy; d m :

b e d s º o t n = .214310.4 s k m e - 5 - e a n e d r e l u [ A d SCORC/SB 337 (10) a vision-only policy;

SCORC/SB 337 Page 5 (1) means any service, supply or procedure for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or other disease, including physical or behavioral health services, to the extent offered by a health benefits plan;

"health insurance carrier" means an entity subject to state insurance laws, including a health insurance company, a health maintenance organization, a hospital and h health service corporation, a provider service network, a g o nonprofit health care plan or any other entity that contracts t hr g e i k or offers to contract, or enters into agreements to provide, h r i s deliver, arrange for, pay for or reimburse any costs of health h , t, care services or that provides, offers or administers a health e u g e b l e e h benefit policy or managed health care plan in the state;

n d d i = = o h P.

"hospital" means a facility offering inpatient l ] b ,d i a º e health care services, nursing care and overnight care for three r i = r t e w d or more individuals on a twenty-four-hours-per-day, seven-days-seven-days-per-week mbasis afor nthe odiagnosis dand mtreatment :of physical, behavioral or rehabilitative health conditions;

b e d s º o t n = .214310.4 s k m e - 6 - e a n e d r e l u [ A d per-week basis for the diagnosis and treatment of physical, behavioral or rehabilitative health conditions;

SCORC/SB 337 Page 6 R.

"participating provider" means a provider or facility that, under express contract with a health insurance carrier or with a health insurance carrier's contractor or h subcontractor, has agreed to provide health care services to g o covered persons, with an expectation of receiving payment t hr g e i k directly or indirectly from the health insurance carrier, h r i s subject to cost sharing;

h , t, V.

"prior authorization" means a pre-service e u g e b l determination made by a health insurance carrier regarding a e e h n d d i = = o h covered person's eligibility for services, medical necessity, l ] b ,d i a º e benefit coverage and the location or appropriateness of r i = r t e w d services, pursuant to the terms of a health benefits plan that mthe ahealth ninsurance ocarrier doffers; m :

b e d s º o t n = .214310.4 s k m e - 7 - e a n e d r e l u [ A d SCORC/SB 337 the health insurance carrier offers;

"provider" means a health care professional, SCORC/SB 337 Page 7 hospital or other facility licensed to furnish health care services;

(1) means a bill that a nonparticipating provider issues to a covered person for health care services rendered in the following circumstances, in an amount that exceeds the covered person's cost-sharing obligation that would apply for the same health care services if these services had h been provided by a participating provider:

u » r (a) emergency care provided by the t h g e nonparticipating provider;

or l i h r i s (b) health care services, that are not h , e h emergency care, rendered by a nonparticipating provider at a t u g e b l participating facility where:

1) a participating provider is e e , gh n d d i = = o h unavailable;

2) a nonparticipating provider renders unforeseen l ] b ,d i a º r services;

or 3) a nonparticipating provider renders services e r = t e w d for which the covered person has not given specific consent for mthat anonparticipating nprovider oto drender mSCORC/SB :337 Page 8 the particular services rendered;

b r e t º o t n = .214310.4 s k m e - 8 - e a n e d r e l u [ A d that nonparticipating provider to render the particular services rendered;

provided that the health care services are not provided as emergency care HHHCº or for services rendered pursuant to Subparagraph (b) of Paragraph (1) of this subsection»HHHC."subsection." SECTION 3.

"[NEW"EMERGENCY MATERIAL] EMERGENCY CARE--REIMBURSEMENT--LIMITATION ON CHARGES.-- A.

A health insurance carrier shall reimburse a h nonparticipating provider for emergency care necessary to g o evaluate and stabilize a covered person if a prudent layperson t hr g e i k would reasonably believe that emergency care is necessary, h r i s regardless of eventual diagnosis.

h , t, B.

A health insurance carrier shall not require e u g e b l e e h that prior authorization for emergency care be obtained by, or n d d i = = o h on behalf of, a covered person prior to the point of l ] b ,d i a º e stabilization of that covered person if a prudent layperson rSCORC/SB i337 =Page r9 t e w d would reasonably believe that the covered person requires memergency acare. n o d m :

b e d s º o t n = .214310.4 s k m e - 9 - e a n e d r e l u [ A d SCORC/SB 337 emergency care.

