SURPRISE MEDICAL BILLING

ST ATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Russell Toal J'si j[W%4i%[gf: i oimama> DEPUTY SUPERINTENDENT Robeit E. Doucette, Jr. BULLETIN 2020-009 APRIL 20, 2020 rAWylex 0 I" a'$t+lla TO: AI,L MAJOR MEDICAL CARE PROVIDERS AND THIS STATE ri'i Ca) HEALTH INSURANCE CARRIERS AND nbhan FACILITIES SUBJECT TO THE JURISDICTION OF RE: SURPRISE MEDICAL BILLING The New Mexico Office of Superintendent of Insurance ("OSI") is working to ensure timely and affordable access to health care services for all New Mexicans. In Docket No. 20-00016, OSI promulgated emergency rules to expedite tlie testing, diagnosis, and treatment of individuals witli COVID-19. In tliat Order, OSI recognized that a consumer's decision to secure appropriate healtli care services may be limited by out-of-pocket costs. OSI therefore eliminated consumer orit-ofpocket cost-sliaring for testing and treatment of COVID-19 sympton'is. As this crisis continues, OSI has learned of additional access issues wliere liospitals may route those seeking care at in-network facilities to out-of-network facilities or providers. In tliese instances, OSI would like to remind carriers of the circui'nstances that trigger responsibilities to hold consumers liarmless for tlie diagnosis, testing, and treatment of COVID-19. Tliese responsibilities include tlie scenarios listed below. * If a medically necessary service is unavailable in-network, a carrier is required to cover tlie service from an out-of-network provider as if tlie service was provided in-network, and tlie covered person sliall only be liable for in-network costsharing. 13.10.22.8 (E) NMAC. OSI clarifies that this provision may be triggered due to lack of beds or providers to treat individuals presenting witli non-COVID- 19 conditions or other critical conditions at an in-network facility, or it may be the result of tlie care triage system put in place for the crisis. A patient's specific consent to receiving out-of-network care sliall not absolve a carrier of its responsibility to cover tlie service. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us B U L L E T l N 2 0 2 0 - 0 0 9 P a g e 2 * If an in-network provider mistakenly refers a patient to an out-of-network provider, the covered person shall only be liable for in-network cost-sharing. 13.10.22.8(E) NMAC. Tl'iis rule applies to all covered services. OSI specifically reqriests that carriers grant in-network providers flexibility to direct or refer patients to appropriate care, wliicli may be out-of-network, as pressures on the healthcare system grow during the COVID-19 crisis. A patient's specific consent to receiving orit-of-network care sliall not absolve a carrier of its responsibility to cover out-of-network services in these circumstances. * If an individual seeks testing or care for COVID-19 symptoms at an out-ofnetwork provider, the testing and associated services, including evaluation and stabilization, are to be covered itarespective of whether the tests results are positive or negative. All out-of-network treatment for COVID-19 symptoms shall be treated as emergency care, including admission to a hospital wliile awaiting diagnosis. * If a covered person at an in-network facility does not have tl'ie ability or oppoitunity to clioose a paiticipating provider who is available to provide tlie covered service, the carrier shall limit the covered person's cost-sliaring to their plan's in-network rates. Section 59A-57A-4, NMSA 1978. OSI aleits caiariers that this may include circumstances where covered persons are treated by contract providers at in-network hospitals. * Ifacoveredpersonisreferredtooneofthestate-sanctionedorcreatedCOVID-19 emergency treatment centers, sucli centers shall be considered an in-network provider, and tlie carrier shall accept tl'ie billings from the center and pay at the carrier's in-network rate for tlie services provided. Covered persons treated at tlie centers sliall not liave any co-pay or cost-sliaring obligations for services received. Witl'i tlie exception of tlie emergency treatment centers mentioned immediately above, carriers shall reimburse out-of-network providers, including facilities, using the surprise billing rate described in Section 59A-57A-13, NMSA 1978. Where tl'iere is no data available in tlie Fair Healtli bencl'u'narking database for a paiticular billing code, a liealtli insurance carrier shall reimburse a provider at 150% of tl'ie 2017 Medicare reimbursement rate. Health care providers sliall submit bills directly to the patient's insurance provider, regardless of whetlier the provider has a contract with the plan. No provider sliall balance or surprise bill a patient. A healtli care provider that knowingly surprise bills a patient for out-of-network care may be subject to a fine pursuant to Section 59A-16-21.3, NMSA 1978. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NA/I87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Plione: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.mn.us B U L L E T I N 2 0 2 0 - 0 0 9 l) a g e 13 Any person aggrieved by a bulletin may request a liearing before tlie Superintendent in accordance with Section 59A-4-15, NMSA 1978. If you liave questions regarding tliis bulletin, please contact tlie Life and Healtli Product Filing Bureau at (505) 827-4601 or LHRFF.osi@state.nm.us. ISSUED this 20" day of April, 2020. :UsesrEin"e',AtoLf Insurance Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Plione: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nin.us