0001| HOUSE BILL 728
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0002| 42ND LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION,
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0003| 1996
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0004| INTRODUCED BY
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0005| EDWARD C. SANDOVAL
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0006|
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0007|
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0008|
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0009|
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0010|
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0011| AN ACT
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0012| RELATING TO HEALTH CARE; ENACTING THE PROVIDER SPONSORED HEALTH
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0013| NETWORKS LAW.
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0014|
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0015| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0016| Section 1. SHORT TITLE.--This act may be cited as the
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0017| "Provider Sponsored Health Networks Law".
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0018| Section 2. PURPOSE OF ACT.--The purpose of the Provider
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0019| Sponsored Health Networks Law is to facilitate the establishment
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0020| of integrated health delivery systems, to encourage cooperative
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0021| health care provider agreements, to promote community
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0022| reinvestment of health expenditures in communities, to protect
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0023| sole community and essential access community hospitals and
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0024| other essential community health care providers, to establish
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0025| state policy and a process of state immunization, to protect
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0001| health care cooperative agreements from federal antitrust
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0002| actions and to provide for the general registration and
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0003| regulation of provider sponsored health networks by the
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0004| department of insurance, the human services department and the
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0005| department of health.
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0006| Section 3. DEFINITIONS.--As used in the Provider Sponsored
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0007| Health Networks Law:
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0008| A. "basic health care services" means medical
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0009| services consisting of preventive care, emergency care,
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0010| inpatient and outpatient hospital and physician care, diagnostic
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0011| laboratory, diagnostic and therapeutic radiological services,
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0012| mental health services or services for alcohol or drug abuse,
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0013| dental, vision services and long-term rehabilitation treatment;
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0014| B. "capitated basis" means fixed per member per
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0015| month payment or percentage of contractual payment wherein the
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0016| provider assumes the full, partial or shared risk for the cost
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0017| of contracted services without regard to the type, value or
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0018| frequency of services provided;
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0019| C. "carrier" means a provider sponsored health
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0020| network, an insurer, a nonprofit health care plan or other
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0021| entity, including the state and federal government, responsible
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0022| for the payment of benefits or provision of services under a
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0023| group contract;
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0024| D. "certificate of public advantage" means a
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0025| certificate issued by the department of health that specifies
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0001| that the department of health, following rules and regulations
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0002| developed by the department, has determined the advantages of a
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0003| provider sponsored health network and that related cooperative
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0004| agreements among providers outweigh possible reductions in
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0005| competition and that the provider sponsored health network is
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0006| beneficial and shall improve the health care delivery of the
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0007| particular geographic area to be serviced;
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0008| E. "community reinvestment" means the portion of
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0009| network revenues that are returned to the community served by
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0010| the provider sponsored health network for programs promoting
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0011| prevention and disease management and where no payment is
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0012| received by the network for services provided;
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0013| F. "cooperative agreement" means an agreement
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0014| between two or more providers for the sharing, allocation or
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0015| referral of patients, personnel, instructional programs, support
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0016| services and facilities, or medical, diagnostic or laboratory
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0017| facilities or procedures or other services traditionally offered
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0018| by providers;
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0019| G. "co-payment" means an amount an enrollee must pay
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0020| in order to receive a specific service that is not fully
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0021| prepaid;
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0022| H. "deductible" means the amount an enrollee is
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0023| responsible to pay out of pocket before the provider sponsored
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0024| health network begins to pay the costs associated with
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0025| treatment;
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0001| I. "enrollee" means an individual who is covered by
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0002| a provider sponsored health network;
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0003| J. "evidence of coverage" means a contract or
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0004| certificate showing the essential features and services of the
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0005| provider sponsored health network coverage that is given to the
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0006| subscriber by the provider sponsored health network or by the
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0007| group contract holder;
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0008| K. "extension of benefits" means the continuation of
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0009| coverage under a particular benefit provided under a contract or
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0010| group contract following termination with respect to an enrollee
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0011| who is totally disabled on the date of termination;
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0012| L. "grievance" means a written complaint submitted
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0013| in accordance with the provider sponsored health network's
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0014| formal grievance procedure by or on behalf of the enrollee
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0015| regarding any aspect of the provider sponsored health network
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0016| relative to the enrollee;
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0017| M. "group contract" means a contract for health care
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0018| services that by its terms limits eligibility to members of a
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0019| specified group and may include coverage for dependents;
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0020| N. "group contract holder" means the person to whom
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0021| a group contract has been issued;
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0022| O. "health care services" means any services
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0023| included in the furnishing to any individual of medical, mental,
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0024| dental or optometric care, hospitalization or nursing home care
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0025| or incident to the furnishing of such care or hospitalization,
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0001| as well as the furnishing to any person of any and all other
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0002| services for the purpose of preventing, alleviating, curing or
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0003| healing human physical or mental illness or injury;
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0004| P. "healthy communities plan" means a plan submitted
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0005| annually by a registrant to the superintendent and the secretary
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0006| of health that describes the provider sponsored health network's
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0007| activities, services and costs as related to community
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0008| reinvestment;
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0009| Q. "individual contract" means a contract for health
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0010| care services issued to and covering an individual and it may
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0011| include dependents of the subscriber;
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0012| R. "insolvent" or "insolvency" means that the
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0013| network has been declared insolvent and placed under an order of
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0014| liquidation by a court of competent jurisdiction;
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0015| S. "managed payment basis" means agreements in which
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0016| the financial risk is related primarily to the degree of
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0017| utilization rather than to the cost of services;
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0018| T. "net worth" means the excess of total admitted
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0019| assets over total liabilities, but the liabilities shall not
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0020| include fully subordinated debt;
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0021| U. "participating provider" means a provider as
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0022| defined in Subsection W of this section who, under an express
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0023| contract with the provider sponsored health network or with its
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0024| contractor or subcontractor, has agreed to provide health care
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0025| services to enrollees with an expectation of receiving payment,
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0001| other than co-payment or deductible, directly or indirectly from
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0002| the provider sponsored health network;
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0003| V. "person" means an individual or any other legal
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0004| entity;
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0005| W. "provider" means any physician, hospital or other
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0006| person licensed or otherwise authorized to furnish health care
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0007| services;
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0008| X. "provider sponsored health network" means any
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0009| group of participating providers that undertake to directly
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0010| provide or arrange for the delivery of basic health care
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0011| services through cooperative agreements integrating different
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0012| providers and contracts to enrollees on a prepaid basis, except
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0013| for enrollee responsibility for co-payments or deductibles;
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0014| Y. "provider sponsored health network agent" means a
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0015| person who solicits, negotiates, effects, procures, delivers,
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0016| renews or continues a contract for provider sponsored health
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0017| network services or who takes or transmits payment for such a
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0018| contract, other than for himself, or a person who advertises or
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0019| otherwise holds himself out to the public as such;
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0020| Z. "replacement coverage" means the benefits
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0021| provided by a succeeding carrier;
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0022| AA. "subscriber" means an individual whose
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0023| employment or other status, except family dependency, is the
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0024| basis for eligibility for enrollment in the provider sponsored
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0025| health network or, in the case of an individual contract, the
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0001| person in whose name the contract is issued;
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0002|
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0003| BB. "superintendent" means the superintendent of
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0004| insurance; and
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0005| CC. "uncovered expenditures" means the costs to the
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0006| provider sponsored health network for health care services that
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0007| are the obligation of the provider sponsored health network for
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0008| which an enrollee, including the federal medicare-medicaid or
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0009| successor program, may also be liable in the event of the
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0010| provider sponsored health network's insolvency and for which no
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0011| alternative arrangements have been made that are acceptable to
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0012| the superintendent.
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0013| Section 4. ESTABLISHMENT OF PROVIDER SPONSORED HEALTH
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0014| NETWORKS.--
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0015| A. Notwithstanding any law of this state to the
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0016| contrary, any person may establish and operate a provider
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0017| sponsored health network in compliance with the Provider
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0018| Sponsored Health Networks Law. No person shall establish or
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0019| operate a provider sponsored health network in this state
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0020| without registering with the department of insurance and
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0021| applying for a certificate of public advantage with the
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0022| department of health.
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0023| B. Each registration and application for a
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0024| certificate of public advantage shall be verified by an officer
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0025| or authorized representative of the applicant, shall be in a
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0001| form prescribed by the superintendent and the secretary of
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0002| health and shall set forth or be accompanied by the following:
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0003| (1) a copy of the organizational documents of
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0004| the applicant, such as the articles of incorporation, articles
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0005| of association, partnership agreement, trust agreement or other
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0006| applicable documents and all amendments thereto;
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0007| (2) a copy of the bylaws, rules and regulations
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0008| or similar document, if any, regulating the conduct of the
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0009| internal affairs of the applicant;
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0010| (3) a list of the names, addresses and official
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0011| positions and biographical information, on forms acceptable to
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0012| the superintendent, of the persons who are to be responsible for
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0013| the conduct of the affairs and day to day operations of the
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0014| applicant, including all members of the board of directors,
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0015| board of trustees, executive committee or other governing board
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0016| or committee and the principal officers in the case of a
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0017| corporation or the partners or members in the case of a
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0018| partnership or association;
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0019| (4) a copy of any contract form made or to be
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0020| made between any class of providers and the provider sponsored
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0021| health network and a copy of any contract made or to be made
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0022| between third party administrators, marketing consultants or
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0023| persons listed in Paragraph (3) of this subsection and the
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0024| provider sponsored health network;
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0025| (5) a copy of the form of evidence of coverage
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0001| to be issued to the enrollees;
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0002| (6) a copy of the form of group contract, if
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0003| any, to be issued to employers, unions, trustees or other
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0004| organizations;
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0005| (7) financial statements showing the
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0006| applicant's assets, liabilities and sources of financial
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0007| support, including both a copy of the applicant's most recent
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0008| regular certified financial statement and an unaudited current
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0009| financial statement;
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0010| (8) a financial feasibility plan that includes
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0011| detailed enrollment projections, the methodology for determining
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0012| costs and charges during the first twelve months of operations,
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0013| certified by an actuary or other person determined by the
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0014| superintendent to be qualified, a three-year projection of
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0015| balance sheets, a three-year projection of cash flow statements
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0016| showing any capital expenditures, purchase and sale of
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0017| investments and deposits with the state and income and expense
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0018| statements anticipated from the start of operations for three
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0019| years or until the network has had net income for at least one
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0020| year, if longer, a description of the proposed method of
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0021| marketing and a statement of the sources of working capital as
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0022| well as any other sources of funding;
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0023| (9) a power of attorney duly executed by the
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0024| applicant, if not domiciled in this state, appointing the
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0025| superintendent, his successors in office and duly authorized
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0001| deputies as the true and lawful attorney of the applicant in and
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0002| for this state upon whom all lawful process in any legal action
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0003| or proceeding against the provider sponsored health network on a
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0004| cause of action arising in this state may be served;
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0005| (10) a statement or map reasonably describing
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0006| the geographic area to be served;
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0007| (11) a description of the internal grievance
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0008| procedures to be utilized for the investigation and resolution
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0009| of enrollee complaints and grievances;
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0010| (12) a description of the proposed quality
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0011| assurance program, including the formal organizational
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0012| structure, methods for developing criteria, procedures for
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0013| comprehensive evaluation of the quality of care rendered to
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0014| enrollees and processes to initiate corrective action and
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0015| reevaluation when deficiencies in provider or organizational
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0016| performance are identified;
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0017| (13) a description of the procedures to be
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0018| implemented to meet the protection against insolvency
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0019| requirements in the Provider Sponsored Health Networks Law;
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0020| (14) a list of the names, addresses and license
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0021| numbers of all providers with which the provider sponsored
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0022| health network has agreements;
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0023| (15) information determining the benefits and
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0024| advantages of a provider sponsored health network to the health
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0025| care delivery access, quality and efficiency for the particular
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0001| geographic area to be served by the network to assist the
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0002| department of health in issuing or renewing a certificate of
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0003| public advantage to the network;
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0004| (16) an annual report as prescribed by the
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0005| secretary of health specifying the benefits and advantages of
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0006| the network regarding health care delivery access, quality and
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0007| efficiency for the particular geographic area to be served by
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0008| the network to facilitate the ongoing supervision and assessment
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0009| of the network; and
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0010| (17) such other information as the
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0011| superintendent or the secretaries of health or human services
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0012| may require.
