HOUSE APPROPRIATIONS AND FINANCE COMMITTEE SUBSTITUTE FOR
HOUSE BILL 779
49th legislature - STATE OF NEW MEXICO - first session, 2009
AN ACT
RELATING TO HEALTH CARE; CREATING THE HEALTH CARE PARTNERSHIP; PROVIDING FOR DUTIES OF THE HEALTH CARE PARTNERSHIP; DIRECTING AND AUTHORIZING THE DEVELOPMENT OF PARTNERSHIP BENEFIT PLANS; PROVIDING FOR PARTICIPATING EMPLOYER PLANS AND PARTICIPATING INSURANCE PLANS; PROVIDING FOR ELIGIBILITY AND BENEFITS; PROVIDING FOR PROCEDURES TO ADDRESS ACCESS TO AND QUALITY AND COST OF HEALTH CARE; ESTABLISHING AFFORDABILITY GUIDELINES; MAKING AN APPROPRIATION.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. SHORT TITLE.--This act may be cited as the "Health Care Partnership Act".
Section 2. PURPOSE.--The purpose of the Health Care Partnership Act is to:
A. create opportunities for all New Mexicans to obtain affordable health care coverage through a combination of public and private options and financing;
B. determine and implement measures to control escalating health care costs; and
C. improve access to and quality of health care for all New Mexicans.
Section 3. DEFINITIONS.--As used in the Health Care Partnership Act:
A. "affordability" means the designation of the percentage or amount of income that a household should reasonably be expected to devote to health care expenditures while still having sufficient income to access other necessities;
B. "health care services" means services rendered by a licensed health care provider, including:
(1) the furnishing to any individual of medical, behavioral health, dental, pharmaceutical or optometric care;
(2) hospitalization or long-term care; and
(3) the furnishing to any person of services to diagnose, prevent, alleviate, cure or heal human physical or mental illness or injury;
C. "health coverage" means a system of financing health care services; provided, however, that "health coverage" does not include coverage issued pursuant to provisions of the Workers' Compensation Act or similar law, automobile medical payment insurance or provisions by which benefits are payable with or without regard to fault and are required by law to be contained in any liability insurance policy;
D. "living in New Mexico" means physically present in New Mexico for at least six months with an intention to remain primarily in New Mexico and not to reside elsewhere except for vacation or other brief visits; and
E. "partnership" means the health care partnership.
Section 4. HEALTH CARE PARTNERSHIP--CREATION.--
A. The "health care partnership" is created and consists of such representatives from each of the following agencies or committees as each may select and designate to participate:
(1) the department of health;
(2) the human services department;
(3) the legislative finance committee;
(4) the New Mexico legislative council;
(5) the interim legislative committee charged with review or oversight of health care issues; and
(6) the insurance division of the public regulation commission.
B. The partnership shall meet at least once each calendar quarter until September 1, 2010. The partnership shall continue to meet as needed to carry out the provisions of the Health Care Partnership Act.
C. To the extent resources are available, the partnership may request staff assistance from any state agency, the legislative finance committee and the legislative council service as appropriate to carry out the provisions of the Health Care Partnership Act.
D. The partnership and any advisory groups that it creates shall be dissolved and discontinue meeting effective July 1, 2014.