A health insurance carrier may impose a cost-cost-sharing sharing or limitation of benefits requirement for emergency care performed by a nonparticipating provider only to the same extent that the copayment, co-insurance or limitation of benefits requirement applies for participating providers and is documented in the policy.

"[NEW"NON-EMERGENCY MATERIAL ] NON-EMERGENCY CARE--LIMITATION ON CHARGES.-- h A.

Other than applicable cost sharing that would u » r apply if a participating provider had rendered the same t h g e services, a health insurance carrier shall provide l i h r i s reimbursement for and a covered person shall not be liable for h , e h charges and fees for covered non-emergency care rendered by a t u g e b l nonparticipating provider that are delivered when:

e e , gh n d d i = = o h (1) the covered person at an in-network l ] b ,d i a º r facility does not have the ability or opportunity to choose a e r = t e w d participating provider who is available to provide the coveredSCORC/SB m337 aPage n10 ocovered dservices; m :

b r e t º o t n = .214310.4 s k m e - 10 - e a n e d r e l u [ A d services;

"[NEW"CREDIT MATERIAL] CREDIT AGAINST MAXIMUM OUT-OF-POCKET COST-COST-SHARING SHARING AMOUNT--COMMUNICATION BY HOSPITALS--ADVANCE NOTIFICATION OF CHARGES FOR HEALTH CARE SERVICES.-- A.

h B.

In accordance with the hearing procedures g o established pursuant to the Patient Protection Act, a covered t hr g e i k person may appeal a health insurance carrier's determination h r i s made regarding a surprise bill.

h , t, C.

By July 1, 2020, the department of health shall e u g e b l require each health facility licensed pursuant to the Public eSCORC/SB e337 hPage n11 d d i = = o h Health Act to post the following on the health facility's l ] b ,d i a º e website in a publicly accessible manner:

r(1) ithe =names rand thyperlinks efor wdirect daccess (1)to the nameswebsites andof hyperlinksall forhealth directinsurance accesscarriers mwith awhich nthe ohospital dhas ma :contract for services;

b e d s º o t n = .214310.4 s k m e - 11 - e a n e d r e l u [ A d SCORC/SB 337 to the websites of all health insurance carriers with which the hospital has a contract for services;

and h (4) instructions for contacting the g o superintendent.

t hr g e i k D.

Any written communication, other than a receipt h r i s of payment, from a provider or health insurance carrier hSCORC/SB ,337 t,Page 12 pertaining to a surprise bill, shall clearly state that the e u g e b l e e h covered person is responsible only for payment of applicable n d d i = = o h in-network cost-sharing amounts under the covered person's l ] b ,d i a º e health benefits plan.

A collection agency collecting medical r i = r t e w d debt from New Mexico residents shall post a notice of consumer mrights apursuant nto othe dSurprise mBilling :Protection Act on its website.

b e d s º o t n = .214310.4 s k m e - 12 - e a n e d r e l u [ A d rights pursuant to the Surprise Billing Protection Act on its website.

"[NEW"COVERED MATERIAL ] COVERED PERSONS--PROVIDERS--OVERPAYMENT.-- A.

If a covered person pays a nonparticipating provider more than the in-network cost-sharing amount for services provided under circumstances giving rise to a surprise bill, the nonparticipating provider shall refund to the covered person within forty-five calendar days of receipt of payment from the health insurance carrier any amount paid SCORC/SB 337 Page 13 in excess of h the in-network cost-sharing amount.

u » r B.

If a nonparticipating provider has not made a t h g e full refund to the covered person of any amount paid in excess l i h r i s of the in-network cost-sharing amount to the covered person h , e h within forty-five calendar days of receipt, interest shall t u g e b l accrue at the rate set for payment of interest on a health e e , gh n d d i = = o h plan's liability for clean claims submitted by eligible l ] b ,d i a º r providers to a health plan pursuant to Chapter 59A, Article 16 e r = t e w d NMSA 1978.

mC. a n o d m :

bA rcovered eperson tmay ºseek orecovery tof nthe =refund .214310.4of sthe kamount mthe ecovered -person 13has -paid ein excess of the in-network cost-sharing amount that a nnonparticipating eprovider dowes, rplus einterest, lpursuant uto [Subsection AB dof SCORC/SBthis 337section C.by filing an appeal with the office of superintendent of insurance.