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0013| C. A provider sponsored health network shall, unless
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0014| otherwise provided for in the Provider Sponsored Health Networks
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0015| Law, file a notice describing any substantial modification of
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0016| the operation set out in the information required by Subsection
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0017| B of this section. The notice shall be filed with the
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0018| superintendent prior to the modification. If the superintendent
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0019| does not disapprove within thirty days of filing, the
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0020| modification shall be deemed approved.
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0021| Section 5. PROVIDER SPONSORED HEALTH NETWORK REGISTRATION
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0022| REQUIREMENTS AND PROCESS.--
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0023| A. Upon receipt of registration, the superintendent
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0024| shall transmit copies of the registration and accompanying
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0025| documents to the secretary of health and the secretary of human
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0001| services if the provider sponsored health network intends to
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0002| serve medicaid and medicare patients.
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0003| B. The secretary of health shall certify to the
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0004| superintendent whether the registrant, with respect to health
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0005| care services to be furnished, has complied with the
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0006| requirements of the Provider Sponsored Health Network Law.
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0007| C. The secretary of health shall certify to the
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0008| superintendent, the registrant and, if necessary, the secretary
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0009| of human services, within twenty days of receipt of the
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0010| registration, that the proposed provider sponsored health
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0011| network meets the requirements of the Provider Sponsored Health
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0012| Networks Law or notify the provider sponsored health network
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0013| that the network does not meet the requirements and specify in
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0014| what respects it is deficient.
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0015| D. The superintendent shall within twenty days of
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0016| receipt of certification or notice of deficiencies from the
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0017| secretary of health pursuant to Subsection C of this section, or
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0018| within thirty days of receipt of the registration indicated in
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0019| Subsection A of this section if no request has been made of the
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0020| secretary of health, notify the registrant of the deficiencies
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0021| to any person filing a completed registration upon receiving the
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0022| prescribed fees and upon the superintendent being satisfied
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0023| that:
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0024| (1) the persons responsible for the conduct of
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0025| the affairs of the applicant are competent, trustworthy and
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0001| possess good reputations;
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0002| (2) any deficiencies identified by the
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0003| secretary of health pursuant to Subsection C of this section
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0004| have been corrected and the secretary of health has certified to
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0005| the superintendent that the provider sponsored health network
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0006| proposed plan of operation meets the requirements of the
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0007| Provider Sponsored Health Networks Law;
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0008| (3) the provider sponsored health network will
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0009| effectively provide or arrange for the provision of basic health
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0010| care services on a prepaid basis, through contract or otherwise,
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0011| except to the extent of reasonable requirements for co-payments
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0012| or deductibles, or both; and
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0013| (4) the provider sponsored health network is in
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0014| compliance with financial and solvency provisions of the
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0015| Provider Sponsored Health Networks Law.
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0016| Section 6. POWERS OF PROVIDER SPONSORED HEALTH NETWORKS.--
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0017| A. The powers of a provider sponsored health network
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0018| include, but are not limited to, the following:
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0019| (1) the purchase, lease, construction,
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0020| renovation, operation or maintenance of hospitals, medical
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0021| facilities, or both, and their ancillary equipment, and such
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0022| property as may reasonably be required for its principal office
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0023| or for such purposes as may be necessary in the transaction of
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0024| the business of the organization;
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0025| (2) transactions between or among affiliated
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0001| entities, including loans and the transfer of responsibility
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0002| under all contracts, including without limitation provider and
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0003| subscriber contracts between or among affiliates or between the
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0004| provider sponsored health network and its parent;
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0005| (3) the furnishing of health care services
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0006| through providers, provider associations or agents for providers
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0007| that are under contract with or employed by the provider
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0008| sponsored health network;
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0009| (4) the contracting with any person for the
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0010| performance on its behalf of certain functions such as
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0011| marketing, enrollment and administration;
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0012| (5) the contracting with an authorized insurer
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0013| in this state for the provision of insurance, indemnity or
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0014| reimbursement against the cost of health care services provided
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0015| by the provider sponsored health network;
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0016| (6) the offering of other health care services,
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0017| in addition to basic health care services; and
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0018| (7) the joint marketing of products with an
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0019| insurer or other provider sponsored health networks authorized
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0020| to do business in this state as long as the company that is
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0021| offering each product is clearly identified.
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0022| B. A provider sponsored health network shall file
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0023| notice, with adequate supporting information, with the
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0024| superintendent prior to the exercise of any power granted in
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0025| Paragraph (1), (2) or (4) of Subsection A of this section that
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0001| may affect the financial soundness of the provider sponsored
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0002| health network. The superintendent shall disapprove such
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0003| exercise of power only if in his opinion it would substantially
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0004| and adversely affect the financial soundness of the provider
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0005| sponsored health network and endanger its ability to meet its
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0006| obligations. If the superintendent does not disapprove within
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0007| thirty days of the filing, it shall be deemed approved.
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0008| C. The superintendent may adopt rules and
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0009| regulations exempting from the filing requirement of Subsection
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0010| B of this section those activities having a de minimis effect.
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0011| Section 7. TAXATION.--Provider sponsored health networks
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0012| shall be subject to the premium tax pursuant to Section 59A-6-2
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0013| NMSA 1978, except that the premium tax liability may be reduced
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0014| by up to fifty percent based on an equivalent amount of
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0015| community reinvestment expenditure by the provider sponsored
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0016| health network as certified by the superintendent and based on
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0017| provisions of services as specified in the healthy communities
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0018| plan submitted by the network and approved by the
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0019| superintendent.
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0020| Section 8. FIDUCIARY RESPONSIBILITIES--FIDELITY BOND.--
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0021| A. Any director, officer, employee or partner of a
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0022| provider sponsored health network who receives, collects,
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0023| disburses or invests funds in connection with the activities of
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0024| the network shall be responsible for the funds in a fiduciary
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0025| relationship to the network.
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0001| B. A provider sponsored health network shall
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0002| maintain in force a fidelity bond or fidelity insurance on the
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0003| employees, officers, directors and partners described in
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0004| Subsection A of this section in an amount not less than two
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0005| hundred fifty thousand dollars ($250,000) for each provider
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0006| sponsored health network or a maximum of five million dollars
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0007| ($5,000,000) in aggregate maintained on behalf of provider
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0008| sponsored health networks owned by a common parent corporation
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0009| or such sum as may be prescribed by the superintendent.
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0010| Section 9. QUALITY ASSURANCE PROGRAM.--
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0011| A. A provider sponsored health network shall
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0012| establish procedures to assure that the health care services
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0013| provided to enrollees shall be rendered under reasonable
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0014| standards of quality of care consistent with prevailing
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0015| professionally recognized standards of medical practice. Such
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0016| procedures shall include mechanisms to assure availability,
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0017| accessibility and continuity of care.
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0018| B. A provider sponsored health network shall have an
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0019| ongoing internal quality assurance program to monitor and
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0020| evaluate its health care services, including primary and
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0021| specialist physician services, and ancillary and preventive
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0022| health care services, across all institutional and non-institutional settings. The program shall include, at a
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0023| minimum, the following:
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0024| (1) a written statement of goals and objectives
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0025| that emphasizes improved health status in evaluating the quality
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0001| of care rendered to enrollees;
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0002| (2) a written quality assurance plan that
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0003| describes the following:
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0004| (a) the provider sponsored health
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0005| network's scope and purpose in quality assurance;
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0006| (b) the organizational structure
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0007| responsible for quality assurance activities;
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0008| (c) contractual arrangements, where
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0009| appropriate, for delegation of quality assurance activities;
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0010| (d) confidentiality policies and
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0011| procedures;
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0012| (e) a system of ongoing evaluation
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0013| activities;
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0014| (f) a system of focused evaluation
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0015| activities;
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0016| (g) a system for credentialing providers
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0017| and performing peer review activities; and
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0018| (h) duties and responsibilities of the
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0019| designated physician responsible for the quality assurance
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0020| activities;
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0021| (3) a written statement describing the system
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0022| of ongoing quality assurance activities, including:
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0023| (a) problem assessment, identification,
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0024| selection and study;
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0025| (b) corrective action, monitoring,
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0001| evaluation and reassessment; and
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0002| (c) interpretation and analysis of
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0003| patterns of care rendered to individual patients by individual
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0004| providers;
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0005| (4) a written statement describing the system
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0006| of focused quality assurance activities based on representative
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0007| samples of the enrolled population that identifies method of
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0008| topic selection, study, data collection, analysis,
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0009| interpretation and report format;
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0010| (5) written plans for taking appropriate
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0011| corrective action whenever, as determined by the quality
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0012| assurance program, inappropriate or substandard services have
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0013| been provided or services that should have been furnished have
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0014| not been provided; and
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0015| (6) other polices and procedures as required by
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0016| medicaid or medicare contracts.
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0017| C. A provider sponsored health network shall record
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0018| proceedings of formal quality assurance program activities and
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0019| maintain documentation in a confidential manner. Quality
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0020| assurance program minutes shall be available for examination by
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0021| the superintendent and by the secretary of health if requested
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0022| by the superintendent, the secretary of health or the secretary
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0023| of human services but shall not be disclosed to third parties
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0024| except as permitted by the provisions the Provider Sponsored
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0025| Health Networks Law.
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0001| D. A provider sponsored health network shall ensure
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0002| the use and maintenance of an adequate patient record system
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0003| that will facilitate documentation and retrieval of clinical
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0004| information for the purpose of the provider sponsored health
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0005| network evaluating continuity and coordination of patient care
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0006| and assessing the quality of health and medical care provided to
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0007| enrollees.
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0008| E. Except as otherwise restricted or prohibited by
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0009| state or federal law, enrollee clinical records shall be
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0010| available to the superintendent or the secretary of health for
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0011| examination and review to ascertain compliance with this
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0012| section.
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0013| F. A provider sponsored health network shall
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0014| establish a mechanism for periodic reporting of quality
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0015| assurance program activities to the governing body, providers,
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0016| appropriate network staff and appropriate state officials.
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0017| Section 10. REQUIREMENTS FOR GROUP CONTRACT, INDIVIDUAL
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0018| CONTRACT AND EVIDENCE OF COVERAGE.--
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0019| A. Every medicaid, medicare, group and individual
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0020| contract holder is entitled to a group or individual contract.