Section 5. HEALTH CARE PARTNERSHIP--DUTIES.--The partnership shall, pursuant to Section 7 of the Health Care Partnership Act and after receiving input and recommendations from the public and advisory groups, develop and present to the governor and the legislature recommendations and proposed action steps for legislative, regulatory, operational and financial initiatives to increase access to and affordability of health care for all people living in New Mexico. The recommendations shall include:
A. a sustainable methodology and time frame for the financing of a health care system that incorporates strategies from the public and private sectors;
B. strategies for health coverage or insurance reform that increase affordability, availability and portability of health coverage and consideration of guaranteed issue and community rating;
C. structural reforms that would improve efficiency in public health coverage programs, including the feasibility of administrative consolidation of pools and joint purchasing of necessary common administrative functions, durable medical equipment, health care supplies and pharmaceuticals;
D. assessment of the impact of state or federal laws and rules and any state or federal changes in the structure of health coverage or policies;
E. statutory and regulatory initiatives necessary to provide cost-effective health care services, including:
(1) access to information that would enable licensed health care providers, consumers and purchasers to evaluate cost data fairly, including contractual terms such as reimbursement rates, provider charges and health benefit plans; and
(2) a statewide uniform health care provider credentialing process;
F. restructuring of the current health care delivery system, including:
(1) developing evidence-based approaches to providing acute medical care, behavioral health care, chronic medical care and disease management, preventive care and wellness, public health and patient education;
(2) developing a system that realigns provider and insurer incentives, reduces duplication, enhances primary care and focuses on evidence-based long-term health improvement; and
(3) providing for accountability by licensed health care providers and health coverage plan incentives for health outcomes;
G. strategies to reduce gender, racial and ethnic health care disparities and to identify underserved populations, taking into account the role of Native American health care systems and financing; and
H. other recommendations and action steps deemed necessary by the partnership to carry out the provisions of the Health Care Partnership Act.
Section 6. PUBLIC INPUT AND ADVISORY GROUPS.--
A. The meetings of the partnership shall be announced publicly and in a timely manner and shall be open to the public. The partnership shall provide opportunities for public input in at least five different geographic areas of the state before formulating its recommendations and action steps. A draft of the partnership's recommendations and action steps shall be available to the public for at least thirty days before being finalized for submission to the legislature and the governor. At least one public meeting shall be held and opportunity for written comment on draft recommendations and action steps shall be provided by the partnership before the recommendations and action steps are finalized for presentation to the legislature and the governor.
B. The partnership shall create advisory groups as the partnership deems necessary to receive and consider advice and reaction from consumers; advocates; licensed health care providers; health insurers; payers, including employers and federal and state agencies; Native American nations, tribes and pueblos; and other interested parties. A person serving as a member of an advisory group shall not be eligible for any reimbursement by the partnership for expenses associated with participation on these advisory groups unless specific funding for this purpose is identified by the partnership. Each advisory group shall be given a specific charge and a specific date to end its work and deliver its advice, whether in writing or through an oral report to the partnership.
Section 7. RECOMMENDATIONS--SUBMISSION--ACTION.--
A. The partnership shall present its final recommendations and proposed action steps to the legislative finance committee, to the interim legislative committee charged with review or oversight of health care issues and to the governor no later than September 1, 2010. The final report of the partnership shall also summarize the advice of all advisory groups and identify any differences between the final recommendations of the partnership and the advice of the advisory groups.
B. The legislative finance committee and the interim legislative committee charged with review or oversight of health care issues shall hold a joint public meeting on the partnership's recommendations and shall each separately take action to approve or reject each recommendation and action step no later than December 1, 2010. Any recommendation not specifically approved shall be deemed to be specifically rejected; provided, however, that the committees may propose modifications of the partnership's recommendations and action steps.
C. The governor shall hold a public meeting and prepare a written response to the partnership's recommendations and proposed action steps, no later than December 1, 2010, setting forth the governor's agreement or disagreement with each of the recommendations and action steps, including any proposed modifications to the partnership's recommendations and actions steps.
Section 8. PARTNERSHIP BENEFIT PLANS--DEVELOPMENT.--
A. The partnership shall develop benefit plan options for essential health care services, expanded health care services, consistent with national standards of care, and long-term care services, consistent with national standards of care, as well as options for patient cost-sharing, health care provider selection opportunities, benefit variations and variable annual limitations. The partnership benefit plans shall take into consideration requirements for federal, state, tribal or local public health care services plans or programs; the New Mexico Insurance Code; existing benefit plans pursuant to the Group Benefits Act, the Retiree Health Care Act, the Public School Insurance Authority Act, the Medical Insurance Pool Act, the Health Insurance Alliance Act; and programs administered by the human services department or a political subdivision of the state.
B. Essential health care services include:
(1) preventive health care services;
(2) health care provider services;
(3) health facility inpatient and outpatient services;
(4) laboratory tests and radiology procedures;
(5) hospice care;
(6) prescription drugs;
(7) inpatient and outpatient mental health services; and
(8) alcohol and substance abuse services.
