44th legislature - STATE OF NEW MEXICO - second session, 2000

REQUESTING THE HUMAN SERVICES DEPARTMENT TO ESTABLISH A DEFINITION OF "MEDICAL NECESSITY" FOR STATE AGENCY AND MEDICAID PURPOSES.

WHEREAS, three state departments have responsibilities related to health care that include decisions on "medical necessity"; and

WHEREAS, each of these agencies uses a different definition of medical necessity; and

WHEREAS, the preponderance of the state's medicaid services are provided through three private independent managed care organizations; and

WHEREAS, each of these three organizations defines medical necessity differently; and

WHEREAS, far from being a matter of vocabulary and expression, the definition of medical necessity determines both the quality and quantity of health care provided to New Mexico citizens; and

WHEREAS, the needs of the mentally ill, developmentally disabled and others requiring special services, including various behavioral health services and treatment foster care, are currently at risk due to managed care policies and lack of sufficient funding; and

WHEREAS, public policies that affect special needs populations require extra effort in their design to ensure the proper care and well-being of this vulnerable group of citizens; and

WHEREAS, as the health insurance purchasing agent for the taxpayers of New Mexico, the human services department has every right to insist on the highest standards of care; and

WHEREAS, the human services department has the responsibility to ensure that its contracts are written with concern for both New Mexico medicaid recipients and other New Mexico taxpayers;

NOW, THEREFORE, BE IT RESOLVED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO that the human services department, together with the department of health, the insurance division of the public regulation commission and other agencies with interests and responsibilities affected, develop a definition of medical necessity that ensures full access to the highest quality of health care for all New Mexico citizens; and

BE IT FURTHER RESOLVED that the definition of medical necessity ensure that services provided under the definition include not only medical and surgical but other health services that diagnose, prevent, cure or treat a health-related condition and that help an individual maintain an optimal level of function and prevent decremental change in either medical or mental condition, and which services are not limited based on a diagnosis or condition and for which an individual health care decision has been made; and

BE IT FURTHER RESOLVED that this definition give full attention to New Mexicans with special needs, especially children; and

BE IT FURTHER RESOLVED that the human services department include in the discussions with the three primary SALUD contractors representatives of the health insurance industry, health and behavioral health providers and health advocacy and health consumer organizations; and

BE IT FURTHER RESOLVED that the human services department report its recommendations to the interim legislative health and human services committee at its September 2000 meeting; and

BE IT FURTHER RESOLVED that copies of this memorial be provided to the human services department, the department of health, the state agency on aging, the insurance division of the public regulation commission, the three primary SALUD contractors, the interim legislative health and human services committee and all other interested parties.