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0021| The contract shall not contain provisions or statements that are
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0022| unjust, unfair, inequitable, misleading or deceptive or that
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0023| encourage misrepresentation as described in Section 59A-16-4
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0024| NMSA 1978. The contract shall contain a clear statement of the
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0025| following:
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0001| (1) name and address of the provider sponsored
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0002| health network;
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0003| (2) eligibility requirements;
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0004| (3) benefits and services within the service
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0005| area;
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0006| (4) emergency care benefits and services;
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0007| (5) out-of-area benefits and services, if any;
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0008| (6) co-payments, deductibles or other out-of-pocket expenses;
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0009| (7) limitations and exclusions;
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0010| (8) enrollee termination;
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0011| (9) enrollee reinstatement, if any;
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0012| (10) claims procedures;
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0013| (11) enrollee grievance procedures;
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0014| (12) continuation of coverage;
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0015| (13) conversion;
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0016| (14) extension of benefits, if any;
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0017| (15) coordination of benefits, if applicable;
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0018| (16) subrogation, if any;
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0019| (17) description of the service area;
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0020| (18) entire contract provision;
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0021| (19) term of coverage;
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0022| (20) cancellation of group or individual
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0023| contract holder;
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0024| (21) renewal;
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0025| (22) reinstatement of group or individual
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0001| contract holder, if any;
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0002| (23) grace period; and
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0003| (24) conformity with state law.
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0004| B. An evidence of coverage may be filed as part of
|
0005| the group contract to describe the provisions required in
|
0006| Paragraphs (1) through (17) and (20) of Subsection A of this
|
0007| section.
|
0008| C. In addition to those provisions required in
|
0009| Paragraphs (1) through (24) of Subsection A of this section, an
|
0010| individual contract shall provide for a ten-day period to
|
0011| examine and return the contract and have the payment refunded.
|
0012| If services were received during the ten-day period and the
|
0013| person returns the contract to receive a refund of the payment
|
0014| paid, the individual shall pay for the services.
|
0015| D. Every subscriber shall receive an evidence of
|
0016| coverage from the group contract holder or the provider
|
0017| sponsored health network. The evidence of coverage shall not
|
0018| contain provisions or statements that are unfair, unjust,
|
0019| inequitable, misleading or deceptive or that encourage
|
0020| misrepresentation as described in Section 59A-16-4 NMSA 1978.
|
0021| The evidence of coverage shall contain a clear statement of the
|
0022| provisions required in Paragraphs (1) through (17) and (20) of
|
0023| Subsection A of this section.
|
0024| E. The superintendent may adopt regulations
|
0025| establishing readability standards for individual contracts,
|
0001| group contracts and evidence of coverage forms.
|
0002| F. No group or individual contract, evidence of
|
0003| coverage or amendment thereto shall be delivered or issued for
|
0004| delivery in this state, unless its form has been filed with and
|
0005| approved by the superintendent, subject to Subsections G and H
|
0006| of this section.
|
0007| G. If an evidence of coverage issued pursuant to and
|
0008| incorporated in a contract issued in this state is intended for
|
0009| delivery in another state and the evidence of coverage has been
|
0010| approved for use in the state in which it is to be delivered,
|
0011| the evidence of coverage need not be submitted to the
|
0012| superintendent for approval.
|
0013| H. Every form of group or individual contract,
|
0014| evidence of coverage or amendment thereto required to be filed
|
0015| pursuant to the provisions of Subsection F of this section shall
|
0016| be filed with the superintendent not less than thirty days prior
|
0017| to delivery or issue for delivery in this state. At the end of
|
0018| the review period, the form is deemed approved if the
|
0019| superintendent has taken no action. The filer shall notify the
|
0020| superintendent in writing prior to using a form that is deemed
|
0021| approved.
|
0022| I. At any time, after thirty days' notice and for
|
0023| cause shown, the superintendent may withdraw approval of any
|
0024| form of group or individual contract, evidence of coverage or
|
0025| amendment thereto, effective at the end of the thirty-day notice
|
0001| period.
|
0002| J. When a filing is disapproved or approval of a
|
0003| form of group or individual contract, evidence of coverage or
|
0004| amendment thereto is withdrawn, the superintendent shall give
|
0005| the provider sponsored health network written notice of the
|
0006| reasons for disapproval and in the notice shall inform the
|
0007| provider sponsored health network that within thirty days of
|
0008| receipt of the notice the provider sponsored health network may
|
0009| request a hearing. A hearing shall be conducted within thirty
|
0010| days after the superintendent has received the request for
|
0011| hearing.
|
0012| K. The superintendent may require the submission of
|
0013| whatever relevant information he deems necessary in determining
|
0014| whether to approve or disapprove a filing made pursuant to this
|
0015| section.
|
0016| Section 11. ANNUAL REPORT.--
|
0017| A. Every provider sponsored health network shall
|
0018| annually, on or before the first day of March, file a report,
|
0019| verified by at least two principal officers, with the
|
0020| superintendent, the secretary of health and the secretary of
|
0021| human services if the network serves medicaid patients covering
|
0022| the preceding calendar year.
|
0023| B. The report shall be on forms prescribed by the
|
0024| superintendent and shall include:
|
0025| (1) a financial statement of the network
|
0001| prepared pursuant to forms prescribed by the superintendent,
|
0002| including its balance sheet and receipts and disbursements for
|
0003| the preceding year;
|
0004| (2) any material changes in the information
|
0005| submitted pursuant to Subsection B of Section 4 of the Provider
|
0006| Sponsored Health Networks Law;
|
0007| (3) the number of persons enrolled during the
|
0008| year and the number of enrollees as of the end of the year; and
|
0009| (4) such other reasonable information
|
0010| materially relating to the performance of the provider sponsored
|
0011| health network as is necessary to enable the superintendent to
|
0012| carry out his duties.
|
0013| C. In addition, the provider sponsored health
|
0014| network shall file by the dates indicated:
|
0015| (1) audited financial statements as of the end
|
0016| of the preceding calendar year on or before June 1 or within one
|
0017| hundred twenty days following the end of its fiscal year,
|
0018| whichever is later;
|
0019| (2) a list of the providers who have executed a
|
0020| contract that complies with Subsection E of Section 13 of the
|
0021| Provider Sponsored Health Networks Law on or before March 1; and
|
0022| (3) a description of the grievance procedures
|
0023| and the total number of grievances handled through such
|
0024| procedures, a compilation of the causes underlying those
|
0025| grievances and a summary of the final disposition of those
|
0001| grievances, on or before March 1.
|
0002| D. The superintendent may require such additional
|
0003| reports as are deemed necessary and appropriate to enable the
|
0004| superintendent to carry out his duties under the Provider
|
0005| Sponsored Health Networks Law.
|
0006| Section 12. INFORMATION TO ENROLLEES OR SUBSCRIBERS.--
|
0007| A. A provider sponsored health network shall provide
|
0008| to its subscribers or to its group contract holders for
|
0009| distribution to subscribers a list of providers upon enrollment
|
0010| and reenrollment.
|
0011| B. Every provider sponsored health network shall
|
0012| notify its subscribers within thirty days of any material change
|
0013| in the operation of the organization that will affect the
|
0014| service to subscribers directly.
|
0015| C. An enrollee shall be notified in writing by the
|
0016| provider sponsored health network of the termination of any
|
0017| designated primary care provider who provided health care
|
0018| services to that enrollee. The provider sponsored health
|
0019| network shall provide assistance to the enrollee in transferring
|
0020| to another participating primary care provider.
|
0021| D. The provider sponsored health network shall
|
0022| provide to subscribers information on how services may be
|
0023| obtained, where additional information on access to services may
|
0024| be obtained and a number where the enrollee may contact the
|
0025| provider sponsored health network at no cost to the enrollee.
|
0001| Section 13. GRIEVANCE PROCEDURES.--
|
0002| A. Every provider sponsored health network shall
|
0003| establish and maintain a grievance procedure that has been
|
0004| approved by the superintendent or the secretary of human
|
0005| services, if the network is serving medicaid patients, to
|
0006| provide procedures for the resolution of grievances initiated by
|
0007| enrollees. The provider sponsored health network shall maintain
|
0008| records regarding grievances received since the date of its last
|
0009| examination of such grievances.
|
0010| B. The superintendent or the secretary of human
|
0011| services, if the provider sponsored health network is serving
|
0012| medicaid patients, may examine such grievance procedures and
|
0013| records.
|
0014| Section 14. PROTECTION AGAINST INSOLVENCY.--
|
0015| A. Provider sponsored health networks shall be
|
0016| subject to the following net worth requirements for conducting
|
0017| business or for providing non-medicaid or medicare program
|
0018| services:
|
0019| (1) the provider sponsored health network shall
|
0020| have an initial net worth of one million five hundred thousand
|
0021| dollars ($1,500,000) and shall thereafter maintain the minimum
|
0022| net worth required under Paragraph (2) of this subsection;
|
0023| (2) except as provided in Paragraphs (3) and
|
0024| (4) of this subsection, every provider sponsored health network
|
0025| shall maintain a minimum net worth equal to the greater of:
|
0001| (a) one million dollars ($1,000,000);
|
0002| (b) two percent of annual contract
|
0003| revenues as reported on the most recent annual financial
|
0004| statement filed with the superintendent on the first one hundred
|
0005| fifty million dollars ($150,000,000) of contract revenues and
|
0006| one percent of annual contract revenue in excess of one hundred
|
0007| fifty million dollars ($150,000,000);
|
0008| (c) an amount equal to the sum of three
|
0009| months, uncovered health care expenditures as reported on the
|
0010| most recent financial statement filed with the superintendent;
|
0011| or
|
0012| (d) an amount equal to the sum of: 1)
|
0013| eight percent of annual health care expenditures for enrollees
|
0014| under prepaid contracts except those paid on a capitated basis
|
0015| or managed hospital payment basis as reported on the most recent
|
0016| financial statement filed with the superintendent; and 2) four
|
0017| percent of annual hospital expenditures for enrollees under
|
0018| prepaid contracts paid on a capitated basis and a managed
|
0019| hospital payment basis as reported on the most recent financial
|
0020| statement filed with the superintendent;
|
0021| (3) a provider sponsored health network serving
|
0022| only medicaid or medicare patients under a medicaid managed care
|
0023| contract pursuant to Section 27-2-12.6 NMSA 1978 shall maintain
|
0024| a minimum net worth to be established by the human services
|
0025| department or:
|
0001| (a) twenty-five percent of the amount
|
0002| required by Paragraph (2) of this subsection by December 31,
|
0003| 1997;
|
0004| (b) fifty percent of the amount required
|
0005| by Paragraph (2) of this subsection by December 31, 1998;
|
0006| (c) seventy-five percent of the amount
|
0007| required by Paragraph (2) of this subsection by December 31,
|
0008| 1999; and
|
0009| (d) one hundred percent of the amount
|
0010| required by Paragraph (2) of this subsection by December 31,
|
0011| 2000; and
|
0012| (4) in determining net worth, other than the
|
0013| networth determined by the human services department, for the
|
0014| purposes of Paragraph (3) of this subsection:
|
0015| (a) no debt shall be considered fully
|
0016| subordinated unless the subordination clause is in a form
|
0017| acceptable to the superintendent and any interest obligation
|
0018| relating to the repayment of any subordinated debt shall be
|
0019| similarly subordinated;
|
0020| (b) the interest expenses relating to the
|
0021| repayment of any fully subordinated debt shall be considered
|
0022| covered expenses;
|
0023| (c) any debt incurred by a surplus note
|
0024| meeting the requirements of Section 59A-34-23 NMSA 1978, and
|
0025| otherwise acceptable to the superintendent, shall not be
|
0001| considered a liability and shall be recorded as equity; and
|
0002| (d) preferred stock shall not be
|
0003| considered debt.
