[HISTORY: Adopted by the Board of County Commissioners of Otero County 5-19-2016 by Ord. No. 16-04. Amendments noted where applicable.]
STATE LAW REFERENCES
Open Meetings Act — See NMSA 1978, § 10-15-1.
Expenses for burial or cremation — See NMSA 1978, § 24-13-3.
Burial after investigation; cost of opening and closing grave — See NMSA 1978, § 24-13-4.
Public Assistance Act — See NMSA 1978, §§ 27-2-1 through 27-2-47.
Indigent Hospital and County Health Care Act — See NMSA 1978, §§ 27-5-1 et seq.
Statewide Health Care Act — See NMSA 1978, §§ 27-10-1 through 27-10-4.
Mental Health and Developmental Disabilities Code — See NMSA 1978, § 43-1-3 et seq.
Administrative appeals; statutory review by District Court of administrative decisions or orders — See NMRA, Rule 1-074.
Editor's Note: This ordinance also superseded former Ch. 140, Indigent Hospital Claims, adopted 8-20-2009 by Ord. No. 09-01, as amended.
The title of this chapter shall be "The Otero County Health Care Assistance Ordinance."
The legal authority for this chapter is the New Mexico Indigent Hospital and County Health Care Act (NMSA 1978, §§ 27-5-1 through 27-5-18, as amended, and NMSA 1978, §§ 27-10-1 through 27-10-4, as amended).
As enacted by the Board of County Commissioners of Otero County on August 20, 2009, the effective date of this chapter is August 20, 2009. All prior and previous ordinances regarding indigent care are hereby repealed.
Pursuant to the Indigent Hospital and County Health Care Act, NMSA 1978, §§ 27-5-1 through 27-5-18, as amended, and pursuant to NMSA 1978, §§ 27-10-1 through 27-10-4, as amended, Otero County is the responsible agency for the care of indigent patients domiciled in the County and must provide the financial means to discharge that duty, and Otero County is authorized by the Legislature of the State of New Mexico to enact a gross receipts tax ordinance dedicating to the County-Supported Medicaid Fund an amount of gross receipts taxes not to exceed 3/8 of 1% applied to the taxable gross receipts reported during the prior fiscal year by persons engaging in business in the County. Therefore, the Board of County Commissioners of Otero County by this chapter hereby provides for the care of indigent patients and the administration of the funds necessary to satisfy the County's obligation to the County Supported Medicaid Fund and Safety Net Care Pool.
As used in this chapter and to enable Otero County to discharge its responsibility, the following definitions shall be used. The definitions shall be interpreted in all cases to achieve the purpose of the Act.
- The New Mexico Indigent Hospital and County Health Care Act (NMSA 1978, §§ 27-5-1 through 27-5-18, and NMSA 1978, §§ 27-10-1 through 27-10-4, as amended).
- ALCOHOL REHABILITATION CENTER
- An agency that operates alcohol abuse rehabilitation programs that meet the standards set by the Department of Health.
- AMBULANCE PROVIDER or AMBULANCE SERVICE
- A specialized carrier based within the State of New Mexico authorized, under provisions and subject to limitations as provided in individual carrier certificates issued by the Public Regulations Commission, to transport persons alive, dead or dying en route by means of ambulance service. The rates and charges established by the Public Regulations Commission's tariff shall govern as to allowable costs. Also included are air ambulance services approved by the Board.
- The patient, the patient's spouse, the patient's parent or guardian if the patient is a minor, or the guarantor of the hospital or ambulance bill. In the event of the death of the patient, the executor, administrator, personal representative, relative of the deceased, the person responsible for the hospital bill or any interested party providing information on behalf of the deceased may be the applicant.
- The Otero County Health Care Board.
- CHILD SUPPORT AGENCY
- Any state or local agency which is responsible by law for enforcement and collection of child support payments under an order of payment, including, but not limited to, the District Attorney.
- CLAIMS ADMINISTRATOR
- The person employed by Otero County to administer claims on a daily basis which are submitted for payment from the fund.