C. Expanded health care services include:
(1) preventive and prophylactic dental services, including an annual dental examination and cleaning;
(2) vision examinations and appliances, including medically necessary contact lenses;
(3) medical supplies, durable medical equipment and selected assistive devices, including hearing and speech assistive devices;
(4) transportation necessary to obtain essential or expanded services;
(5) experimental or investigational procedures or treatments not otherwise covered in essential health care services; and
(6) other health care services as the partnership may determine appropriate.
D. Long-term services include:
(1) in-home, community-based and institutional long-term services for any diagnosable conditions for which such services are necessary; and
(2) habilitation and rehabilitation services for any diagnosable conditions for which such services are necessary.
Section 9. PARTNERSHIP BENEFIT PLANS--COSTS AND FINANCING.--
A. The partnership shall project approximate costs to the state and to individuals and groups for partnership benefit plans based on expected take-up and utilization of services and on availability of federal, state, local and other funds that may be used to pay for the plans, taking into account variations in the amount, duration and scope of the plans and affordability criteria proposed pursuant to Section 10 of the Health Care Partnership Act.
B. The partnership shall recommend financing options for the plans, including subsidies to assist individuals or families to purchase partnership benefit plans, based on affordability guidelines. In recommending the financing options, the partnership shall consider:
(1) available state and federal funding options, including potential waivers available for certain federal programs;
(2) current state law regarding assessments and tax credits to contain costs through the Health Insurance Alliance Act and the Medical Insurance Pool Act;
(3) limitations and exclusions that are reasonable and necessary to ensure that partnership benefit plans provide appropriate coverage while remaining actuarially sound;
(4) the feasibility of requiring or encouraging publicly funded health care agencies pursuant to the Health Care Purchasing Act to use partnership benefit plans as options for their eligible participants;
(5) an employer's contribution for all or part of an employee's or a retiree's premium for a partnership benefit plan, provided that a collective bargaining agreement is not violated; and
(6) the impact on costs and financing if all persons living in New Mexico were required to have health coverage.
C. The partnership shall prepare a report with the specific options and recommendations for financing pursuant to this section by September 1, 2010.
Section 10. AFFORDABILITY GUIDELINES.--
A. The partnership shall propose affordability guidelines for individuals and families, including subsidies that might be needed for various household sizes, income levels and health needs for premiums for partnership benefit plans and for patient cost-sharing and other out-of-pocket expenditures. The partnership shall consider existing state and federal requirements regarding allowed premiums and cost-sharing in publicly financed programs. Changes in affordability guidelines shall be proposed by the governor and set by the legislature as part of the regular appropriation process, provided that nothing in this section shall require the governor to propose and the legislature to appropriate funds to pay for subsidies identified by the affordability guidelines.
B. The partnership shall recommend affordability guidelines for employers, based on employer type, size and annual revenue.
Section 11. PARTNERSHIP BENEFIT PLANS--OFFERED.--
A. To the extent resources are available, the human services department shall make available partnership benefit plans to anyone living in New Mexico through persons authorized by the state pursuant to the New Mexico Insurance Code to issue insurance or other health coverage; provided, however, that nothing shall preclude the human services department from directly paying for health care services or health coverage pursuant to Chapter 27 NMSA 1978.
B. To the extent practicable and within available resources, agents, brokers or solicitors authorized pursuant to Chapter 59A, Article 12 NMSA 1978 or otherwise authorized by the state to sell, solicit or negotiate insurance or other health coverage may be used to offer the partnership benefit plans to individuals and groups.
C. Premiums for partnership benefit plans shall be paid for by individuals, employers and other groups interested in participating in the health partnership plans. To the extent possible, federal and other available resources shall be used to provide subsidies for persons covered through the plans, according to the affordability guidelines set by the partnership pursuant to Section 10 of this act. Based on available resources and on compliance with state and federal laws, the human services department may develop eligibility guidelines for individuals or households that may receive subsidies.