|
0004| B. Provider sponsored health networks shall be
|
0005| subject to the following deposit requirements:
|
0006| (1) unless otherwise provided in Paragraph (2)
|
0007| of this subsection, each provider sponsored health network shall
|
0008| deposit with the superintendent or, at the discretion of the
|
0009| superintendent, with any network or trustee acceptable to him
|
0010| through which a custodial or controlled account is utilized,
|
0011| cash, securities or any combination of these or other measures
|
0012| that are acceptable to him that at all times shall have a value
|
0013| of not less than three hundred thousand dollars ($300,000);
|
0014| (2) a provider sponsored health network that is
|
0015| in operation on July 1, 1996 shall make a deposit equal to one
|
0016| hundred fifty thousand dollars ($150,000) and, in the second
|
0017| year, the amount of the additional deposit for a provider
|
0018| sponsored health network that is in operation on July 1, 1996
|
0019| shall be equal to one hundred fifty thousand dollars ($150,000),
|
0020| for a total of three hundred thousand dollars ($300,000);
|
0021| (3) the deposit shall be an admitted asset of
|
0022| the provider sponsored health network in the determination of
|
0023| net worth;
|
0024| (4) all income from deposits shall be an asset
|
0025| of the network, but a provider sponsored health network that has
|
0001| made a securities deposit may withdraw that deposit or any part
|
0002| thereof after making a substitute deposit of cash, securities or
|
0003| any combination of these or other assets of equal amount and
|
0004| value;
|
0005| (5) any securities deposited pursuant to the
|
0006| provisions of this subsection shall be approved by the
|
0007| superintendent before being deposited or substituted;
|
0008| (6) the deposit shall be used to protect the
|
0009| interests of the provider sponsored health network's enrollees
|
0010| and to assure continuation of health care services to enrollees
|
0011| of a provider sponsored health network that is in rehabilitation
|
0012| or conservation;
|
0013| (7) the superintendent may use a deposit made
|
0014| pursuant to the provisions of this subsection for administrative
|
0015| costs directly attributable to a receivership or liquidation,
|
0016| and if the provider sponsored health network is placed in
|
0017| receivership or liquidation, the deposit shall be an asset
|
0018| subject to the provisions of the applicable liquidation law; and
|
0019| (8) the superintendent may reduce or eliminate
|
0020| the deposit requirement if the provider sponsored health network
|
0021| deposits with the state treasurer, superintendent or other
|
0022| official body of the state or jurisdiction of domicile for the
|
0023| protection of all subscribers and enrollees, wherever located,
|
0024| of such provider sponsored health network, cash, acceptable
|
0025| securities or surety and delivers to the superintendent a
|
0001| certificate to such effect, duly authenticated by the
|
0002| appropriate state official holding the deposit.
|
0003| C. Every provider sponsored health network shall
|
0004| include when determining liabilities an amount estimated in the
|
0005| aggregate to provide for:
|
0006| (1) any unearned contract or capitated payment;
|
0007| (2) the payment of all claims for health care
|
0008| expenditures that have been incurred, whether reported or
|
0009| unreported, which are unpaid and for which the provider
|
0010| sponsored health network is or may be liable;
|
0011| (3) the expense of adjustment or settlement of
|
0012| the claims described in Paragraph (2) of this subsection; and
|
0013| (4) contract liabilities for continuation of
|
0014| coverage or conversion rights not covered by future premiums,
|
0015| contracts, capitated payments or hold harmless agreements.
|
0016| D. Liabilities described in Subsection C of this
|
0017| section shall be computed in accordance with regulations adopted
|
0018| by the superintendent upon reasonable consideration of the
|
0019| ascertained experience and character of the provider sponsored
|
0020| health network.
|
0021| E. Every contract between a provider sponsored
|
0022| health network and a participating provider of health care
|
0023| services shall be in writing and shall set forth that in the
|
0024| event the provider sponsored health network fails to pay for
|
0025| health care services as set forth in the contract, the
|
0001| subscriber or enrollee shall not be liable to the provider for
|
0002| any sums owed by the provider sponsored health network. In the
|
0003| event that the participating provider contract has not been
|
0004| reduced to writing or the contract fails to contain the required
|
0005| prohibition, the participating provider shall not collect or
|
0006| attempt to collect from the subscriber or enrollee sums owed by
|
0007| the provider sponsored health network. No participating
|
0008| provider or agent, trustee or assignee thereof may maintain any
|
0009| action at law against a subscriber or enrollee to collect sums
|
0010| owed by the provider sponsored health network.
|
0011| F. The superintendent or the secretary of human
|
0012| services shall require that each provider sponsored health
|
0013| network have a plan for handling insolvency that allows for
|
0014| continuation of benefits for the duration of the contract period
|
0015| and continuation of benefits to members who are confined on the
|
0016| date of insolvency in an inpatient facility until their
|
0017| discharge or expiration of benefits. In considering the plan,
|
0018| the superintendent or the secretary of human services may
|
0019| require:
|
0020| (1) insurance to cover the expenses to be paid
|
0021| for continued benefits after an insolvency;
|
0022| (2) provisions in provider contracts that
|
0023| obligate the provider to provide services for the duration of
|
0024| the period after the provider sponsored health network's
|
0025| insolvency for which premium payment has been made and until the
|
0001| enrollees' discharge from inpatient facilities;
|
0002| (3) insolvency reserves;
|
0003| (4) acceptable letters of credit; or
|
0004| (5) any other arrangements to assure that
|
0005| benefits are continued as specified in Paragraphs (1) through
|
0006| (4) of this subsection.
|
0007| G. An agreement to provide health care services
|
0008| between a provider and a provider sponsored health network shall
|
0009| require that if the provider terminates the agreement, the
|
0010| provider shall give the organization at least sixty days'
|
0011| advance notice of termination.
|
0012| Section 15. UNCOVERED EXPENDITURES INSOLVENCY DEPOSIT.--
|
0013| A. If at any time uncovered expenditures exceed ten
|
0014| percent of total health care expenditures, a provider sponsored
|
0015| health network shall place an uncovered expenditures insolvency
|
0016| deposit with the superintendent, the secretary of human services
|
0017| or with any organization or trustee acceptable to the
|
0018| superintendent through which a custodial or controlled account
|
0019| is maintained, cash or securities that are acceptable to the
|
0020| superintendent. Such deposit shall at all times have a fair
|
0021| market value in an amount of one hundred twenty percent of the
|
0022| provider sponsored health network's outstanding liability for
|
0023| uncovered expenditures for enrollees in this state, including
|
0024| incurred but not reported claims, and shall be calculated as of
|
0025| the first day of the month and maintained for the remainder of
|
0001| the month. If a provider sponsored health network is not
|
0002| otherwise required to file a quarterly report, it shall file a
|
0003| report within forty-five days of the end of the calendar quarter
|
0004| with information sufficient to demonstrate compliance with this
|
0005| subsection.
|
0006| B. The deposit required by Subsection A of this
|
0007| section is in addition to the deposit required by Section 13 of
|
0008| the Provider Sponsored Health Networks Law and is an admitted
|
0009| asset of the provider sponsored health network in the
|
0010| determination of net worth. All income from such deposits or
|
0011| trust accounts shall be assets of the provider sponsored health
|
0012| network and may be withdrawn from such deposit or account
|
0013| quarterly with the approval of the superintendent or the
|
0014| secretary of human services if the income from deposits or trust
|
0015| accounts relates to medicaid managed care contracts.
|
0016| C. A provider sponsored health network that has made
|
0017| a deposit may withdraw that deposit or any part of the deposit
|
0018| if a substitute deposit of cash or securities of equal amount
|
0019| and value is made, the fair market value of the deposit exceeds
|
0020| the amount of the required deposit or the required deposit under
|
0021| Subsection A of this section is reduced or eliminated.
|
0022| Deposits, substitutions or withdrawals may be made only with the
|
0023| prior written approval of the superintendent or the secretary of
|
0024| human services if the deposits, substitutions or withdrawals are
|
0025| made from medicaid managed care contracts.
|
0001| D. The deposit required under Subsection A of this
|
0002| section is in trust and may be used only as provided under this
|
0003| section. The superintendent or the secretary of human services
|
0004| in regard to medicaid managed care contracts may use the deposit
|
0005| of an insolvent provider sponsored health network for
|
0006| administrative costs associated with administering the deposit
|
0007| and payment of claims of enrollees of this state for uncovered
|
0008| expenditures in this state. Claims for uncovered expenditures
|
0009| shall be paid on a pro rata basis based on assets available to
|
0010| pay such ultimate liability for incurred expenditures. Partial
|
0011| distribution may be made pending final distribution. Any amount
|
0012| of the deposit remaining shall be paid into the liquidation or
|
0013| receivership of the provider sponsored health network.
|
0014| E. The superintendent or the secretary of human
|
0015| services in regard to medicaid managed care contracts may by
|
0016| regulation prescribe the time, manner and form for filing claims
|
0017| under Subsection D of this section.
|
0018| F. The superintendent or the secretary of human
|
0019| services in regard to medicaid managed care contracts may by
|
0020| regulation or order require provider sponsored health networks
|
0021| to file annual, quarterly or more frequent reports as he deems
|
0022| necessary to demonstrate compliance with this section. The
|
0023| superintendent or the secretary of human services may require
|
0024| that the reports include liability for uncovered expenditures as
|
0025| well as an audit opinion.
|
0001| Section 16. ENROLLMENT PERIOD--REPLACEMENT COVERAGE IN THE
|
0002| EVENT OF INSOLVENCY.--
|
0003| A. In the event of an insolvency of a provider
|
0004| sponsored health network, upon order of the superintendent or
|
0005| the secretary of human services in regard to medicaid managed
|
0006| care contracts, all other carriers that participated in the
|
0007| enrollment process with the insolvent provider sponsored health
|
0008| network at a group's last regular enrollment period shall offer
|
0009| such group's enrollees of the insolvent provider sponsored
|
0010| health network a thirty-day enrollment period commencing upon
|
0011| the date of insolvency. Each carrier shall offer such enrollees
|
0012| of the insolvent provider sponsored health network the same
|
0013| coverages and rates that it had offered to the enrollees of the
|
0014| group at its last regular enrollment period.
|
0015| B. If no other carrier had been offered to some
|
0016| groups enrolled in the insolvent provider sponsored health
|
0017| network or if the superintendent or the secretary of human
|
0018| services in regard to medicaid managed care contracts determines
|
0019| that the other health benefit plans lack sufficient health care
|
0020| delivery resources to assure that health care services will be
|
0021| available and accessible to all of the group enrollees of the
|
0022| insolvent provider sponsored health network, the superintendent
|
0023| or the secretary of human services shall allocate equitably the
|
0024| insolvent provider sponsored health network's group contracts
|
0025| for such groups among all provider sponsored health networks
|
0001| that operate within a portion of the insolvent provider
|
0002| sponsored health network's service area, taking into
|
0003| consideration the health care delivery resources and total
|
0004| membership of each provider sponsored health network. Each
|
0005| provider sponsored health network to which groups are so
|
0006| allocated shall offer the groups the provider sponsored health
|
0007| network's existing coverage that is most similar to each group's
|
0008| coverage with the insolvent provider sponsored health network at
|
0009| rates determined in accordance with the successor provider
|
0010| sponsored health network's existing rating methodology.
