S.B. 337, SURPRISE BILLING PROTECTION ACT.

ST ATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE DEPUTY SUPERINTENDENT Robert E. Doucette, Jr. OTPCt O) NEW MEXICO iuptui+noiotrii Cll 1}illlRANCE DEPUTY SUPERINTENDENT Andy Romero SUPERINTENDENT OF mSURANCE John G. Franchini BULLETIN 2019-012 August 12, 2019 a-fl "I 71 ;if: t'il i -n TO: ALL INSURANCE CARRIERS THAT OFFER HEALTH BENEFITS PLANS SUBJECT TO THE SURPRISE BILLING PROTECTION ACT RE: S.B. 337, SURPRISE BILLING PROTECTION ACT THE FOLLOWING BULLETIN is issued pursuant to Sections 59A-2-8 and 59A-2-10 NMSA 1978 and 13.1.2.1 to 13.1.2.10 NMAC. On April 4, 2019, Governor Michelle Lujan Grisham signed Senate Bill 337, the Surprise Billing Protection Act ("the Act"), effective January 1, 2020. The Act may apply when a covered person receives out-of-network emergency care or receives non-emergent care from a nonparticipating provider at a participating facility. Under these circumstances, the Act provides that consumers are responsible only for the amount theywould pay if theyhad received the services from a participating facility or provider. See S.B. 337, § 2(Y). The Act also establishes a reimbursement mechanism for the balance due to a provider from a carrier for the services rendered. The Act sets a reimbursement rate for surprise medical bills where no contract exists between the provider of services and the covered person's insurer uld pay if theyhad received the services from a participating facility or provider. See S.B. 337, § 2(Y). The Act also establishes a reimbursement mechanism for the balance due to a provider from a carrier for the services rendered. The Act sets a reimbursement rate for surprise medical bills where no contract exists between the provider of services and the covered person's insurer. This reimbursement rate is defined as "the sixtieth percentile of the allowed commercial reimbursement rate for the particular health care service performed by a provider in the same or similar specialty in the same geographic area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Superintendent of Insurance after consultation with health care stakeholders; provided that no surprise bill reimbursement rate shall be paid at less than 150% of the Medicare reimbursement Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd HE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186 i Toll Free: (855) 4 - ASK - OSI www.osi.state.iu'n.us B [l L L E -l' I N 2 (i I €) - O l 2 P a '=' e 2 ratefortheapplicablehealthcareserviceprovided." Laws20l9,Chapter227,Sectionl3(C). The Act requires that the nonprofit organization be conflict-'free and unaffiliated with any stakeholder in the health care sector. On May 13, 2019, the Office of Superintendent of Insurance (OSI) posted a Request for Information (RFI) for data benchrnarking firms that meet the specifications in the Surprise Billing ProtectionAct. OSI also distributed the RFI to stakeholders from the health care provider, carrier, consumer advocate, consulting, and agent and broker communities. OSI received only one response to this RFI; that response was from the data benchmarking non-profit firm Fair Health ion (RFI) for data benchrnarking firms that meet the specifications in the Surprise Billing ProtectionAct. OSI also distributed the RFI to stakeholders from the health care provider, carrier, consumer advocate, consulting, and agent and broker communities. OSI received only one response to this RFI; that response was from the data benchmarking non-profit firm Fair Health. Fair Health's response to the RFI is available on the OSI website at this link or upon request. Fair Health appears to be the only data-benchmarking firm that fits the criteria outlined in the Surprise Billing Protection Act. Additionally, Fair Health will not charge the agency for the requested data, nor will it charge health insurance carriers or providers to provide claims data to the firm. Accordingly, OSI has selected Fair Health to provide claims data for the "surprise bill reimbursement rate" established rinder the Surprise Billing Protection Act. This selection will remain in effect until further notice. Any person aggrieved by a bulletin may request a hearing before the Superintendent in accordance with Section 59A-4-15 NMSA 1978. If you have questions regarding this Bulletin, please contact the Life and Health Product Filing Bureau at (505) 827-4601 or LHRFF.osi@state.nrn.us. DONEANDORDEREDthis 12I'1 dayofAugust20l9. G. FRANCHINI perintendent of Insurance Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 SatelliteOffice: 6200UptownBlvdNE,SuitelOO,Albuquerque,HA/I87110 Main Phone: (505) 827-4601 Satellite Phone: (505) 322-2186 Toll Free: (855) 4 - ASK - OSI www.osi.state.ntn.us