- The New Mexico Health Policy Commission.
- All allowable costs of providing health care services incurred for an indigent patient by a health care provider as defined herein. Allowable costs shall be based on Medicaid fee-for-service reimbursement rates for hospitals, licensed medical doctors and osteopathic physicians.
- Otero County, New Mexico.
- COUNTY ASSISTANCE
- The financial assistance that Otero County provides to indigent patients under authority of the New Mexico Indigent Hospital and County Health Act.
- COUNTY COMMISSION
- The Board of County Commissioners of Otero County.
- Calendar days, and includes weekends and holidays.
- The Human Services Department of the State of New Mexico.
- DOMICILE or RESIDENCE
- A person's actual physical dwelling in Otero County and where a person clearly intends to make Otero County the person's permanent home.
- DRUG REHABILITATION CENTER
- An agency that operates drug abuse rehabilitation programs that meet the standards and requirements set by the Department of Health.
- A house, apartment, mobile home, trailer, manufactured home, cabin, motel, hotel, triplex, duplex, hut or any other type of building or physical structure intended or used for human habitation.
- EMPLOYED OR CONTRACTED PHYSICIANS
- A physician who is employed by or contracts with a health care provider to provide services which are billed through and by the health care provider on a routine, normal or regular basis.
- A spouse, former spouse, child, cousin, aunt, uncle, parent, grandparent, and persons who are natural or adoptive parents of a child, regardless of whether they have been married or have lived together at any time.
- The Otero County Health Care Assistance Fund, which shall consist of the revenues generated solely through the gross receipts tax referred to above, and shall not, under any circumstances, exceed the amounts so dedicated by the Board of County Commissioners, nor shall the fund be considered to be any other funds of the County of Otero.
- HEALTH CARE INSTITUTION
- Any general or limited hospital or clinic licensed by the Health and Environment Department, whether nonprofit or for-profit, or owned by the state or a political subdivision, and shall include licensed out-of-state health care institutions where treatment provided is necessary for the proper care of an indigent patient, when such care is not available in an in-state health care institution as determined by the Otero County Health Care Board; and shall include in-state licensed home health agencies which comply with the provisions of the Indigent Hospital and County Health Care Act.
- A. A nursing home;
- B. An in-state home health agency;
- C. An in-state licensed hospice;
- D. A community-based health care program operated by a political subdivision of the State of New Mexico or other nonprofit health organization that provides for prenatal care delivered by New Mexico licensed, certified or registered health care practitioners;
- E. A community-based health program operated by a political subdivision of the State of New Mexico or other nonprofit health care organization that provides primary care delivered by New Mexico licensed, certified or registered health care practitioners;
- F. A drug rehabilitation center;
- G. An alcohol rehabilitation center;
- H. A mental health center;
- I. A licensed medical doctor, osteopathic physician, dentist, optometrist or expanded practice nurse when providing services in a hospital or outpatient setting that are necessary for conditions that endanger the life or threatened permanent disability to an indigent patient;
- J. A dental clinic providing dental care;
- K. An optometry or ophthalmology clinic providing vision care; or
- L. Any health facility contracted with Otero County to provide health care services.
- HEALTH CARE SERVICES
- All treatment and services designed to promote improved health in the County indigent population, including primary care, prenatal care, dental care, behavioral health care, alcohol or drug detoxification and rehabilitation, hospital care, provision of prescription drugs, preventative care or health outreach services, to the extent determined by resolution of the Board.
- INDIGENT PATIENT
- A person whose principal place of residence is, and whose domicile is located within Otero County for at least 90 days preceding the provision of medical service and/or ambulance transportation, and to whom an ambulance service or a health care provider has provided medical care or ambulance transportation and who can normally support the person's self and the person's dependents on present income and liquid assets available to the person but, taking into consideration the person's income, assets and requirements for other necessities of life for the person and the person's dependents, is unable to pay the cost of the ambulance transportation or medical care administered, or both; provided, however, it shall not include any person whose annual income, together with the spouse's annual income, totals an amount which is 50% greater than the per-capita personal income for New Mexico as shown for the most recent year available in the survey of current business published by the United States Department of Commerce. The term "indigent patient" shall include a minor who has received ambulance transportation or medical care, or both, and whose parent, or the person having custody, would qualify as an indigent patient if transported by ambulance, or admitted to a health care provider for care, or both. The term "indigent patient" shall also include persons who are incarcerated in the Otero County Detention Center.
