0001| SENATE BILL 1240
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0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997
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0003| INTRODUCED BY
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0004| MANNY M. ARAGON
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0005|
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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| AN ACT
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0011| RELATING TO HEALTH CARE; ENACTING THE HEALTH CARE ACT TO
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0012| PROVIDE FOR COMPREHENSIVE STATEWIDE HEALTH CARE, PLANNING AND
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0013| COST SAVINGS; CREATING A COMMISSION; PROVIDING ITS POWERS AND
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0014| DUTIES; PROVIDING FOR TRANSFERS; MAKING AN APPROPRIATION.
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0015|
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0016| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0017| Section 1. SHORT TITLE.--This act may be cited as the
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0018| "Health Care Act"
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0019| Section 2. PURPOSE OF ACT.--The purpose of the Health
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0020| Care Act is to create a publicly financed statewide health
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0021| program to provide coverage for health care services for all
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0022| state residents and to control escalating health care costs.
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0023| Section 3. DEFINITIONS.--As used in the Health Care Act:
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0024| A. "capital budget" means that portion of a health
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0025| care facility's global budget that applies to real property and
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0001| tangible personal property, including buildings, machinery and
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0002| equipment and transportation equipment;
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0003| B. "capitation" means a set fee for providing
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0004| specified health care services for all members of an enrolled
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0005| group;
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0006| C. "commission" means the health care commission
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0007| created pursuant to the Health Care Act;
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0008| D. "director" means the director of the commission;
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0009| E. "eligible person" means:
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0010| (1) except as provided in Paragraphs (2)
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0011| through (7) of this subsection, a person who has resided in the
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0012| state for at least one year and any child of that person who
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0013| lives with the person and is in the legal custody of the
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0014| person;
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0015| (2) a public employee, including an employee
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0016| of the state or any political subdivision of the state and an
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0017| employee of a public school or state educational institution;
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0018| (3) a medicaid or medicare recipient as
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0019| participation is authorized by federal statute, regulation,
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0020| waiver or agreement;
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0021| (4) a person entitled to health care services
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0022| through the veterans' administration as participation is
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0023| authorized by federal statute, regulation, waiver or agreement;
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0024| (5) a person, except federal retirees covered
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0025| by other federal health insurance plans as participation is
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0001| authorized by federal statute, regulation, waiver or agreement;
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0002| (6) a person covered by a health insurance
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0003| plan pursuant to the provisions of the federal Employee
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0004| Retirement Income Security Act of 1974 as participation is
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0005| authorized by federal statute, regulation, waiver or agreement
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0006| or as a business covered by the provisions of that act chooses
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0007| to be covered under the provisions of the health care plan; or
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0008| (7) a person becoming eligible by paymnt of a
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0009| premium pursuant to Section 17 of the Health Care Act,
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0010| F. "global budget" means the prospective operating
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0011| budget of a health care facility, excluding the capital budget;
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0012| G. "group practice" means a health maintenance
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0013| organization or other association of health care providers that
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0014| provides one or more specialized health care services, such as
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0015| laboratory services, x-Ray services, emergency care and
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0016| inpatient or outpatient hospital services;
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0017| H. "health care facility" means a clinic, general
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0018| or special hospital, outpatient facility, psychiatric hospital,
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0019| laboratory, skilled nursing facility or nursing facility. For
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0020| the purpose of determining global budgets, "health care
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0021| facility" includes a group practice or transportation service;
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0022| I. "health care provider" means:
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0023| (1) a person licensed or certified in New
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0024| Mexico as a:
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0025| (a) physician;
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0001| (b) osteopathic physician;
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0002| (c) physician assistant or osteopathic
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0003| physician's assistant;
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0004| (d) chiropractic physician;
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0005| (e) dentist;
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0006| (f) psychologist, social worker;
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0007| professional clinical mental health counselor, professional
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0008| mental health counselor, marriage and family therapist or
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0009| registered mental health counselor;
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0010| (g) optometrist;
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0011| (h) podiatrist;
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0012| (I) pharmacist;
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0013| (j) pharmacist clinician;
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0014| (k) registered nurse or certified nurse
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0015| practitioner;
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0016| (l) visiting nurse service, private duty
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0017| registry or other certified home health agency;
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0018| (m) doctor of oriental medicine;
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0019| (n) physical therapist;
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0020| (o) massage therapist;
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0021| (p) occupational therapist;
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0022| (q) speech-language pathologist;
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0023| (r) audiologist;