A covered person may seek recovery of the refund of the amount the covered person has paid in excess of the in- network cost-sharing amount that a nonparticipating provider owes, plus interest, pursuant to Subsection B of this section by filing an appeal with the office of superintendent of insurance.

"[NEW"NONPARTICIPATING MATERIAL ] NONPARTICIPATING PROVIDERS--REBATES AND INDUCEMENTS--PROHIBITION.--A nonparticipating provider shall 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 plan as an inducement for the covered person to seek a health care serviceSCORC/SB h337 Page 14 service from that nonparticipating provider.

The superintendent may u » r impose fines on providers for unlawful rebates and inducements;

t h g e provided that a provider on which the superintendent intends to l i h r i s impose a fine shall be entitled to a hearing in accordance with h , e h the provisions of Section 59A-4-15 NMSA 1978." t u g e b l SECTION 8.

A new section of the New Mexico Insurance Code e e , gh n d d i = = o h is enacted to read:

l"HEALTH ] b ,d i a º r "[NEW MATERIAL ] HEALTH CARE PROVIDER REIMBURSEMENT RATES--RATES--SURPRISE e r = t e w d SURPRISE BILLING.-- mA. a n o d m :

bThe rsuperintendent eshall tconvene ºappropriate ostakeholders, tincluding nrural =providers, .214310.4insurers sand kconsumer madvocates, eand -review 14the -reimbursement erate afor nsurprise ebills dannually rto eensure lfairness uto [providers Aand dto A.evaluate the impact on health insurance premiums and health benefits plan networks.

The superintendent shall convene appropriate stakeholders SJCº, including rural providers, insurers and consumer advocates,»SJC and review the reimbursement rate for surprise bills annually to ensure fairness to providers and to evaluate the impact on health insurance premiums and health benefits plan networks.

"[NEW"REASONABLE MATERIAL] REASONABLE HEALTH CARE COST MANAGEMENT SCORC/SB 337 Page 15 PERMITTED.--Nothing in the Surprise Billing Protection Act shall be construed to prohibit a health insurance carrier from appropriately using reasonable health care cost management techniques." h SECTION 10.

A new section of the New Mexico Insurance g o Code is enacted to read:

t hr g e i k "[NEW MATERIAL] PRIVATE CAUSE OF ACTION.--Except as h r i s provided in Subsection C of Section 6 of the Surprise Billing h , t, Protection Act, nothing in that act shall be construed to e u g e b l e e h create or imply a private cause of action for a violation of n d d i = = o h that act." l ] b ,d i a º e SECTION 11.

A new section of the New Mexico Insurance r i = r t e w d Code is enacted to read:

m a n o d m :

b e d s º o t n = .214310.4 s k m e - 15 - e a n e d r e l u [ A d SCORC/SB 337 "[NEW MATERIAL] SJCºRULEMAKING»SJC SJCºINFORMATION FROM PROVIDER NETWORKS»SJC.--The superintendent:

SJCº A.

shall promulgate rules as may be necessary to appropriately implement the provisions of the Surprise Billing Protection Act;

and»SJC SJCº B.

A.»SJC may require SJCºby rule»SJC that health insurance carriers report the annual percentage of claims and expenditures paid to nonparticipating providers for health care services SJCº."»SJC SJCº B.

may require by rule a report on changes to the percent of claims paid as an emergency claim."»SJC SECTION 12.

"[NEW"PRIVATE MATERIAL]CAUSE APPLICABILITY.--TheOF provisionsACTION.--Except as provided in Subsection C of Section 6 of the Surprise Billing Protection ActAct, applynothing toin thethat followingact typesshall ofbe healthconstrued coverageto deliveredcreate or issuedimply a private cause of action for deliverya inviolation thisof state:that act." SECTION 11.

hA A.new section of the New Mexico Insurance Code is enacted to read:

group"INFORMATION healthFROM coveragePROVIDER governedNETWORKS.--The bysuperintendent: the provisions g o t hr of the Health Care Purchasing Act;

gA. e i k B.

individualmay healthrequire insurancethat policies, health h r i s benefits plans and certificates of insurance governedcarriers byreport the hannual ,percentage t,of eclaims uand gexpenditures provisionspaid ofto Chapternonparticipating 59A,providers Articlefor 22health NMSAcare 1978;services;

eand bB. l e e h C.