- Permissive or discretionary but not mandatory.
- A person who is eligible for medical assistance from the Department.
- MEDICAL SERVICES
- The type and number of services which usually and naturally flow from and are associated with ambulance transportation services, health care institutions and health care providers.
- MEDICAL TREATMENT ELIGIBILITY AND PAYMENT
- No approval of payments will be made from the fund when the patient has health insurance coverage available to make any payment for medical services provided. No approval of payments will be made from the fund for the purpose of paying health insurance deductible amounts that are the responsibility of the patient.
- MENTAL HEALTH CENTER
- A center that provides outpatient mental health services that meet the standards set by the Department of Health.
- MINOR or CHILD
- A person who is less than 18 years of age.
- ONE YEAR
- Three-hundred-sixty-five calendar days; for leap years "one year" means 366 calendar days.
- The person who has actually received ambulance, hospital or health care services.
- The development of a Countywide or multicounty health plan to improve and fund health services in the County based on the County's needs assessment and inventory of existing services and resources and that demonstrates coordination between the County and state and local health planning efforts.
- PUBLIC AGENCY
- Any state, local, tribal, or federal government unit, agency, department, division or bureau which is publicly funded.
- A. A hospital that qualifies under the provisions of the federal Medicare guidelines; or
- B. An acute care general care hospital licensed by the Department of Health that is qualified, pursuant to the rules adopted by the state agency primarily responsible for the Medicaid program, to receive distributions from the Safety Net Care Pool Fund.
- Mandatory or without choice.
- THREE MONTHS
- Ninety calendar days and includes weekends and holidays.
In the event a particular case presents circumstances requiring interpretation of this chapter, this chapter shall be interpreted broadly in order to accomplish its purpose which purpose is contained in § 140-4.
The Otero County Health Care Board (Board) shall be composed of three members who shall reside in and be appointed from each County Commission District. The appointment required herein shall be accomplished by nomination of the Commissioner from each district with the approval of the whole Board of County Commissioners.
No member of the Board shall be an employee of Otero County.
Members of the Board shall receive no compensation but shall be reimbursed for their actual per-diem and mileage in an amount not to exceed the per-diem and mileage paid to the County Commissioners.
The County shall furnish each member of the Board a surety bond premium, which shall be paid from the fund executed by a surety company licensed to do business in New Mexico, conditioned that the Board member shall faithfully perform Board member duties and account for the funds. The bond shall be in the sum of $5,000 running to the benefit of the Board for payments into the fund.
Until such time as the Board of County Commissioners of Otero County appoints a County Health Care Board, the Board of County Commissioners shall perform all of the responsibilities of the County Health Care Board.
Rules and regulations.
The Board shall meet as determined by the Board and as often as otherwise necessary, but no less than quarterly each calendar year.
At its first meeting of each year and from among its members, the Board shall elect a Chair and Vice Chair, and subsequently at the same meeting, certify the amount needed for the fund for the next fiscal year. The Chair or Vice Chair shall have the authority to maintain decorum and order at Board meetings and shall administer oaths to persons appearing as witnesses before the Board.
At its last meeting in December of each year, the Board shall review and establish the standards for eligibility and allowable costs which shall apply to the following calendar year.
The Board shall hold meetings in the Otero County Courthouse, in the City of Alamogordo and at other sites within Otero County at the direction of the Board. The meetings of the Board shall be subject to the requirements of the New Mexico Open Meetings Act, and accordingly the Board shall adopt an open meetings resolution at its first meeting in the month of January of each year. The Board shall keep a record of all of its proceedings.
Editor's Note: See NMSA 1978, § 10-15-1 et seq.