|
0011| C. The superintendent or the secretary of human
|
0012| services in regard to medicaid managed care contracts shall also
|
0013| allocate equitably the insolvent provider sponsored health
|
0014| network's nongroup enrollees that are unable to obtain other
|
0015| coverage among all provider sponsored health networks that
|
0016| operate within a portion of the insolvent provider sponsored
|
0017| health network service's area, taking into consideration the
|
0018| health care delivery resources of each such provider sponsored
|
0019| health network. Each provider sponsored health network to which
|
0020| nongroup enrollees are allocated shall offer such nongroup
|
0021| enrollees the provider sponsored health network's existing
|
0022| coverage for individual or conversion coverage as determined by
|
0023| his type of coverage in the insolvent provider sponsored health
|
0024| network at rates determined in accordance with the successor
|
0025| provider sponsored health network's existing rating methodology.
|
0001| Successor provider sponsored health networks that do not offer
|
0002| direct nongroup enrollment may aggregate all of the allocated
|
0003| nongroup enrollees into one group for rating and coverage
|
0004| purposes.
|
0005| D. Any carrier providing replacement coverage with
|
0006| respect to group hospital, medical or surgical expense or
|
0007| service benefits within a period of sixty days from the date of
|
0008| discontinuance of a prior provider sponsored health network
|
0009| contract or policy providing such hospital, medical or surgical
|
0010| expense or service benefits shall cover immediately all
|
0011| enrollees who were covered validly under the previous provider
|
0012| sponsored health network contract or policy at the date of
|
0013| discontinuance and who would otherwise be eligible for coverage
|
0014| under the succeeding carrier's contract, regardless of any
|
0015| provisions of the contract relating to active employment,
|
0016| hospital confinement or pregnancy. For purposes of this
|
0017| section, "discontinuance" means the termination of the contract
|
0018| between the group contract holder and a provider sponsored
|
0019| health network due to the insolvency of the provider sponsored
|
0020| health network and does not refer to the termination of any
|
0021| agreement between any individual enrollee and the provider
|
0022| sponsored health network.
|
0023| E. Except to the extent benefits for the condition
|
0024| would have been reduced or excluded under the prior contractor
|
0025| or carrier's contract or policy, no provision in a succeeding
|
0001| contractor's or carrier's contract of replacement coverage that
|
0002| would operate to reduce or exclude benefits on the basis that
|
0003| the condition giving rise to benefits existed before the
|
0004| effective date of the succeeding carrier's contract shall be
|
0005| applied with respect to those enrollees validly covered under
|
0006| the prior carrier's contract or policy on the date of
|
0007| discontinuance.
|
0008| Section 17. FILING REQUIREMENTS FOR RATING INFORMATION.--
|
0009| A. No contract rate may be used until either a
|
0010| schedule of rates or methodology for determining rates has been
|
0011| filed with and approved by the superintendent or the secretary
|
0012| of human services in regard to medicaid managed care contracts.
|
0013| At the time the provider sponsored health network files the rate
|
0014| with the superintendent or the secretary of human services, it
|
0015| shall also file a schedule of benefits to which the rate
|
0016| applies.
|
0017| B. Either a specific schedule of rates or a
|
0018| methodology for determining rates shall be established in
|
0019| accordance with actuarial principles for various categories of
|
0020| enrollees; provided that the payment applicable to an enrollee
|
0021| shall not be individually determined based on the status of the
|
0022| enrollee's health. A certification by a qualified actuary or
|
0023| other qualified person acceptable to the superintendent or the
|
0024| secretary of human services in regard to medicaid managed care
|
0025| contracts as to the appropriateness of the rates or of the use
|
0001| of the methodology, based on reasonable assumptions, shall
|
0002| accompany the filing along with adequate supporting information.
|
0003| C. The superintendent or the secretary of human
|
0004| services in regard to medicaid managed care contracts may
|
0005| disapprove any such rates or methodology for determining rates
|
0006| found by him to be excessive, inadequate or unfairly
|
0007| discriminatory, considering the benefits to be provided. If the
|
0008| superintendent or secretary of human services disapproves the
|
0009| filing, he shall notify the provider sponsored health network,
|
0010| specifying the reasons for his disapproval. A hearing shall be
|
0011| conducted within thirty days after a request in writing by the
|
0012| person filing. The schedule or methodology shall be deemed
|
0013| approved if the superintendent or secretary of human services
|
0014| does not disapprove the filing within thirty days.
|
0015| Section 18. REGULATION OF PROVIDER SPONSORED HEALTH
|
0016| NETWORKS AGENTS.--
|
0017| A. Requirements and procedures for licensing of
|
0018| provider sponsored health networks agents shall be governed by
|
0019| the provisions of Chapter 59A, Articles 11 and 12 NMSA 1978 and
|
0020| any regulations adopted by the superintendent or the secretary
|
0021| of human services in regard to medicaid managed care contracts
|
0022| pertaining to those articles.
|
0023| B. None of the following shall be required to hold a
|
0024| provider sponsored health network agent license:
|
0025| (1) any regular salaried officer or employee of
|
0001| a provider sponsored health network who devotes substantially
|
0002| all of his time to activities other than the taking or
|
0003| transmitting of applications or membership fees or premiums for
|
0004| provider sponsored health network membership or who receives no
|
0005| commission or other compensation directly dependent upon the
|
0006| business obtained and who does not solicit or accept from the
|
0007| public applications for provider sponsored health network
|
0008| membership;
|
0009| (2) employers or their officers or employees or
|
0010| the trustees of any employee benefit plan to the extent that
|
0011| such employers, officers, employees or trustees are engaged in
|
0012| the administration or operation of any program of employee
|
0013| benefits involving the use of provider sponsored health network
|
0014| memberships, if those employers, officers, employees or trustees
|
0015| are not compensated directly or indirectly by the provider
|
0016| sponsored health network issuing the provider sponsored health
|
0017| network memberships;
|
0018| (3) banks or their officers and employees to
|
0019| the extent that such banks, officers and employees collect and
|
0020| remit charges by charging same against accounts of depositors on
|
0021| the orders of such depositors; or
|
0022| (4) any person or the employee of any person
|
0023| who has contracted to provide administrative, management or
|
0024| health care services to a provider sponsored health network and
|
0025| who is compensated for those services by the payment of an
|
0001| amount calculated as a percentage of the revenues, net income or
|
0002| profit of the provider sponsored health network, if that method
|
0003| of compensation is the sole basis for subjecting that person or
|
0004| the employee of the person to the provisions of the Provider
|
0005| Sponsored Health Networks Law.
|
0006| C. The superintendent or the secretary of human
|
0007| services in regard to medicaid managed care contracts may by
|
0008| rule exempt certain classes of persons from the requirement of
|
0009| obtaining a license if:
|
0010| (1) the functions they perform do not require
|
0011| special competence, trustworthiness or the regulatory
|
0012| surveillance made possible by licensing; or
|
0013| (2) other existing safeguards make regulation
|
0014| unnecessary.
|
0015| Section 19. POWERS OF INSURERS.--
|
0016| A. An authorized insurer may either directly or
|
0017| through a subsidiary or affiliate organize and operate a
|
0018| provider sponsored health network under the provisions of the
|
0019| Provider Sponsored Health Networks Law. Notwithstanding any
|
0020| other law that may be inconsistent with the cited law, any two
|
0021| or more such insurance companies or their subsidiaries or
|
0022| affiliates may jointly organize and operate a provider sponsored
|
0023| health network. The business of insurance is deemed to include
|
0024| the providing of health care by a provider sponsored health
|
0025| network owned or operated by an insurer or its subsidiary.
|
0001| B. An authorized insurer may contract with a
|
0002| provider sponsored health network to provide insurance or
|
0003| similar protection against the cost of care provided through
|
0004| provider sponsored health networks and to provide coverage in
|
0005| the event of the failure of the provider sponsored health
|
0006| network to meet its obligations. Among other things, under such
|
0007| contracts the insurer may make benefit payments to provider
|
0008| sponsored health networks for health care services rendered by
|
0009| providers.
|
0010| Section 20. EXAMINATIONS.--
|
0011| A. The superintendent or the secretary of human
|
0012| services in regard to medicaid managed care contracts may make
|
0013| an examination of the affairs of any provider sponsored health
|
0014| network and providers with whom the provider sponsored health
|
0015| network has contracts, agreements or other arrangements as often
|
0016| as is reasonably necessary for the protection of the interests
|
0017| of the people of this state, but not less frequently than once
|
0018| every three years.
|
0019| B. The superintendent or the secretary of human
|
0020| services in regard to medicaid managed care contracts may make
|
0021| or request the secretary of health to make an examination
|
0022| concerning the quality assurance program of the provider
|
0023| sponsored health network and of any providers with whom the
|
0024| provider sponsored health network has contracts, agreements or
|
0025| other arrangements as often as is reasonably necessary for the
|
0001| protection of the interests of the people of this state.
|
0002| C. Every provider sponsored health network and
|
0003| provider shall submit its books and records for examination and
|
0004| in every way facilitate the completion of the examination.
|
0005| Medical records of individuals and contract providers shall not
|
0006| be subject to examination. For the purpose of examinations, the
|
0007| superintendent, the secretary of health and the secretary of
|
0008| human services may administer oaths to and examine the officers
|
0009| and agents of the provider sponsored health network and the
|
0010| principals of the providers concerning their business.
|
0011| D. The expenses of examinations under this section
|
0012| shall be assessed against the provider sponsored health network
|
0013| being examined and remitted to the superintendent and the
|
0014| secretary of human services in regard to medicaid managed care
|
0015| contracts.
|
0016| E. In lieu of examination, the superintendent or the
|
0017| secretary of human services in regard to medicaid managed care
|
0018| contracts may accept the report of an examination made by the
|
0019| superintendent, secretary of health or secretary of human
|
0020| services of another state.
|
0021| F. Examination procedures shall be governed by the
|
0022| applicable provisions of Chapter 59A, Article 4 NMSA 1978.
