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hereby repealed.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.
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.
APPLICANT
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.
BOARD
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.
COMMISSION
The New Mexico Health Policy Commission.
COSTS
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.
COUNTY
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.
DAYS
Calendar days, and includes weekends and holidays.
DEPARTMENT
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.
DWELLING
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.
FAMILY
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.
FUND
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.
HEALTH CARE PROVIDER
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;
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.
MAY
Permissive or discretionary but not mandatory.
MEDICAID-ELIGIBLE
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.
ONE YEAR
Three-hundred-sixty-five calendar days; for leap years "one
year" means 366 calendar days.
PATIENT
The person who has actually received ambulance, hospital
or health care services.
PLANNING
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.
QUALIFYING HOSPITAL
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.
SHALL
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 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.
To facilitate the advantageous use of the available funds and
the equitable distribution of the funds available, the following exclusions
and limitations are applicable:
A. 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.
B. 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.
C. 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.
D. 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.
E. 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.
F. 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.
G. 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.
H. 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.
I. 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.
J. Psychiatric care claims shall be limited to and paid as follows:
(1) 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.
(2) 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.
(3) In no event shall any other psychiatric care be paid.
(4) 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.
(5) 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.
(6) Psychiatric care or hospitalization shall only include:
(a)
Hospital room and board charges;
(c)
Reasonable laboratory examinations related to the psychiatric
diagnosis and treatment.
(7) 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.
(8) The Board shall have absolute discretion and may reject any claim
in whole or any line item billed.
K. 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.
L. 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.
M. 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.
N. Indigent burials.
(1) 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.
(2) 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.
(3) 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.
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.