At its quarterly meeting in June of each year, the Board shall approve, as amended, the Otero County Annual Report of Health Care Assistance, which shall then be submitted to the Commission for the Commission to then submit to the Local Government Division of the State Department of Finance and Administration.
Shall administer claims pursuant to the provisions of the Indigent Hospital and County Health Care Act (NMSA 1978, § 27-5-1 et seq.);
Shall prepare or submit in March of each year a budget to the County Commission for the amount needed to defray claims made upon the fund and to pay costs of administration of the Act, which costs of administration and planning shall in no event exceed the following percentages of revenues based on the previous fiscal year's revenues for a fund that has existed for at least one fiscal year or based on projected revenues for the year being budgeted for a fund that may be used for administrative costs is equal to the sum of the following:
Shall make rules and regulations necessary to carry out the provisions of the Act, provided that the standards for eligibility and allowable costs for Otero County indigent patients shall be no more restrictive than the standards for eligibility and allowable costs prior to December 31, 1992;
Shall set criteria and cost limitations for medical care by licensed out-of-state hospitals, ambulance services or health care providers;
Shall cooperate with appropriate state agencies to use available funds efficiently and to make health care more available;
Shall cooperate with the Department in making any investigation to determine the validity of claims and upon the fund for any indigent patient;
May accept contributions, which shall be deposited in the fund;
Shall be assigned the Otero County Claims Administrator, who shall be delegated the daily administration of the fund;
Shall review all claims presented by a hospital, ambulance service, or health care provider to determine compliance with this chapter, the rules and regulations adopted by the Board or with the provisions of the Act, determine whether the patient for whom the claim is made is an indigent patient and determine the allowable medical or ambulance service costs, provided that the burden of proof of any claims shall be upon the hospital, ambulance service or health care provider; shall state, in writing, the reason for rejecting or disapproving any claim and shall notify the submitting hospital, ambulance service, or health care provider of the decision;
Shall certify all claims that are not matched with federal funds under the state Medicaid program and that have been approved by the Board from the fund;
Shall determine in accordance with this chapter the types of health care providers that will be eligible to submit claims under the Indigent Hospital and County Health Care Act;
Shall transfer to the State Treasurer by the last day of March, June, September, and December of each year an amount equal to 1/4 of the County's payment for support of the Safety Net Care Pool Fund as calculated by the Department for the County for the current fiscal year. This money shall be deposited in the Safety Net Care Pool Fund;
May provide for the transfer of money from the Health Care Assistance Fund to the Otero County supported Medicaid Fund to meet the requirements of the Statewide Health Care Act (NMSA 1978, §§ 27-10-1 to 27-10-4, as amended);
Shall, through and under authority of the Otero County Board of Commissioners, file an annual report on health care assistance funded in whole or in part by Otero County with the Local Government Division of the New Mexico State Department of Finance and Administration.
The report shall contain:
Otero County's eligibility criteria for indigent patients;
Services provided to indigent patients;
Restrictions on services provided to indigent patients;
Conditions for reimbursement to providers of health care;
Revenue sources used to pay for indigent health care; and
Other related information determined by the Local Government Division of the New Mexico State Department of Finance and Administration;
The report shall be submitted by July 31 of each year on a form provided by the Local Government Division and shall provide information from the previous fiscal year. The Local Government Division makes the public report available to any interested person;
Shall, through and under authority of the County Commission, and for the purpose of providing funds for the administration of the Act, at its quarterly meeting in January each year, certify the amount needed to the County Commission. The Board shall use the previous year's experience to determine the amount necessary;
May develop through its rules and regulations a policy and procedure providing for the certification of and/or payment of claims regarding prescription drugs necessary to the medical treatment of patients who are otherwise eligible for benefits pursuant to this chapter.
There is created in the Otero County treasury an Otero County Health Care Assistance Fund.
