SB 337 Page 1 1 the Difference Between the Nonparticipating Provider's Billed
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1 AN ACT 2 RELATING TO HEALTH COVERAGE; ENACTING THE SURPRISE BILLING 3 PROTECTION ACT; PROVIDING FOR PROTECTION OF COVERED PERSONS 4 FROM UNEXPECTED BILLING FROM PROVIDERS THAT DO NOT 5 PARTICIPATE IN THE COVERED PERSON'S HEALTH BENEFITS PLAN; 6 PROHIBITING SURPRISE BILLING AS AN UNFAIR PRACTICE; 7 ESTABLISHING PENALTIES; PROVIDING FOR A CONTINGENT REPEAL. 8 9 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: 10 SECTION 1. A new section of the New Mexico Insurance 11 Code is enacted to read: 12 "SHORT TITLE.--Sections 1 through 13 of this act may be 13 cited as the "Surprise Billing Protection Act"." 14 SECTION 2. A new section of the New Mexico Insurance 15 Code is enacted to read: 16 "DEFINITIONS.--As used in the Surprise Billing 17 Protection Act: 18 A. "allowed amount" means the maximum portion of 19 a billed charge that a health insurance carrier will pay, 20 including any applicable covered person cost-sharing 21 responsibility, for a covered health care service or item 22 rendered by a participating provider or by a nonparticipating 23 provider; 24 B. "balance billing" means a nonparticipating 25 provider's practice of issuing a bill to a covered person for SCORC/SB 337 Page 1 1 the difference between the nonparticipating provider's billed 2 charges on a claim and any amount paid by the health 3 insurance carrier as reimbursement for that claim, excluding 4 any cost-sharing amount due from the covered person; 5 C. "claim" means a request from a provider for 6 payment for health care services rendered; 7 D. "co-insurance" means a cost-sharing method that 8 requires a covered person to pay a stated percentage of 9 medical expenses after any deductible amount is paid; 10 provided that co-insurance rates may differ for different 11 types of services under the same health benefits plan; 12 E. "copayment" means a cost-sharing method that 13 requires a covered person to pay a fixed dollar amount when 14 health care services are received, with the health insurance 15 carrier paying the balance allowable amount; provided that 16 there may be different copayment requirements for different 17 types of services under the same health benefits plan; 18 F. "cost sharing" means a copayment, co-insurance, 19 deductible or any other form of financial obligation of a 20 covered person other than premium or share of premium, or any 21 combination of any of these financial obligations as defined 22 by the terms of a health benefits plan; 23 G. "covered benefits" means those health care 24 services to which a covered person is entitled under the 25 terms of a health benefits plan; SCORC/SB 337 Page 2 1 H. "covered person" means: 2 (1) an enrollee, policyholder or subscriber; 3 (2) the enrolled dependent of an enrollee, 4 policyholder or subscriber; or 5 (3) another individual participating in a 6 health benefits plan; 7 I. "deductible" means a fixed dollar amount that a 8 covered person may be required to pay during the benefit 9 period before the health insurance carrier begins payment for 10 covered benefits; provided that a health benefits plan may 11 have both individual and family deductibles and separate 12 deductibles for specific services; 13 J. "emergency care" means a health care procedure, 14 treatment or service, excluding ambulance transportation 15 service, which procedure, treatment or service is delivered 16 to a covered person after the sudden onset of what reasonably 17 appears to be a medical or behavioral health condition that 18 manifests itself by symptoms of sufficient severity, 19 including severe pain, that the absence of immediate medical 20 attention, regardless of eventual diagnosis, could be 21 expected by a reasonable layperson to result in jeopardy to a 22 person's physical or mental health or to the health or safety 23 of a fetus or pregnant person, serious impairment of bodily 24 function, serious dysfunction of a bodily organ or part or 25 disfigurement to a person; SCORC/SB 337 Page 3 1 K. "facility" means an entity providing a health 2 care service, including: 3 (1) a general, special, psychiatric or 4 rehabilitation hospital; 5 (2) an ambulatory surgical center; 6 (3) a cancer treatment center; 7 (4) a birth center; 8 (5) an inpatient, outpatient or residential 9 drug and alcohol treatment center; 10 (6) a laboratory, diagnostic or other 11 outpatient medical service or testing center; 12 (7) a health care provider's office or 13 clinic; 14 (8) an urgent care center; 15 (9) a freestanding emergency room; or 16 (10) any other therapeutic health care 17 setting; 18 L. "freestanding emergency room" means a facility 19 licensed by the department of health that is separate from an 20 acute care hospital and that provides