|
0023| Section 21. CEASE AND DESIST ORDERS.--
|
0024| A. The superintendent and the secretary of human
|
0025| services in regard to medicaid managed care contracts may issue
|
0001| cease and desist orders to any provider sponsored health network
|
0002| if:
|
0003| (1) the provider sponsored health network is
|
0004| operating significantly in contravention of its basic
|
0005| organizational document or in a manner contrary to that
|
0006| described in any other information submitted under Section 4 of
|
0007| the Provider Sponsored Health Networks Law, unless amendments to
|
0008| such submissions have been filed with and approved by the
|
0009| superintendent;
|
0010| (2) the provider sponsored health network
|
0011| issues an evidence of coverage or uses a schedule of charges for
|
0012| health care services that does not comply with the requirements
|
0013| of Sections 9 and 16 of the Provider Sponsored Health Networks
|
0014| Law;
|
0015| (3) the provider sponsored health network does
|
0016| not provide or arrange for basic health care services;
|
0017| (4) the secretary of health has certified to
|
0018| the superintendent that the provider sponsored health network is
|
0019| unable to fulfill its obligations to furnish health care
|
0020| services;
|
0021| (5) the provider sponsored health network is no
|
0022| longer financially responsible and may reasonably be expected to
|
0023| be unable to meet its obligations to enrollees or prospective
|
0024| enrollees;
|
0025| (6) the provider sponsored health network has
|
0001| failed to correct, within the time prescribed by Subsection C of
|
0002| this section, any deficiency occurring due to the provider
|
0003| sponsored health network's prescribed minimum net worth being
|
0004| impaired;
|
0005| (7) the provider sponsored health network has
|
0006| failed to implement the grievance procedures required by Section
|
0007| 12 of the Provider Sponsored Health Networks Law in a reasonable
|
0008| manner to resolve valid complaints;
|
0009| (8) the provider sponsored health network or
|
0010| any person on its behalf has engaged in any practice that under
|
0011| Chapter 59A, Article 16 NMSA 1978 is defined or prohibited as or
|
0012| determined to be an unfair method of competition or an unfair or
|
0013| deceptive act or practice or fraudulent;
|
0014| (9) the continued operation of the provider
|
0015| sponsored health network would be hazardous to its enrollees; or
|
0016| (10) the provider sponsored health network has
|
0017| otherwise failed substantially to comply with the provisions of
|
0018| the Provider Sponsored Health Networks Law.
|
0019| B. In addition to a cease and desist order pursuant
|
0020| to this section, the registrant or provider sponsored health
|
0021| network may be subjected to an administrative penalty of up to
|
0022| five thousand dollars ($5,000) for each cause for suspension or
|
0023| revocation, but if the violation is willful or intentional, the
|
0024| administrative penalty may be up to ten thousand dollars
|
0025| ($10,000).
|
0001| C. Whenever the superintendent or the secretary of
|
0002| human services in regard to medicaid managed care contracts
|
0003| finds that the net worth maintained by any provider sponsored
|
0004| health network subject to the provisions of the Provider
|
0005| Sponsored Health Networks Law is less than the minimum net worth
|
0006| required to be maintained pursuant to the provisions of Section
|
0007| 13 of the Provider Sponsored Health Networks Law, he shall give
|
0008| written notice to the provider sponsored health network of the
|
0009| amount of the deficiency and require the provider sponsored
|
0010| health network to:
|
0011| (1) file with the superintendent or the
|
0012| secretary of human services a plan for correction of the
|
0013| deficiency acceptable to the superintendent or the secretary;
|
0014| and
|
0015| (2) correct the deficiency within a reasonable
|
0016| time, not to exceed sixty days, unless an extension of time, not
|
0017| to exceed sixty additional days, is granted by the
|
0018| superintendent or the secretary of human services.
|
0019| D. A deficiency found to exist by the superintendent
|
0020| or the secretary of human services pursuant to the provisions of
|
0021| Subsection C of this section shall be deemed an impairment, and
|
0022| failure to correct the impairment in the prescribed time shall
|
0023| be grounds for issuance of a cease and desist order to the
|
0024| provider sponsored health network or for placing it in
|
0025| conservation, rehabilitation or liquidation.
|
0001| E. The provider sponsored health network or
|
0002| registrant may in writing request a hearing within thirty days
|
0003| from the date of mailing a cease and desist order or imposing an
|
0004| administrative penalty. If no written request is made, the
|
0005| order shall be final upon the expiration of the thirty days.
|
0006| F. If the provider sponsored health network or
|
0007| registrant requests a hearing pursuant to the provisions of
|
0008| Subsection G of this section, the superintendent or secretary of
|
0009| human services shall issue a written notice of hearing and send
|
0010| it to the provider sponsored health network or registrant by
|
0011| certified or registered mail stating:
|
0012| (1) a specific time for the hearing, which may
|
0013| not be less than twenty or more than thirty days after mailing
|
0014| of the notice of hearing; and
|
0015| (2) a specific place for the hearing, which may
|
0016| be either in Santa Fe county or in the county where the provider
|
0017| sponsored health network's or registrant's principal place of
|
0018| business is located.
|
0019| G. After a hearing held pursuant to the provisions
|
0020| of Subsection E of this section or upon failure of the provider
|
0021| sponsored health network to appear at the hearing, the
|
0022| superintendent or secretary of human services shall take
|
0023| whatever action he deems necessary based on written findings and
|
0024| shall mail his decision to the provider sponsored health network
|
0025| or registrant.
|
0001| H. The provisions of Chapter 59A, Article 4 NMSA
|
0002| 1978 shall apply to proceedings under this section to the extent
|
0003| they are not in conflict with Subsection F of this section.
|
0004| I. When a cease and desist order has been invoked
|
0005| the provider sponsored health network shall proceed, immediately
|
0006| following the effective date of the order to cease and desist,
|
0007| to wind up its affairs and shall conduct no further business
|
0008| except as may be essential to the orderly conclusion of the
|
0009| affairs of the organization. It shall engage in no further
|
0010| advertising or solicitation whatsoever. The superintendent or
|
0011| secretary of human services may, by written order, permit such
|
0012| further operation of the network as he may find to be in the
|
0013| best interest of enrollees, to the end that enrollees will be
|
0014| afforded the greatest practical opportunity to obtain continuing
|
0015| health care coverage.
|
0016| Section 22. SUMMARY ORDERS AND SUPERVISION.--
|
0017| A. Whenever the superintendent or secretary of human
|
0018| services in regard to medicaid managed care contracts determines
|
0019| that the financial condition of any provider sponsored health
|
0020| network is such that its continued operation might be hazardous
|
0021| to its enrollees, creditors or the general public or that it has
|
0022| violated any provision of the Provider Sponsored Health Networks
|
0023| Law, he may, after notice and hearing, order the provider
|
0024| sponsored health network to take such action as may be
|
0025| reasonably necessary to rectify the condition or violation,
|
0001| including but not limited to one or more of the following:
|
0002| (1) reduce the total amount of present and
|
0003| potential liability for benefits by reinsurance or other method
|
0004| acceptable to the superintendent;
|
0005| (2) reduce the volume of new business being
|
0006| accepted;
|
0007| (3) reduce expenses by specified methods;
|
0008| (4) suspend or limit the writing of new
|
0009| business for a period of time;
|
0010| (5) increase the provider sponsored health
|
0011| network's capital and surplus by contribution; or
|
0012| (6) take such other steps as the superintendent
|
0013| or secretary of human services may deem appropriate under the
|
0014| circumstances, including suspension or revocation of the
|
0015| certificate of public advantage or assessment of administrative
|
0016| penalties as provided in Section 20 of the Provider Sponsored
|
0017| Health Networks Law.
|
0018| B. For purposes of this section, the violation by a
|
0019| provider sponsored health network of any law of this state to
|
0020| which the provider sponsored health network is subject shall be
|
0021| deemed a violation of the provisions of the Provider Sponsored
|
0022| Health Networks Law.
|
0023| C. The superintendent or secretary of human services
|
0024| in regard to medicaid managed care contracts is authorized to
|
0025| make rules and regulations setting uniform standards and
|
0001| criteria for early warning that the continued operation of any
|
0002| provider sponsored health network might be hazardous to its
|
0003| enrollees, creditors or the general public and setting standards
|
0004| for evaluating the financial condition of any provider sponsored
|
0005| health network, which standards shall be consistent with the
|
0006| purposes expressed in Subsection A of this section.
|
0007| D. The remedies and measures available to the
|
0008| superintendent pursuant to provisions of this section shall be
|
0009| in addition to, and not in lieu of, the remedies and measures
|
0010| available to the superintendent under the provisions of Chapter
|
0011| 59A, Article 41 NMSA 1978.
|
0012| Section 23. REGULATIONS.--The superintendent and the
|
0013| secretary of human services in regard to medicaid managed care
|
0014| contracts may, after notice and hearing, adopt and promulgate
|
0015| reasonable rules and regulations as are necessary or proper to
|
0016| carry out the provisions of the Provider Sponsored Health
|
0017| Networks Law.
|
0018| Section 24. PENALTIES AND ENFORCEMENT.--
|
0019| A. The superintendent or the secretary of health
|
0020| may, in lieu of suspension or revocation of a certificate of
|
0021| public advantage or an application for registration pursuant to
|
0022| the provisions of Section 20 of the Provider Sponsored Health
|
0023| Networks Law, levy an administrative penalty in an amount up to
|
0024| five thousand dollars ($5,000), except that if the violation is
|
0025| willful or intentional, the administrative penalty may be up to
|
0001| ten thousand dollars ($10,000). The superintendent may augment
|
0002| this penalty by an amount equal to the sum that he calculates to
|
0003| be the damages suffered by enrollees or other members of the
|
0004| public.
|
0005| B. If the superintendent for any reason has cause to
|
0006| believe that any violation of the provisions of the Provider
|
0007| Sponsored Health Networks Law has occurred or is threatened, the
|
0008| superintendent may give notice to the provider sponsored health
|
0009| network and to the representatives or other persons who appear
|
0010| to be involved in the suspected violation to arrange a
|
0011| conference with the alleged violators or their authorized
|
0012| representatives for the purpose of attempting to ascertain the
|
0013| facts relating to the suspected violation and, in the event it
|
0014| appears that any violation has occurred or is threatened, to
|
0015| arrive at an adequate and effective means of correcting or
|
0016| preventing the violation.
|
0017| C. A conference arranged under the provisions of
|
0018| Subsection B of this section shall not be governed by any formal
|
0019| procedural requirements and may be conducted in such manner as
|
0020| the superintendent or the secretary of human services in regard
|
0021| to medicaid managed care contracts deems appropriate under the
|
0022| circumstances.
|
0023| D. The superintendent or secretary of human services
|
0024| in regard to medicaid managed care contracts may issue an order
|
0025| directing a provider sponsored health network or a
|
0001| representative of a provider sponsored health network to cease
|
0002| and desist from engaging in any act or practice in violation of
|
0003| the provisions of the Provider Sponsored Health Networks Law.
|
0004| Within thirty days after service of the cease and desist order,
|
0005| the respondent may request a hearing on the question of whether
|
0006| acts or practices in violation of that law have occurred. Such
|
0007| hearings shall be governed by the provisions of Chapter 59A,
|
0008| Article 4 NMSA 1978.
|
0009| E. In the case of any violation of the provisions of
|
0010| the Provider Sponsored Health Networks Law, if the
|
0011| superintendent or secretary of human services in regard to
|
0012| medicaid managed care contracts elects not to issue a cease and
|
0013| desist order or in the event of noncompliance with a cease and
|
0014| desist order issued pursuant to Subsection D of this section,
|
0015| the superintendent or secretary may institute a proceeding to
|
0016| obtain injunctive or other appropriate relief in the Santa Fe
|
0017| county district court.
|
0018| F. Notwithstanding any other provisions of the
|
0019| Provider Sponsored Health Networks Law, if a provider sponsored
|
0020| health network fails to comply with the net worth requirement of
|
0021| that law, the superintendent or the secretary of human services
|
0022| in regard to medicaid managed care contracts is authorized to
|
0023| take appropriate action to assure that the continued operation
|
0024| of the provider sponsored health network will not be hazardous
|
0025| to its enrollees.