All contributions and taxes collected pursuant to this chapter and pursuant to state law as those funds are dedicated by the Board of County Commissioners to meet the County's obligation, pursuant to NMSA 1978, §§ 27-10-1 through 27-10-4, the Statewide Health Care Act, shall be placed into the fund, and the amount placed therein shall be budgeted and expended only for the purposes specified in the Indigent Hospital and County Health Care Act as interpreted from time to time by the Taxation and Revenue Department of the State of New Mexico, or as allowed by law. Certification of requests for reimbursement shall be made upon an application approved by a majority of the Board that is signed by the Chairman of the Board and attested by the County Clerk, and no other Otero County fund shall be taken into consideration or be deemed responsible to make payment for the purposes set forth in this chapter.
When calculating the maximum amount to be certified for medical care specified above, the Administrator shall include any amounts paid on behalf of the indigent by health insurance providers. When submitting bills for reimbursement, hospitals, health care institutions, health care providers and ambulance providers shall certify to the Administrator the amount paid, if any, on the bill by any health insurance providers.
The fund shall be audited in the manner that all Otero County funds are audited, and all records of payments and verified statements of qualification upon which payments were made from the fund shall be open to the public.
Any balance remaining in the fund at the end of the fiscal year may be expended as allowed by law, or in accordance with the Taxation and Revenue Department Letter of December 14, 1994. Alternatively, such balance shall carry over into the ensuing year, and such balance shall be taken into consideration in the determination of the ensuing year's budget and certification of need for the purposes of making a tax levy pursuant to the Indigent Hospital and County Health Care Act and/or for the purposes of designating funds collected pursuant to the County Gross Receipts Tax Act for use in the Otero County Health Care Assistance Fund.
Money may be transferred into the fund from other sources, but no transfers shall be made from the fund for any purposes other than specified in this chapter or the Indigent Hospital and County Health Care Act.
The Board of County Commissioners of Otero County, upon the certification of the Otero County Health Care Board, may impose a levy against the taxable value of the property in Otero County sufficient to raise the amounts certified by the Board for any deficiency in the fund. Any levy so made shall be made in strict compliance with and pursuant to NMSA 1978, § 27-5-9, as amended, including submission of the question of imposing an indigent hospital levy to the electors of Otero County.
A hospital shall not be paid from the fund under the Indigent Hospital and County Health Care Act for any costs when the patient has been determined by the Human Services Department to be eligible for Medicaid reimbursement.
No action for collection of claims under the Indigent Hospital and County Health Care Act shall be allowed against an indigent patient who is Medicaid-eligible for Medicaid-covered services, nor shall action be allowed against the person who is legally responsible for the care of the indigent patient during the time that person is Medicaid-eligible, and is receiving assistance pursuant to this chapter.
Any eligible recipient health care providers in New Mexico or licensed out-of-state health care providers and ambulance services are required to file the following data:
Current data, statistics, schedules and information deemed necessary by the Board to determine the cost for all patients in that institution or tariff rates or charges of an ambulance service;
Proof that such health care provider or ambulance service is licensed, where required, under the laws of this state or the state in which the health care provider or ambulance service operates; and
Any other information or data deemed necessary by the Board.
Only actual hospital costs will be considered for certification.
Prior to the consideration of any individual claim, a health care institution, health care provider or ambulance service filing a claim with the Board shall:
File claims with the Board only for indigent patients whose principal place of residence is located in or who have been domiciled in Otero County for more than 90 days prior to the date upon which the ambulance or medical services were rendered;
File claims for each patient separately, with an itemized statement detailing the total cost;
File with the claim a verified statement of qualification for indigent hospital care signed by the patient, or by the parent or person having custody, to the effect that he qualifies under the provisions of the Indigent Hospital and County Health Care Act as an indigent patient and is unable to pay the cost for the care administered and listing all assets owned by the patient or any person legally responsible for care. The statement shall constitute an oath of the person signing it, and any false statements in the statement made knowingly shall constitute a felony.
Claims from eligible health care facilities outside of Otero County but located within the State of New Mexico must be filed in the same manner as claims in Otero County, but such claims will be considered for certification only if funds are available within the fiscal year in which the claim is filed, after certification of all in-County claims.