twenty-four-hour 21 emergency care to patients at the same level of care that a 22 hospital-based emergency room delivers; 23 M. "health benefits plan" means a policy or 24 agreement entered into or offered or issued by a health 25 insurance carrier to provide, deliver, arrange for, pay for SCORC/SB 337 Page 4 1 or reimburse any of the costs of health care services; 2 provided that "health benefits plan" does not include any of 3 the following: 4 (1) an accident-only policy; 5 (2) a credit-only policy; 6 (3) a long- or short-term care or disability 7 income policy; 8 (4) a specified disease policy; 9 (5) coverage provided pursuant to Title 18 10 of the federal Social Security Act, as amended; 11 (6) coverage provided pursuant to Title 19 12 of the federal Social Security Act and the Public Assistance 13 Act; 14 (7) a federal TRICARE policy, including a 15 federal civilian health and medical program of the uniformed 16 services supplement; 17 (8) a fixed or hospital indemnity policy; 18 (9) a dental-only policy; 19 (10) a vision-only policy; 20 (11) a workers' compensation policy; 21 (12) an automobile medical payment policy; 22 or 23 (13) any other policy specified in rules of 24 the superintendent; 25 N. "health care services": SCORC/SB 337 Page 5 1 (1) means any service, supply or procedure 2 for the diagnosis, prevention, treatment, cure or relief of a 3 health condition, illness, injury or other disease, including 4 physical or behavioral health services, to the extent offered 5 by a health benefits plan; and 6 (2) does not mean ambulance transportation 7 services; 8 O. "health insurance carrier" means an entity 9 subject to state insurance laws, including a health insurance 10 company, a health maintenance organization, a hospital and 11 health service corporation, a provider service network, a 12 nonprofit health care plan or any other entity that contracts 13 or offers to contract, or enters into agreements to provide, 14 deliver, arrange for, pay for or reimburse any costs of 15 health care services or that provides, offers or administers 16 a health benefit policy or managed health care plan in the 17 state; 18 P. "hospital" means a facility offering inpatient 19 health care services, nursing care and overnight care for 20 three or more individuals on a twenty-four-hours-per-day, 21 seven-days-per-week basis for the diagnosis and treatment of 22 physical, behavioral or rehabilitative health conditions; 23 Q. "inducement" means the act or process of 24 enticing or persuading another person to take a certain 25 course of action; SCORC/SB 337 Page 6 1 R. "network" means the group or groups of 2 participating providers that have been contracted to provide 3 health care services under a network plan; 4 S. "network plan" means a health benefits plan 5 that either requires a covered person to use or creates 6 incentives, including financial incentives, for a covered 7 person to use providers and facilities managed, owned, under 8 contract with or employed by the health insurance carrier 9 offering the health benefits plan; 10 T. "nonparticipating provider" means a provider 11 who is not a participating provider; 12 U. "participating provider" means a provider or 13 facility that, under express contract with a health insurance 14 carrier or with a health insurance carrier's contractor or 15 subcontractor, has agreed to provide health care services to 16 covered persons, with an expectation of receiving payment 17 directly or indirectly from the health insurance carrier, 18 subject to cost sharing; 19 V. "prior authorization" means a pre-service 20 determination made by a health insurance carrier regarding a 21 covered person's eligibility for services, medical necessity, 22 benefit coverage and the location or appropriateness of 23 services, pursuant to the terms of a health benefits plan 24 that the health insurance carrier offers; 25 W. "provider" means a health care professional, SCORC/SB 337 Page 7 1 hospital or other facility licensed to furnish health care 2 services; 3 X. "stabilize" means to provide emergency care to 4 a patient as may be necessary to ensure, within reasonable 5 medical probability, that no material deterioration of the 6 condition is likely to result from or occur during the 7 transfer of the patient to a facility or, with respect to 8 emergency labor, to deliver, including the delivery of a 9 placenta; and 10 Y. "surprise bill": 11 (1) means a bill that a nonparticipating 12 provider issues to a covered person for health care services 13 rendered in the following circumstances, in an amount that 14 exceeds the covered person's cost-sharing obligation that 15 would apply for the same health care services if these 16 services had been provided by a participating provider: 17 (a) emergency care provided by the 18 nonparticipating provider; or 19 (b)