multiple-employermay welfarerequire arrangementsby governedrule na dreport don ichanges =to =the opercent hof byclaims thepaid provisionsas ofan Sectionemergency 59A-15-20claim." NMSASECTION 1978;12.

lA ]new bsection ,dof ithe aNew ºMexico eInsurance D.Code is enacted to read:

group"APPLICABILITY.--The andprovisions blanketof healththe insuranceSurprise policies,Billing rProtection iAct =apply rto tthe efollowing wtypes dof m a n o health benefitscoverage plansdelivered andor certificatesissued offor insurancedelivery governedin bythis dstate: m :

bA. e d s º o t n = .214310.4 s k m e - 16 - e a n e d r e l u [ A d the provisions of Chapter 59A, Article 23 NMSA 1978;

group health coverage governed by the SCORC/SB 337 Page 16 provisions of the Health Care Purchasing Act;

B.

individual health insurance policies, health benefits plans and certificates of insurance governed by the provisions of Chapter 59A, Article 22 NMSA 1978;

C.

multiple-employer welfare arrangements governed by the provisions of Section 59A-15-20 NMSA 1978;

D.

group and blanket health insurance policies, health benefits plans and certificates of insurance governed by the provisions of Chapter 59A, Article 23 NMSA 1978;

"[NEW"PROVIDERS--REIMBURSEMENT MATERIAL] PROVIDERS--REIMBURSEMENT FOR A SURPRISE BILL.-- A.

For services provided pursuant to Section 3 or 4 of the Surprise Billing Protection Act, a health insurance carrier shall directly reimburse a nonparticipating provider for care rendered the surprise bill reimbursement rate for services.

The surprise bill reimbursement rate shall be calculated using claims data reflecting the allowed amounts SCORC/SB 337 Page 17 paid for claims paid in the 2017 plan year.

h C.

As used in this section, "surprise bill g o reimbursement rate" means the sixtieth percentile of the t hr g e i k allowed commercial reimbursement rate for the particular health h r i s care service performed by a provider in the same or similar h , t, specialty in the same geographic area, as reported in a e u g e b l benchmarking database maintained by a nonprofit organization e e h n d d i = = o h specified by the superintendent after consultation with health l ] b ,d i a º e care sector stakeholdersstakeholders; SJCº ;

provided that no surprise bill r i = r t e w d reimbursement rate shall be paid at less than one hundred fifty mpercent aof nthe o2017 dmedicare mreimbursement :rate for the applicable health care service provided.

b e d s º o t n = .214310.4 s k m e - 17 - e a n e d r e l u [ A d SCORC/SB 337 percent of the 2017 medicare reimbursement rate for the applicable health care service provided»SJC.

The nonprofit organization shall be conflict-conflict-free free and unaffiliated with any stakeholder in the health care sector." SECTION 14.

A new section of Chapter 59A, Article 16 NMSA 1978 is enacted to read:

"[NEW"HEALTH MATERIAL ] HEALTH CARE PROVIDERS--SURPRISE BILLING PROHIBITED.-- A.

A provider shall not knowingly submit to a covered person a surprise bill for health care services, which surprise bill demands payment for any amount in excess of the cost-sharing amounts that would have been imposed by the covered person's health benefits plan if the health care service from which the surprise bill arises had been rendered SCORC/SB 337 Page 18 by a participating provider.

h B.

It shall be an unfair practice for a health care g o t hr provider to knowingly submit a surprise bill to a collection g e i k agency.

h r i s C.

h , t, (1) "covered person" means:

e u g e b l e e h (a) an enrollee, policyholder or n d d i = = o h subscriber;

l ] b ,d i a º e (b) the enrolled dependent of an r i = r t e w d m a n o enrollee, policyholder or subscriber;

or d(c) manother :individual participating in a health benefits plan;

b e d s º o t n = .214310.4 s k m e - 18 - e a n e d r e l u [ A d (c) another individual participating in a health benefits plan;

SCORC/SB 337 Page 19 (3) "facility" means an entity providing a health care service, including:

h (b) an ambulatory surgical center;

g o (c) a cancer treatment center;

t hr g e i k (d) a birth center;

h r i s (e) an inpatient, outpatient or h , t, residential drug and alcohol treatment center;

e u g e b l (f) a laboratory, diagnostic or other e e h n d d i = = o h outpatient medical service or testing center;

l ] b ,d i a º e (g) a health care provider's office or r i = r t e w d clinic;

m(h) aan nurgent ocare dcenter; m :

b e d s º o t n = .214310.4 s k m e - 19 - e a n e d r e l u [ A d SCORC/SB 337 (h) an urgent care center;

