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

REQUESTING THE NEW MEXICO HEALTH POLICY COMMISSION TO ESTABLISH A TASK FORCE TO DEFINE "MEDICAL NECESSITY".

WHEREAS, the concept of medical necessity is widely used in the field of health insurance to determine what care is appropriate and will be covered by an insurance company; and

WHEREAS, the concept of medical necessity is not uniformly interpreted or applied by health insurance companies operating in New Mexico; and

WHEREAS, this issue arises in the context of both commercial insurance coverage and medicaid managed care; and

WHEREAS, if an inappropriately narrow definition of medical necessity is applied, appropriate care that is a covered benefit may be denied to a patient; and

WHEREAS, it is essential that a definition of medical necessity be used that ensures that appropriate care is provided to New Mexicans; and

WHEREAS, the definition of medical necessity should take into account individual needs and situations rather than being arbitrarily applied in an inflexible way; and

WHEREAS, the definition of medical necessity should recognize the special needs of patients with a particular health condition, including chronic disease, disability, mental illness and other circumstances; and

WHEREAS, the definition of medical necessity should ensure that decisions regarding medical necessity are made on the basis of adequate information; and

WHEREAS, the role of treating health care providers should be adequately recognized in making medical necessity decisions;

NOW, THEREFORE, BE IT RESOLVED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO that the New Mexico health policy commission form a task force to study this issue and make recommendations to the legislature regarding a definition of medical necessity to be used in making decisions regarding health care for New Mexicans; and

BE IT FURTHER RESOLVED that the task force include representatives of the health care insurance industry, a broad array of health care providers, consumer organizations and advocates and state agencies with responsibilities in this area; and

BE IT FURTHER RESOLVED that the New Mexico health policy commission ensure that consumers and consumer representatives are adequately represented on the task force so that consumer viewpoints are properly considered; and

BE IT FURTHER RESOLVED that the New Mexico health policy commission report its recommendations to the legislative health and human services committee at its September 2000 meeting; and

BE IT FURTHER RESOLVED that copies of this memorial be transmitted to the New Mexico health policy commission, the insurance division of the public regulation commission, the human services department, the department of health, the state agency on aging, the New Mexico legislative council, the legislative health and human services committee and other interested parties.