D. An employer, group or other plan that provides health care benefits for its employees after retirement, including coverage for payment of medicare supplementary coverage, may agree to participate in the partnership benefit plans. An employer that participates in a partnership benefit plan shall contribute to the plan for the benefit of the retiree, and the agreement shall ensure that the employer's, group's or other plan's health benefit coverage for the retiree shall be restored in the event of the retiree's ineligibility for partnership benefit plan coverage.
Section 12. PARTNERSHIP BENEFIT PLAN--COVERAGE OF NONRESIDENT STUDENTS.--An educational institution shall require health coverage for its nonresident students and shall purchase health coverage under one or more of the partnership benefit plans or other health coverage options for its nonresident students not otherwise covered, through fees assessed to those students or a combination of fees and contributions by the educational institutions.
Section 13. VOLUNTARY PURCHASE OF OTHER INSURANCE.--Nothing in the Health Care Partnership Act shall be construed to prohibit the voluntary purchase of insurance or health coverage for health care services allowed to be purchased in the state.
Section 14. INSURANCE RATES--SUPERINTENDENT OF INSURANCE--DUTIES.--
A. The superintendent of insurance shall work closely with the partnership to identify premium rates that may be necessary for partnership benefit plans and premium rates associated with health coverage in workers' compensation and automobile medical coverage. The superintendent of insurance shall develop an estimate of expected reduction in workers' compensation and automobile medical coverage rates based upon assumptions of health care services or health coverage pursuant to the Health Care Partnership Act.
B. If the superintendent of insurance finds that a reduction pursuant to Subsection A of this section exists, the superintendent shall ensure or recommend to the appropriate authorities that workers' compensation and automobile insurance premiums on insurance policies written in the state reflect a lower, actuarially sound rate to account for medical payments assumed by the partnership benefit plans.
Section 15. QUALITY OF CARE--HEALTH CARE PROVIDER AND HEALTH FACILITIES--PRACTICE STANDARDS.--
A. Based on the recommendations of the partnership and subject to available resources, the department of health shall review and adopt quality improvement standards for health care services provided in the state. These standards shall consider evidence-based medicine, best practices, outcome measurements, consumer education and patient safety.
B. By July 1, 2011, the department of health shall propose a health care quality improvement program, based on the recommendations of the partnership, to the governor and the legislature with requirements for funding and time lines for implementation based on available resources. The quality improvement program shall include an ongoing system for monitoring patterns of practice.
C. The department of health, in consultation with health care provider practice and licensure boards and provider associations, shall review and adopt professional practice guidelines developed by state and national medical and specialty organizations, federal agencies for health care policy and research and other organizations as it deems necessary to promote the quality and cost-effectiveness of health care services provided in the state.
D. In consultation with health care provider practice and licensure boards and provider associations, the department of health shall establish a system of peer education for health care providers or health facilities determined to be engaging in patterns of practice that do not meet the standards pursuant to Subsection A of this section. The department may refer health care providers continuing to engage in practices that do not meet those standards to the appropriate licensing or certifying board.
Section 16. ACCESS TO HEALTH CARE.--
A. By July 1, 2011, the department of health, in consultation with health care provider certification and licensing boards and provider associations, shall propose to the governor and the legislature a program and time line for increasing the numbers and capacity of the health care provider work force in the state, pursuant to the recommendations of the partnership. The program shall include:
(1) standards for access to various types of primary, specialty and emergency health care within identified time frames and distances;
(2) standards for the reasonable availability of primary and specialty health care providers in the various regions of the state that are used for planning by the interagency behavioral health purchasing collaborative; and
(3) methods and costs for achieving these standards.
B. In developing these standards and programs, the department shall consider the role of the Indian health service and the role of traditional practices of healing among Native American nations, tribes and pueblos in the state.
Section 17. APPROPRIATION.--Up to five hundred thousand dollars ($500,000) is appropriated from legislative cash balances to the legislative council service for expenditure in fiscal years 2010 and 2011 to support the activities of the health care partnership and accomplish the purposes of this act. Any unexpended or unencumbered balance remaining at the end of fiscal year 2011 shall revert to legislative cash balances.
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