Out-of-state claims will be considered for certification and shall be filed in the same manner as claims from within Otero County, but such claims will only be considered for certification if it is documented that the care or service was not available in Otero County, if funds are available within the fiscal year in which the claim is filed, after certification of all claims from within Otero County, and after certification of all claims from outside of Otero County within the State of New Mexico.
Claims must be filed within 75 days of the patient's discharge from the health care provider or the transportation date by an ambulance service.
Within 75 days of receipt of services, applicants shall submit to the Claims Administrator a complete application form and required attachments. Application forms are available at the Otero County offices, and at ambulance, hospital and health care provider offices.
In order to obtain expedited processing, the application should be submitted to the Claims Administrator within 15 days of the patient receiving a statement of charges for ambulance, hospital or health care services.
The Claims Administrator shall determine if the patient is eligible. The application shall contain, either in the application or by attachments, the following information:
The patient's most recent three paycheck or payroll stubs.
State and federal tax returns for the tax year immediately preceding the application. This subsection does not apply to persons who are exempt from paying taxes, provided that the applicant shall submit proof of exemption.
Evidence of other income.
Gross family income.
The names of agencies providing any other public financial assistance to the patient.
Proof of residency in Otero County for three months:
Utility bills include those from phone, electric, gas and cable television companies.
Landlord or family member statements that the patient has been domiciled or resided in Otero County for three months prior to the date the services were rendered are acceptable only when the Claims Administrator determines that individual circumstances permit statements instead of utility bills.
Status of applications.
A file shall be maintained by the Claims Administrator and shall be in chronological and alphabetical order by year and patient name and shall include files which are subject to current processing or payment from the fund.
Applicants who fail to complete their file within 75 days of the date it was submitted shall be denied.
The Claims Administrator shall review the applications and attachments for accuracy and patient eligibility.
Inaccurate or incomplete applications shall be returned to the applicant for correction or for completion.
The Claims Administrator shall assist the applicant to make corrections and completions to the application and to gather necessary information. Written instructions and lists to applicants from the Claims Administrator are encouraged.
No applications are allowed before a patient receives ambulance, hospital or health care provider services.
Only actual or allowable costs shall be reimbursed.
The Claims Administrator shall ensure that the patient has exhausted all available sources of other public agency financial assistance.
The patient or applicant shall provide proof of such exhaustion of all other sources of public agency financial assistance. Letters of denial of assistance from other agencies are the preferred method of proof, but, in the Claims Administrator's judgment and with approval of the Board, other types of authentic proof may be used.
In the event the patient has not exhausted other sources, the Claims Administrator shall direct the patient or applicant to those other unexhausted public agency sources before proceeding forward with the Otero application.
In the event the patient has received or is eligible to receive only partial assistance from other public agency sources, charities, and/or private insurance, the Claims Administrator shall continue forward with the application but only to the extent that the Board may approve fund assistance for the amount of costs not covered by those other sources of financial assistance.
The Claims Administrator may combine several related applications which are the result of one patient receiving prolonged physician-recommended treatment which requires hospital services, provided that the application is filed within 75 days after receipt by the applicant of the latest in the series of treatments involved.
To facilitate the advantageous use of the available funds and the equitable distribution of the funds available, the following exclusions and limitations are applicable:
Claims for outpatient and emergency room services from any health care provider in the amount of $350 or less will not be considered for certification. This limitation shall not apply to health care providers operating or providing services in the various County clinics.
A hospital shall not be paid from the fund under the Indigent Hospital and County Health Care Act for costs of an indigent patient for services that have been determined by the Department to be eligible for Medicaid reimbursement. However, nothing in this chapter shall be construed to prevent the Board from transferring money from the fund to the Safety Net Care Pool or the County Supported Medicaid Fund for support of the state Medicaid program.
No action for collection of claims under this chapter shall be allowed against an indigent patient who is Medicaid-eligible for Medicaid-covered services, nor shall action be allowed against the person who is legally responsible for the care of the indigent patient during the time that the person is Medicaid-eligible.