|
0001| Section 25. FILINGS AND REPORTS AS PUBLIC DOCUMENTS.--All
|
0002| applications, filings and reports required by the Provider
|
0003| Sponsored Health Networks Law shall be treated as public
|
0004| documents, except those that are trade secrets or privileged or
|
0005| confidential quality assurance, commercial or financial
|
0006| information, other than any annual financial statement that may
|
0007| be required under Section 10 of that act.
|
0008| Section 26. CONFIDENTIALITY OF MEDICAL INFORMATION AND
|
0009| LIMITATION OF LIABILITY.--
|
0010| A. Any data or information pertaining to the
|
0011| diagnosis, treatment or health of any enrollee or applicant
|
0012| obtained from such person or from any provider by any provider
|
0013| sponsored health network shall be held in confidence and shall
|
0014| not be disclosed to any person except:
|
0015| (1) to the extent that it may be necessary to
|
0016| carry out the purposes of the Provider Sponsored Health Networks
|
0017| Law;
|
0018| (2) upon the express consent of the enrollee or
|
0019| applicant;
|
0020| (3) pursuant to statute or court order for the
|
0021| production of evidence or the discovery thereof; or
|
0022| (4) in the event of claim or litigation between
|
0023| the person and the provider sponsored health network in which
|
0024| the data or information is pertinent.
|
0025| B. A provider sponsored health network shall be
|
0001| entitled to claim any statutory privileges against disclosure of
|
0002| information described in Subsection A of this section that the
|
0003| provider who furnished the information to the provider sponsored
|
0004| health network is entitled to claim.
|
0005| C. A person who in good faith and without malice
|
0006| takes any action or makes any decision or recommendation as a
|
0007| member, agent or employee of a health care review committee or
|
0008| who furnishes any records, information or assistance to such a
|
0009| committee shall not be subject to liability for civil damages or
|
0010| any legal action in consequence of such action, nor shall the
|
0011| provider sponsored health network that established the committee
|
0012| or the officers, directors, employees or agents of the provider
|
0013| sponsored health network be liable for the activities of any
|
0014| such person. The provisions of this subsection do not relieve
|
0015| any person of liability arising from treatment of a patient.
|
0016| D. The information considered by a health care
|
0017| review committee and the records of its actions and proceedings
|
0018| shall be confidential and not subject to subpoena or order to
|
0019| produce except in proceedings before the appropriate state
|
0020| licensing or certifying agency or in an appeal, if permitted,
|
0021| from the committee's findings or recommendations. No member of
|
0022| a health care review committee or officer, director or other
|
0023| member of a provider sponsored health network or its staff
|
0024| engaged in assisting the committee or any person assisting or
|
0025| furnishing information to the committee may be subpoenaed to
|
0001| testify in any judicial or quasi-judicial proceeding if the
|
0002| subpoena is based solely on such activities.
|
0003| E. Information considered by a health care review
|
0004| committee and the records of its actions and proceedings that
|
0005| are used pursuant to Subsection D of this section by a state
|
0006| licensing or certifying agency or in an appeal shall be kept
|
0007| confidential and shall be subject to the same provision
|
0008| concerning discovery and use in legal actions as are the
|
0009| original information and records in the possession and control
|
0010| of a health care review committee.
|
0011| F. To fulfill its obligations under Section 8 of the
|
0012| Provider Sponsored Health Networks Law, the provider sponsored
|
0013| health network shall have access to treatment records and other
|
0014| information pertaining to the diagnosis, treatment or health
|
0015| status of any enrollee.
|
0016| Section 27. AUTHORITY TO CONTRACT.--The secretary of
|
0017| health and the secretary of human services, in carrying out
|
0018| their obligations under the provisions of the Provider Sponsored
|
0019| Health Networks Law, may contract with qualified persons to make
|
0020| recommendations concerning the determinations required to be
|
0021| made by them, which recommendations may be accepted in full or
|
0022| in part or rejected entirely.
|
0023| Section 28. CONTINUATION OF COVERAGE AND CONVERSION
|
0024| RIGHT.--
|
0025| A. Every individual or group contract entered into
|
0001| by a provider sponsored health network and that is delivered,
|
0002| issued for delivery or renewed in this state on or after January
|
0003| 1, 1996 shall provide covered family members of subscribers the
|
0004| right to continue such coverage through a converted or separate
|
0005| contract upon the death of the subscriber or upon the divorce,
|
0006| annulment or dissolution of marriage or legal separation of the
|
0007| spouse from the subscriber. Where a continuation of coverage or
|
0008| conversion is made in the name of the spouse of the subscriber,
|
0009| such coverage may, at the option of the spouse, include coverage
|
0010| to dependent children for whom the spouse has responsibility for
|
0011| care and support.
|
0012| B. The right to a continuation of coverage or
|
0013| conversion pursuant to this section shall not exist with respect
|
0014| to any covered family member of a subscriber in the event the
|
0015| coverage terminates for nonpayment or nonrenewal of the contract
|
0016| or the expiration of the term for which the contract is issued.
|
0017| With respect to any covered family member who is eligible for
|
0018| medicaid or medicare or any other similar federal or state
|
0019| health program, the right to a continuation of coverage or
|
0020| conversion shall be limited to coverage under a medicare
|
0021| supplement insurance contract as defined by the rules and
|
0022| regulations adopted by the superintendent.
|
0023| C. Coverage continued through the issuance of a
|
0024| converted or separate contract shall be provided at a
|
0025| reasonable, nondiscriminatory rate and shall consist of a form
|
0001| of coverage then being offered by the provider sponsored health
|
0002| network as a conversion contract. Continued and converted
|
0003| coverages shall contain renewal provisions that are not less
|
0004| favorable to the subscriber than those contained in the contract
|
0005| from which the conversion is made, except that the person who
|
0006| exercises the right of conversion is entitled only to have
|
0007| included a right to coverage under a medicaid or medicare
|
0008| supplement insurance contract, as defined by the rules and
|
0009| regulations adopted by the superintendent, after the attainment
|
0010| of the age or other standards of eligibility established for
|
0011| medicaid or medicare or any other similar federal or state
|
0012| health program.
|
0013| D. At the time of inception of coverage, the
|
0014| provider sponsored health network shall provide each covered
|
0015| family member eighteen years of age or older a statement setting
|
0016| forth in summary form the continuation of coverage and
|
0017| conversion provisions of the subscriber's contract.
|
0018| E. The eligible covered family member exercising the
|
0019| continuation or conversion right must notify the provider
|
0020| sponsored health network and make payment of the applicable cost
|
0021| within thirty days following the date such coverage otherwise
|
0022| terminates as specified in the contract from which continuation
|
0023| or conversion is being exercised.
|
0024| F. Coverage shall be provided through continuation
|
0025| or conversion without additional evidence of insurability and
|
0001| shall not impose any preexisting condition, limitations or other
|
0002| contractual time limitations other than those remaining
|
0003| unexpired under the contract from which continuation or
|
0004| conversion is exercised.
|
0005| G. Any probationary or waiting period set forth in
|
0006| the converted or separate contract is deemed to commence on the
|
0007| effective date of the applicant's coverage under the original
|
0008| contract.
|
0009| Section 29. GOVERNING BODY.--The governing body of any
|
0010| provider sponsored health network shall include providers or
|
0011| other individuals, or both. Such governing body shall establish
|
0012| a mechanism to afford the enrollees an opportunity to
|
0013| participate in matters of policy and operation through the
|
0014| establishment of advisory panels, by the use of advisory
|
0015| referenda on major policy decisions or through the use of other
|
0016| mechanisms.
|
0017| Section 30. PROHIBITED PRACTICES.--
|
0018| A. No provider sponsored health network or
|
0019| representative may cause or knowingly permit the use of
|
0020| advertising which is untrue or misleading, solicitation which is
|
0021| untrue or misleading, or any form of evidence of coverage which
|
0022| is deceptive. For purposes of the Provider Sponsored Health
|
0023| Networks Law:
|
0024| (1) a statement or item of information is
|
0025| deemed to be untrue if it does not conform to fact in any
|
0001| respect which is or may be significant to an enrollee of, or
|
0002| person considering enrollment in, a provider sponsored health
|
0003| network;
|
0004| (2) a statement or item of information is
|
0005| deemed to be misleading, whether or not it may be literally
|
0006| untrue, if, in the total context in which such statement is made
|
0007| or such item of information is communicated, such statement or
|
0008| item of information may be reasonably understood by a reasonable
|
0009| person, not possessing special knowledge regarding health care
|
0010| coverage, as indicating any benefit or advantage or the absence
|
0011| of any exclusion, limitation or disadvantage of possible
|
0012| significance to an enrollee of, or person considering enrollment
|
0013| in, a provider sponsored health network, if such benefit or
|
0014| advantage or absence of limitation, exclusion or disadvantage
|
0015| does not in fact exist; and
|
0016| (3) an evidence of coverage is deemed to be
|
0017| deceptive if the evidence of coverage taken as a whole, and with
|
0018| consideration given to typography and format, as well as
|
0019| language, shall be such as to cause a reasonable person, not
|
0020| possessing special knowledge regarding health care coverage and
|
0021| evidences of coverage therefor, to expect benefits, services,
|
0022| charges or other advantages which the evidence of coverage does
|
0023| not provide or which the provider sponsored health network
|
0024| issuing such evidence of coverage does not regularly make
|
0025| available for enrollees covered under such evidence of coverage.
|
0001| B. An enrollee may not be canceled or nonrenewed on
|
0002| the basis of the status of his health.
|
0003| C. No provider sponsored health network, unless also
|
0004| licensed as an insurer, may use in its name, contracts or
|
0005| literature any of the words "insurance", "casualty", "surety",
|
0006| "mutual" or any other words descriptive of the insurance,
|
0007| casualty or surety business if such words are used in a manner
|
0008| to imply that such coverages are being illegally offered by the
|
0009| provider sponsored health network or if deceptively similar to
|
0010| the name or description of any insurance or surety corporation
|
0011| doing business in the state.
|
0012| D. Any person not in possession of a valid
|
0013| registration and certificate of public advantage issued pursuant
|
0014| to the Provider Sponsored Health Networks Law shall not use the
|
0015| phrase "provider sponsored health network" or "PSHN" in the
|
0016| course of operation.
|
0017| Section 31. PROVIDER DISCRIMINATION PROHIBITED.--No class
|
0018| of licensed individual providers willing to meet the terms and
|
0019| conditions offered by a provider sponsored health network shall
|
0020| be excluded from a provider sponsored health network. For
|
0021| purposes of this section, "providers" means those persons
|
0022| licensed under Chapter 61, Article 2, 4, 5, 6, 8, 9, 10 or 11
|
0023| NMSA 1978.
|
0024| Section 32. DOCTOR OF ORIENTAL MEDICINE--DISCRIMINATION
|
0025| PROHIBITED.--Doctors of oriental medicine as a class of licensed
|
0001| providers willing to meet the terms and conditions offered by a
|
0002| provider sponsored health network shall not be excluded from a
|
0003| provider sponsored health network.
|
0004| Section 33. COVERAGE FOR ADOPTED CHILDREN.--
|
0005| A. No individual or group provider sponsored health
|
0006| network contract shall be offered, issued or renewed in New
|
0007| Mexico on or after January 1, 1997 unless the contract covers
|
0008| adopted children of the subscriber or enrollee on the same basis
|
0009| as other eligible dependents.
