[HISTORY: Adopted by the Board of County Commissioners of
Otero County 5-19-2016 by Ord.
No. 16-04.[1] 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.
[1]
Editor's Note: This ordinance also superseded former Ch. 140,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hereby repealed.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).
An agency that operates alcohol abuse rehabilitation programs
that meet the standards set by the Department of Health.
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.
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.
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.
The financial assistance that Otero County provides to indigent
patients under authority of the New Mexico Indigent Hospital and County
Health Act.
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.
A person's actual physical dwelling in Otero County
and where a person clearly intends to make Otero County the person's
permanent home.
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.
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.
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 nursing home;
An in-state home health agency;
An in-state licensed hospice;
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;
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;
A drug rehabilitation center;
An alcohol rehabilitation center;
A mental health center;
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;
A dental clinic providing dental care;
An optometry or ophthalmology clinic providing vision care;
or
Any health facility contracted with Otero County to provide
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.
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.
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.
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.
A center that provides outpatient mental health services
that meet the standards set by the Department of Health.
A person who is less than 18 years of age.
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.
Any state, local, tribal, or federal government unit, agency,
department, division or bureau which is publicly funded.
A hospital that qualifies under the provisions of the federal
Medicare guidelines; or
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.
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.
A.
Membership.
(1)
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.
(2)
No member of the Board shall be an employee of Otero County.
(3)
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.
(4)
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.
(5)
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.
B.
Rules and regulations.
(1)
The Board shall meet as determined by the Board and as often as otherwise
necessary, but no less than quarterly each calendar year.
(2)
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.
(3)
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.
(4)
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,[1] 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.
[1]
Editor's Note: See NMSA 1978, § 10-15-1 et
seq.
(5)
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.
The Board:
A.
Shall administer claims pursuant to the provisions of the Indigent
Hospital and County Health Care Act (NMSA 1978, § 27-5-1
et seq.);
B.
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:
C.
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;
D.
Shall set criteria and cost limitations for medical care by licensed
out-of-state hospitals, ambulance services or health care providers;
E.
Shall cooperate with appropriate state agencies to use available
funds efficiently and to make health care more available;
F.
Shall cooperate with the Department in making any investigation to
determine the validity of claims and upon the fund for any indigent
patient;
G.
May accept contributions, which shall be deposited in the fund;
H.
Shall be assigned the Otero County Claims Administrator, who shall
be delegated the daily administration of the fund;
I.
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;
J.
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;
K.
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;
L.
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;
M.
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);
N.
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.
(1)
The report shall contain:
(a)
Otero County's eligibility criteria for indigent patients;
(b)
Services provided to indigent patients;
(c)
Restrictions on services provided to indigent patients;
(d)
Conditions for reimbursement to providers of health care;
(e)
Revenue sources used to pay for indigent health care; and
(f)
Other related information determined by the Local Government
Division of the New Mexico State Department of Finance and Administration;
(2)
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;
O.
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;
P.
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.
A.
There is created in the Otero County treasury an Otero County Health
Care Assistance Fund.
B.
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.
C.
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.
D.
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.
E.
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.
F.
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.
Assistance provisions.
(1)
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.
(2)
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.
B.
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:
(1)
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;
(2)
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
(3)
Any other information or data deemed necessary by the Board.
C.
Only actual hospital costs will be considered for certification.
D.
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:
(1)
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;
(2)
File claims for each patient separately, with an itemized statement
detailing the total cost;
(3)
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.
E.
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.
F.
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.
G.
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.
A.
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.
B.
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.
C.
The Claims Administrator shall determine if the patient is eligible.
The application shall contain, either in the application or by attachments,
the following information:
(1)
The patient's most recent three paycheck or payroll stubs.
(2)
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.
(3)
Evidence of other income.
(4)
Family size.
(5)
Gross family income.
(6)
The names of agencies providing any other public financial assistance
to the patient.
(7)
Proof of residency in Otero County for three months:
(a)
Utility bills include those from phone, electric, gas and cable
television companies.
(b)
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.
D.
Status of applications.
(1)
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.
(2)
Applicants who fail to complete their file within 75 days of the
date it was submitted shall be denied.
E.
The Claims Administrator shall review the applications and attachments
for accuracy and patient eligibility.
(1)
Inaccurate or incomplete applications shall be returned to the applicant
for correction or for completion.
(2)
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.
(3)
No applications are allowed before a patient receives ambulance,
hospital or health care provider services.
(4)
Only actual or allowable costs shall be reimbursed.
F.
The Claims Administrator shall ensure that the patient has exhausted
all available sources of other public agency financial assistance.
(1)
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.
(2)
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.
(3)
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.
G.
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:
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.
(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.
A.
Required information.
(1)
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:
(a)
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.
(b)
Proof that the hospital, ambulance service or health care provider
is licensed, where required, under the laws of New Mexico.
(c)
Any other information or data deemed necessary by the Board.
(2)
Each permanent file shall be inspected each December by the Claims
Administrator to determine if each permanent file is current.
B.
A hospital, ambulance service or health care provider claiming payment
from the fund shall:
(1)
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;
(2)
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
(3)
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.
B.
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.
C.
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.
D.
The hearing shall be conducted by a hearing officer appointed by
the County Administrator.
(1)
The powers of the hearing officer shall include administering oaths
or affirmations to witnesses taking testimony, examining witnesses,
and admitting or excluding evidence.
(2)
The technical rules of evidence and the rules of civil procedure
shall not apply.
(3)
The hearing shall be conducted so that the issues are fairly and
fully presented.
(4)
Either party may be represented by counsel or a family member or
other representatives of the person's designation.
(5)
Cross-examination may be conducted by either party.
(6)
Any oral or documentary evidence may be received, but the hearing
officer may exclude irrelevant, hearsay or repetitive evidence.
E.
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.