The maximum amount to be certified for medical care or services for a single claim shall not exceed $10,000. Should claims for any individual patient in excess of $10,000 be received, the maximum certification for reimbursement shall be $30,000 for approved claims of any individual patient in any fiscal year. The maximum amount to be certified for a single claim for ambulance service shall be $500.
Whenever the balance of the fund is inadequate to certify all qualified claims as they become due, the claims of in-state, in-County health care providers providing acute medical care shall have priority for certification over all other claims, regardless of the dates the other claims were submitted, unless an out-of-County, out-of-state health care provider has demonstrated that the care was not available in Otero County. The Board shall, on a regular basis, estimate future demands upon the fund, based on past experience, and set aside sufficient funds to assure certification for in-state health care providers providing acute medical care and then address, on a regular basis, the claims from other health care providers or ambulance services. Out-of-state and out-of-County health care providers must provide documentation that treatment/service was required and was not available at a health care provider in Otero County.
An unpaid claim made to the Board for certification for the care of an indigent patient shall not expire or become invalid because of the lack of money in the fund during any fiscal year but shall be carried over into the ensuing year and, notwithstanding the provisions of any other law, shall be reviewed for certification in six-month intervals during the ensuing fiscal year.
Any health care provider or ambulance service which shall make application for certification on behalf of a patient from the fund shall immediately discontinue further efforts to make collections of outstanding balances from the patient, guarantor or responsible party. In the event that the Healthcare Assistance Fund shall make all or partial certification of the indebtedness due by the patient to the health care provider or ambulance service, the health care provider or ambulance service, as a condition to receipt of such certification, shall forgive the balance due from the patient in accordance with the Indigent Hospital and County Health Care Act.
A health care provider shall not be paid, nor be allowed certification for reimbursement from the fund, for any charges when the patient has been determined by the Human Services Department to be eligible for medical assistance from that Department. The Board reserves the right to reject any claim or any part of any claim submitted by any health care provider or ambulance service within the limitations set forth in the statutes of the State of New Mexico or the rules adopted by the Board.
To be considered for certification, ambulance claims shall be submitted in the same manner as health care provider claims and shall be certified in the same order of priority.
Psychiatric care claims shall be limited to and paid as follows:
Emergency situations in which there exists the likelihood of serious harm to the patient or to others, as defined in NMSA 1978, § 43-1-3 et seq.
In any event, payment for psychiatric care shall not be authorized for care which exceeds five days' hospitalization, provided that, in the event that a voluntary or involuntary commitment to the State Hospital is instituted within said five-day period, payment may be made for an additional two days at the discretion of the Board.
In no event shall any other psychiatric care be paid.
Under no circumstances shall the Otero County Health Care Board authorize any payment for more than one psychiatric claim per patient in any twelve-month period of time.
Claims for psychiatric care or hospitalization for the treatment of alcohol or other substance abuse shall only be eligible if such care meets the above requirements and will be paid only once per twelve-month period of time, and payment shall not exceed 28 days for each period of hospitalization care or service.
Psychiatric care or hospitalization may include reasonable charges for counseling or other therapy which may be in addition to the usual and customary charges for nursing services on nonpsychiatric wards which are usually expressed in terms of room-per-day charges.
The Board shall have absolute discretion and may reject any claim in whole or any line item billed.
Payment to a hospital from the fund of any claim shall operate as an assignment to the Board of any cause of action to the extent of the payment from the fund to the hospital. Accordingly, in the event the hospital is subrogated to liability claims which are the patient's, the hospital shall provide subrogation to the Board. Likewise, any applicant who receives reimbursement through a liability claim shall provide subrogation to the Board. Notice of the potential of reimbursement through subrogation to the proceeds of a liability claim shall accompany the original application.
Claims for reimbursement under the provisions of the Act and/or this chapter will be excluded if the injury requiring hospitalization or ambulance service is the result of any conduct or activity of the patient which constitutes criminal conduct. In the event that there is a question regarding the criminal nature of the circumstances giving rise to the injury, the claim will be held in suspense pending the final determination by the District Attorney's office.