|
0010| B. The coverage required by this section is
|
0011| effective from the date of placement for the purpose of adoption
|
0012| and continues, unless the placement is disrupted prior to legal
|
0013| adoption and the child is removed from placement. Coverage
|
0014| shall include the necessary care and treatment of medical
|
0015| conditions existing prior to the date of placement.
|
0016| C. As used in this section, "placement" means in the
|
0017| physical custody of the adoptive parent.
|
0018| Section 34. NEWLY BORN CHILDREN COVERAGE.--
|
0019| A. All individual and group provider sponsored
|
0020| health network contracts delivered or issued for delivery in
|
0021| this state shall also provide that the health benefits
|
0022| applicable for children shall be payable with respect to a newly
|
0023| born child of the subscriber or the subscriber's spouse from the
|
0024| moment of birth.
|
0025| B. All individual and group provider sponsored
|
0001| health network contracts delivered or issued for delivery in
|
0002| this state that do not provide health benefits applicable for
|
0003| children shall provide for an option to add to the coverage any
|
0004| newly born child of the insured, provided that the requirements
|
0005| of Subsection D of this section have been met.
|
0006| C. The coverage for newly born children shall
|
0007| consist of coverage of injury or sickness, including the
|
0008| necessary care and treatment of medically diagnosed congenital
|
0009| defects and birth abnormalities and, where necessary to protect
|
0010| the life of the infant, transportation, including air transport,
|
0011| to the nearest available tertiary care facility for newly born
|
0012| infants.
|
0013| D. If a specific payment is required to provide
|
0014| coverage for a child, the contract may require that a
|
0015| notification of birth of a newly born child and payment be
|
0016| furnished to the provider sponsored health network within
|
0017| thirty-one days after the date of birth in order to have the
|
0018| coverage from birth.
|
0019| E. As used in this section and in Section 35 of the
|
0020| Provider Sponsored Health Networks Law, "tertiary care facility"
|
0021| means a hospital unit which provides complete perinatal care and
|
0022| intensive care of intrapartum and perinatal high-risk patients
|
0023| with responsibilities for coordination of transport,
|
0024| communication, education and data analysis systems for the
|
0025| geographic area served.
|
0001| Section 35. COVERAGE OF CHILDREN.--
|
0002| A. A provider sponsored health network shall not
|
0003| deny enrollment of a child under the health plan of the child's
|
0004| parent on the grounds that the child:
|
0005| (1) was born out of wedlock;
|
0006| (2) is not claimed as a dependent on the
|
0007| parent's federal tax return; or
|
0008| (3) does not reside with the parent or in the
|
0009| network's service area.
|
0010| B. When a child has health coverage through a
|
0011| provider sponsored health network of a noncustodial parent, the
|
0012| provider sponsored health network shall:
|
0013| (1) provide such information to the custodial
|
0014| parent as may be necessary for the child to obtain benefits
|
0015| through that coverage;
|
0016| (2) permit the custodial parent or the
|
0017| provider, with the custodial parent's approval, to submit claims
|
0018| for covered services without the approval of the noncustodial
|
0019| parent; and
|
0020| (3) make payments on claims submitted in
|
0021| accordance with Paragraph (2) of this subsection directly to the
|
0022| custodial parent, the provider or the state medicaid agency.
|
0023| C. When a parent is required by a court or
|
0024| administrative order to provide health coverage for a child and
|
0025| the parent is eligible for family health coverage, the provider
|
0001| sponsored health network shall be required:
|
0002| (1) to permit the parent to enroll, under the
|
0003| family coverage, a child who is otherwise eligible for the
|
0004| coverage without regard to any enrollment season restrictions;
|
0005| (2) if the parent is enrolled but fails to make
|
0006| application to obtain coverage for the child, to enroll the
|
0007| child under family coverage upon application of the child's
|
0008| other parent, the state agency administering the medicaid
|
0009| program or the state agency administering 42 U.S.C. Sections 651
|
0010| through 669, the child support enforcement program; and
|
0011| (3) not to disenroll or eliminate coverage of
|
0012| the child unless the network is provided satisfactory written
|
0013| evidence that:
|
0014| (a) the court or administrative order is
|
0015| no longer in effect; or
|
0016| (b) the child is or will be enrolled in
|
0017| comparable health coverage through another insurer or network
|
0018| that will take effect not later than the effective date of
|
0019| disenrollment.
|
0020| D. A provider sponsored health network shall not
|
0021| impose requirements on a state agency that has been assigned the
|
0022| rights of an individual eligible for medical assistance under
|
0023| the medicaid program and covered for health benefits from the
|
0024| network that are different from requirements applicable to an
|
0025| agent or assignee of any other individual so covered.
|
0001| Section 36. MATERNITY TRANSPORT REQUIRED.--All individual
|
0002| and group provider sponsored health network contracts delivered
|
0003| or issued for delivery in this state which provide maternity
|
0004| coverage shall also provide, where necessary to protect the life
|
0005| of the infant or mother, coverage for transportation, including
|
0006| air transport, for the medically high-risk pregnant woman with
|
0007| an impending delivery of a potentially viable infant to the
|
0008| nearest available tertiary care facility as defined in Section
|
0009| 33 of the Provider Sponsored Health Networks Law for newly born
|
0010| infants.
|
0011| Section 37. HOME HEALTH CARE SERVICE OPTION REQUIRED.--
|
0012| A. Each provider sponsored health network which
|
0013| delivers or issues for delivery in this state an individual or
|
0014| group contract shall make available to the contract holder the
|
0015| option of home health care coverage which includes benefits for
|
0016| the services described in this section.
|
0017| B. Home health care coverage offered shall include:
|
0018| (1) services provided by a registered nurse or
|
0019| a licensed practical nurse;
|
0020| (2) health services provided by physical,
|
0021| occupational and respiratory therapists and speech pathologists;
|
0022| and
|
0023| (3) health services provided by a home health
|
0024| aide.
|
0025| C. Home health care coverage may be limited to:
|
0001| (1) services provided on the written order of a
|
0002| licensed physician, provided such order is renewed at least
|
0003| every sixty days;
|
0004| (2) services provided, directly or through
|
0005| contractual agreements, by a home health agency licensed in the
|
0006| state in which the home health services are delivered; and
|
0007| (3) services, as set forth in Subsection B of
|
0008| this section, without which the insured would have to be
|
0009| hospitalized.
|
0010| D. Coverage shall be provided for at least one
|
0011| hundred home visits per enrollee per year, with each home visit
|
0012| including up to four hours of home health care services.
|
0013| E. For the purposes of this section, "home health
|
0014| care" means health services provided on a part-time,
|
0015| intermittent basis to an individual confined to his home due to
|
0016| physical illness.
|
0017| Section 38. COVERAGE FOR MAMMOGRAMS.--
|
0018| A. Each individual and group provider sponsored
|
0019| health network contract delivered or issued for delivery in this
|
0020| state shall provide coverage for low-dose screening mammograms
|
0021| for determining the presence of breast cancer. Such coverage
|
0022| shall make available one baseline mammogram to persons age
|
0023| thirty-five through thirty-nine, one mammogram biennially to
|
0024| persons age forty through forty-nine and one mammogram annually
|
0025| to persons age fifty and over. After January 1, 1997 coverage
|
0001| shall be available only for screening mammograms obtained on
|
0002| equipment designed specifically to perform low-dose mammography
|
0003| in imaging facilities that have met American college of
|
0004| radiology accreditation standards for mammography.
|
0005| B. Coverage for mammograms may be subject to
|
0006| deductibles and co-insurance consistent with those imposed on
|
0007| other benefits under the same contract.
|
0008| Section 39. COVERAGE FOR CYTOLOGIC SCREENING.--
|
0009| A. Each individual and group provider sponsored
|
0010| health network contract delivered or issued for delivery in this
|
0011| state shall provide coverage for cytologic screening to
|
0012| determine the presence of precancerous or cancerous conditions
|
0013| and other health problems. The coverage shall make available
|
0014| cytologic screening, as determined by the health care provider
|
0015| in accordance with national medical standards, for women who are
|
0016| eighteen years of age or older and for women who are at risk of
|
0017| cancer or at risk of other health conditions that can be
|
0018| identified through cytologic screening.
|
0019| B. Coverage for cytologic screening may be subject
|
0020| to deductibles and co-insurance consistent with those imposed on
|
0021| other benefits under the same contract.
|
0022| C. For the purposes of this section:
|
0023| (1) "cytologic screening" means a Papanicolaou
|
0024| test and pelvic exam for asymptomatic as well as symptomatic
|
0025| women; and
|
0001| (2) "health care provider" means any person
|
0002| licensed within the scope of his practice to perform cytologic
|
0003| screening, including physicians, physician assistants, certified
|
0004| nurse midwives and nurse practitioners.
|
0005| State of New Mexico
|
0006| House of Representatives
|
0007|
|
0008| FORTY-SECOND LEGISLATURE
|
0009| SECOND SESSION, 1996
|
0010|
|
0011| February 2, 1996
|
0012|
|
0013|
|
0014| Mr. Speaker:
|
0015|
|
0016| Your RULES AND ORDER OF BUSINESS COMMITTEE, to
|
0017| whom has been referred
|
0018|
|
0019| HOUSE BILL 728
|
0020|
|
0021| has had it under consideration and finds same to be
|
0022| GERMANE in accordance with constitutional provisions.
|
0023|
|
0024| Respectfully submitted,
|
0025|
|
0001|
|
0002|
|
0003|
|
0004| Barbara A. Perea Casey,
|
0005| Chairperson
|
0006|
|
0007|
|
0008| Adopted Not Adopted
|
0009|
|
0010| (Chief Clerk) (Chief Clerk)
|
0011|
|
0012| Date
|
0013|
|
0014| The roll call vote was 8 For 0 Against
|
0015| Yes: 8
|
0016| Excused: Nicely, Olguin, Pederson, Picraux, Rodella,
|
0017| J. G. Taylor, Wallach
|
0018| Absent: None
|
0019|
|
0020| H0728RC1 State of New Mexico
|
0021| House of Representatives
|
0022|
|
0023| FORTY-SECOND LEGISLATURE
|
0024| SECOND SESSION, 1996
|
0025|
|
0001| February 2, 1996
|
0002|
|
0003|
|
0004| Mr. Speaker:
|
0005|
|
0006| Your RULES AND ORDER OF BUSINESS COMMITTEE, to
|
0007| whom has been referred
|
0008|
|
0009| HOUSE BILL 728
|
0010|
|
0011| has had it under consideration and finds same to be
|
0012| GERMANE in accordance with constitutional provisions.
|
0013|
|
0014| Respectfully submitted,
|
0015|
|
0016|
|
0017|
|
0018|
|
0019| Barbara A. Perea Casey,
|
0020| Chairperson
|
0021|
|
0022|
|
0023| Adopted Not Adopted
|
0024|
|
0025| (Chief Clerk) (Chief Clerk)
|
0001|
|
0002| Date
|
0003|
|
0004| The roll call vote was 8 For 0 Against
|
0005| Yes: 8
|
0006| Excused: Nicely, Olguin, Pederson, Picraux, Rodella,
|
0007| J. G. Taylor, Wallach
|
0008| Absent: None
|
0009|
|
0010| H0728RC1
|