New Mexico and Texas Select FAIR Health Data to Address Surprise Billing

New Mexico and Texas have joined the list of states using FAIR Health benchmark data to address surprise billing. Each of these two states enacted a surprise bill law referencing an independent benchmarking database, and in each case the database selected was that of FAIR Health.

Surprise bills are those that are sent to consumers from out-of-network providers for emergency services or for nonemergency services unexpectedly rendered by an out-of-network provider, typically at an in-network facility. Under the surprise bill laws in both New Mexico and Texas, consumers are protected from paying more for a surprise bill than they would for an in-network bill, but the two states took different approaches toward determining the amount that health plans should pay out-of-network providers for such care. New Mexico mandated a specific reimbursement rate while Texas established an independent dispute resolution process—with both approaches utilizing FAIR Health data.

New Mexico
Pursuant to a request for information process, FAIR Health was selected by New Mexico’s Office of the Superintendent of Insurance (OSI) to provide FH® Benchmark data for the surprise bill reimbursement rate established under New Mexico’s Surprise Billing Protection Act, effective January 1, 2020. The law applies to bills from both medical professionals and facilities. The Act sets a reimbursement rate for surprise medical bills at the 60th percentile benchmark for allowed amounts as reported in a 2017 benchmarking database maintained by a nonprofit organization specified by the Superintendent of Insurance, provided that no payment is less than 150 percent of the Medicare reimbursement rate. The nonprofit organization, which must be conflict-free and unaffiliated with any healthcare stakeholder, was designated by OSI as FAIR Health.

Texas
Senate Bill 1264, which also became effective January 1, 2020, directed the Texas Department of Insurance (TDI) to select a benchmarking database for use in surprise bill arbitration of cases involving services provided by healthcare professionals. The database must be maintained by an organization unaffiliated with any healthcare provider, plan or other stakeholder. TDI selected FAIR Health. The arbitrator must consider a list of factors, among them FAIR Health’s 50th percentile of allowed amounts and 80th percentile of billed charges for the specific service in the area where the service was rendered.

Other States
FH® Benchmarks already serve as official reference points for a New York law addressing out-of-network emergency and surprise bills and a Connecticut law focused on out-of-network emergency bills. In addition, many states rely on FAIR Health data as the designated source of cost information for a variety of state health-related programs, including workers’ compensation. FAIR Health provides a broad range of data and assistance to states, from supplying benchmarks that serve as standards for payment under various laws and regulations to helping evaluate economic and clinical trends and to supporting research with data and analytics.

FAIR Health President Robin Gelburd commented: “We were pleased to have been chosen by New Mexico and Texas as an independent source of reliable, objective data with which to address surprise billing. FAIR Health has come to serve as a trusted and unbiased nationwide resource to advance a variety of state health-related programs.”

For information about the wide range of services and data products FAIR Health offers state health programs and initiatives, contact FAIR Health by email at info@fairhealth.org or call 855-301-3247, Monday through Friday, 9 am to 6 pm ET.