Section 59A-57A-11 – Information from provider networks.
The superintendent: A. may require that health insurance carriers report the annual percentage of claims and expenditures paid to nonparticipating providers for health care services; and B. may require by rule a report on changes to the percent of claims paid as an emergency claim. History: Laws 2019, ch. 227, § 11. ANNOTATIONS Effective dates. […]
Section 59A-57A-12 – Applicability.
The provisions of the Surprise Billing Protection Act apply to the following types of health coverage delivered or issued for delivery in this state: A. group health coverage governed by the provisions of the Health Care Purchasing Act [Chapter 13, Article 7 NMSA 1978]; B. individual health insurance policies, health benefits plans and certificates of […]
Section 59A-57A-13 – Providers; reimbursement for a surprise bill. (Repealed effective July 1, 2023.)
A. For services provided pursuant to Section 3 [59A-57A-3 NMSA 1978] or 4 [59A-57A-4 NMSA 1978] 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. B. The surprise bill reimbursement rate shall be calculated using claims data reflecting […]
Section 59A-57A-1 – Short title.
Sections 1 through 13 [59A-57A-1 to 59A-57A-13 NMSA 1978] of this act may be cited as the “Surprise Billing Protection Act”. History: Laws 2019, ch. 227, § 1. ANNOTATIONS Effective dates. — Laws 2019, ch. 227, § 16 made Laws 2019, ch. 227 effective January 1, 2020.
Section 59A-57A-2 – Definitions.
As used in the Surprise Billing Protection Act: A. “allowed amount” means the maximum portion of a billed charge that a health insurance carrier will pay, including any applicable covered person cost-sharing responsibility, for a covered health care service or item rendered by a participating provider or by a nonparticipating provider; B. “balance billing” means […]
Section 59A-57A-3 – Emergency care; reimbursement; limitation on charges.
A. A health insurance carrier shall reimburse a nonparticipating provider for emergency care necessary to evaluate and stabilize a covered person if a prudent layperson would reasonably believe that emergency care is necessary, regardless of eventual diagnosis. B. A health insurance carrier shall not require that prior authorization for emergency care be obtained by, or […]
Section 59A-57A-4 – Non-emergency care; limitation on charges.
A. Other than applicable cost sharing that would apply if a participating provider had rendered the same services, a health insurance carrier shall provide reimbursement for and a covered person shall not be liable for charges and fees for covered non-emergency care rendered by a nonparticipating provider that are delivered when: (1) the covered person […]
Section 59A-57A-5 – Credit against maximum out-of-pocket cost-sharing amount; communication by hospitals; advance notification of charges for health care services.
A. A nonparticipating provider shall not knowingly submit a surprise bill to a covered person. B. In accordance with the hearing procedures established pursuant to the Patient Protection Act [Chapter 59A, Article 57 NMSA 1978], a covered person may appeal a health insurance carrier’s determination made regarding a surprise bill. C. By July 1, 2020, […]
Section 59A-57A-6 – 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 in excess of the […]
Section 59A-57A-7 – 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 […]