(5) "health benefits plan" means a policy or agreement entered into, offered or issued by a health insurance carrier to provide, deliver, arrange for, pay for SCORC/SB 337 Page 20 or reimburse any of the costs of health care services;

h (c) a long- or short-term care or g o disability income policy;

t hr g e i k (d) a specified disease policy;

h r i s (e) coverage provided pursuant to Title h , t, 18 of the federal Social Security Act, as amended;

e u g e b l e e h (f) coverage provided pursuant to Title n d d i = = o h 19 of the federal Social Security Act and the Public Assistance l ] b ,d i a º e Act;

r(g) ia =federal rTRICARE tpolicy, eincluding w d (g) a federal TRICAREcivilian policy,health includingand mmedical aprogram nof othe duniformed mservices :supplement;

b e d s º o t n = .214310.4 s k m e - 20 - e a n e d r e l u [ A d a federal civilian health and medical program of the uniformed services supplement;

SCORC/SB 337 Page 21 (6) "health care services":

h (7) "health insurance carrier" means an entity g o subject to state insurance laws, including a health insurance t hr g e i k company, a health maintenance organization, a hospital and h r i s health service corporation, a provider service network, a h , t, nonprofit health care plan or any other entity that contracts e u g e b l or offers to contract, or enters into agreements to provide, e e h n d d i = = o h deliver, arrange for, pay for or reimburse any costs of health l ] b ,d i a º e care services or that provides, offers or administers a health r i = r t e w d benefit policy or managed health care plan in the state;

m(8) "hospital" means a nfacility ooffering dinpatient mhealth :care services, nursing care and overnight care for three or more individuals on a twenty-four-hours-per-day, seven-days-per-week basis for the diagnosis and treatment of physical, behavioral or rehabilitative health conditions;

b(9) e"nonparticipating dprovider" smeans º o t n = .214310.4 s k m e - 21 - e a n e d r e l u [ A d SCORC/SB 337 (8)Page "hospital"22 meansprovider awho facilityis offeringnot inpatient health care services, nursing care and overnight care for three or more individuals on a twenty-four-hours-per-day,participating seven-days-per-weekprovider; basis for the diagnosis and treatment of physical, behavioral or rehabilitative health conditions;

(9) "nonparticipating provider" means a provider who is not a participating provider;

(11) "prior authorization" means a pre-service determination made by a health insurance carrier regarding a h covered person's eligibility for health care services, medical u » r necessity, benefit coverage and the location or appropriateness t h g e of services, pursuant to the terms of a health benefits plan l i h r i s that the health insurance carrier offers;

h , e h (12) "provider" means a health care t u g e b l professional, hospital or other facility licensed to furnish e e , gh n d d i = = o h health care services;

and l ] b ,d i a º r (13) "surprise bill":

e(a) rmeans =a tbill ethat wa dnonparticipating (a)provider meansissues to a billcovered person for health care services rendered in the following circumstances, in an amount that aexceeds nonparticipatingthe mcovered person's cost-sharing obligation that would apply for the same health care services if these services had been provided by a nparticipating oSCORC/SB d337 mPage :23 provider:

b r e t º o t n = .214310.4 s k m e - 22 - e a n e d r e l u [ A d provider issues to a covered person for health care services rendered in the following circumstances, in an amount that exceeds the covered person's cost-sharing obligation that would apply for the same health care services if these services had been provided by a participating provider:

or 2) received for health care services rendered by a h nonparticipating provider to a covered person whose coverage is u » r provided pursuant to a preferred provider plan;

provided that t h g e the health care services are not provided as emergency care." l i h r i s SECTION 15.

DELAYED REPEAL.--Section 13 of this act is h , e h repealed effective July 1, 2023.

t u g e b l SECTION 16.

EFFECTIVE DATE.--The effective date of the e e , gh n d d i = = o h provisions of this act is January 1, 2020.

lSCORC/SB ]337 bPage ,d24 i25 a º r - 23 - e r = t e w d m a n o d m :

b r e t º o t n = .214310.4 s k m e e a n e d r e l u [ A d