Assistance shall be paid for incarcerated persons by the STMII (Short Term Medicaid For Incarcerated Individuals) Program prior to application for assistance from the Otero County Health Care Fund in accordance with STMII eligibility. Proof of denial must be attached to the application for assistance from the Otero County Health Care Fund.
To the extent that a deceased person is indigent, the burial or cremation expenses shall be paid by the County's Indigent Hospital Claims Fund in an amount up to but not exceeding $600 for the burial or cremation of any adult or minor as provided in NMSA 1978, § 24-13-3.
To the extent that a deceased person is indigent, the cost for opening and closing of a grave, or storage of an urn containing cremated remains, shall be paid by the County's Indigent Fund in a sum not to exceed $600, which sum shall be in addition to the sum enumerated in Subsection N(1) above and as provided for in NMSA 1978, § 24-13-4.
Any provider being paid pursuant to the provisions of Subsection N(2) above shall also retain and store cremated remains (ashes) for a period of at least two years, and after the allotted two years may dispose of but retain a record of the place and manner of disposition of the cremated remains (ashes) for an additional five years.
Before filing a claim with the Board, through the Claims Administrator, any ambulance service, hospital or health care provider shall have placed on permanent file with the Board:
Current data, statistics, schedules and information deemed necessary by the Board to determine the cost for all patients in that hospital or cared for by that health care provider or tariff rates or charges of an ambulance service.
Proof that the hospital, ambulance service or health care provider is licensed, where required, under the laws of New Mexico.
Any other information or data deemed necessary by the Board.
Each permanent file shall be inspected each December by the Claims Administrator to determine if each permanent file is current.
A hospital, ambulance service or health care provider claiming payment from the fund shall:
Within 75 days of the patient's discharge from the hospital or the date of the ambulance transportation or latest care provided by a health care provider, submit a claim to the Claims Administrator;
Submit one claim for each patient separately, with an itemized detail of the total cost. In those instances where repetitive services are being provided to a patient, such as chemotherapy, physical therapy, dialysis or other such procedures, the health care provider may combine up to 90 days' accumulation of such repetitive services and submit one claim covering that period of time; and
Submit with the claims verified statements of qualifications for ambulance service, indigent hospital care or care from a health care provider signed by the patient or by the parent or person having custody of the patient to the effect that the patient qualifies as an indigent patient and is unable to pay the cost for the care administered, listing all assets of the patient or any person legally responsible for care. The statement shall constitute an oath of the person signing it, and any false statements in the statement made knowingly constitute a crime.
The written request for a hearing shall be to the Claims Administrator within 30 days of fund denial or fund assistance modification or fund assistance termination. Failure to timely submit a written request for hearing shall result in the denial, modification or termination being deemed final.
Upon timely receipt of a hearing request, the Claims Administrator shall inform the Board Chair, who shall then direct the Claims Administrator to schedule the appeal for reconsideration by the Board. If the applicant remains dissatisfied with Board action on reconsideration, the applicant shall request a second hearing, in writing, within 15 days of the meeting at which the matter was reconsidered. The Administrator shall schedule a hearing before a hearing officer within 30 days.
The hearing shall be conducted by a hearing officer appointed by the County Administrator.
The powers of the hearing officer shall include administering oaths or affirmations to witnesses taking testimony, examining witnesses, and admitting or excluding evidence.
The technical rules of evidence and the rules of civil procedure shall not apply.
The hearing shall be conducted so that the issues are fairly and fully presented.
Either party may be represented by counsel or a family member or other representatives of the person's designation.
Cross-examination may be conducted by either party.
Any oral or documentary evidence may be received, but the hearing officer may exclude irrelevant, hearsay or repetitive evidence.
Within five days of the hearing, the hearing officer shall render a written decision, by findings of jurisdiction and facts.
Any ambulance service, health care provider, or patient who is aggrieved by a decision of the II-IC Board may seek judicial review of the decision pursuant to NMRA, Rule 1-074.