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0024| (s) respiratory care practitioner;
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0025| (t) midwife;
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0001| (u) dietician or nutritionist;
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0002| (v) transportation service; or
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0003| (w) other practitioner of the healing
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0004| arts designated as a health care provider by the commission;
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0005| (2) a person licensed or certified by a
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0006| nationally recognized professional organization and designated
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0007| as a health care provider by the commission as a:
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0008| (a) prosthetist;
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0009| (b) orthotist; or
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0010| (c) oculist; or
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0011| (3) a group practice or transportation service
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0012| for that portion of the group practice or transportation
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0013| service that is paid pursuant to a fee schedule established by
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0014| the commission;
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0015| J. "health plan" means the mechanism developed by
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0016| the commission for provision of health care services pursuant
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0017| to the Health Care Act;
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0018| K. "implicit price deflator" means a measure of
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0019| inflation that is published in the United States department of
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0020| commerce survey of current business;
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0021| L. "major capital expenditure" means the purchase
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0022| of diagnostic, treatment or transportation equipment costing
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0023| fifty thousand dollars ($50,000) or more or construction or
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0024| renovation of facilities;
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0025| M. "person" means a legal entity;
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0001| N. "primary care provider" means a licensed
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0002| physician, osteopathic physician, nurse practitioner,
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0003| physician's assistant, osteopathic physician's assistant,
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0004| pharmacist clinician or other provider certified by the
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0005| commission as a primary care provider who provides the first
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0006| level of health care for an eligible person's health needs, as
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0007| specified by the commission;
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0008| O. "provider budget" means the fee schedule
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0009| established by the commission each year to pay for health care
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0010| services provided by health care providers participating in the
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0011| health plan; and
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0012| P. "transportation service" means ambulance,
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0013| helicopter or other transport that is equipped with emergency
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0014| supplies and equipment and is used to transport patients to
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0015| health care providers or facilities and other transportation
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0016| authorized by the commission.
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0017| Section 4. HEALTH CARE COMMISSION CREATED--VOTING AND
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0018| NONVOTING MEMBERS.--
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0019| A. The "health care commission" is created as an
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0020| adjunct agency pursuant to the Executive Reorganization Act.
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0021| The general services department, the department of health and
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0022| the human services department shall cooperate with the
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0023| commission and assist it as needed. The commission consists of
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0024| fifteen voting members and nine nonvoting members. The voting
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0025| members, all of whom shall be appointed by the governor with
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0001| the advice and consent of the senate, are:
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0002| (1) four persons who represent consumer
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0003| interests, at least one of whom represents elderly consumer
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0004| interests and at least one of whom represents Native American
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0005| interests;
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0006| (2) two persons who represent persons with
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0007| physical or mental impairments that limit one or more of their
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0008| major life activities;
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0009| (3) five persons who represent either health
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0010| care providers or health care facilities;
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0011| (4) two persons who represent business
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0012| ownership interests, with one person representing employers of
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0013| more than fifteen persons and one person representing employers
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0014| of fifteen persons or fewer; and
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0015| (5) two persons who represent organized labor.
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0016| B. The voting members appointed shall reflect the
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0017| ethnic, gender, economic and geographic diversity of the state.
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0018| To ensure fair geographic representation of all areas of the
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0019| state, members shall be appointed from each of the state board
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0020| of education districts established by the 1991 Educational
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0021| Redistricting Act as follows:
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0022| (1) two from state board of education district
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0023| 1;
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0024| (2) one from state board of education district
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0025| 2;
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0001| (3) one from state board of education district
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0002| 3;
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0003| (4) two from state board of education district
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0004| 4;
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0005| (5) two from state board of education district
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0006| 5;
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0007| (6) one from state board of education district
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0008| 6;
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0009| (7) two from state board of education district
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0010| 7;
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0011| (8) two from state board of education district
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0012| 8;
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0013| (9) one from state board of education district
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0014| 9; and
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0015| (10) one from state board of education
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0016| district 10.
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0017| C. The initial voting members of the commission
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0018| shall be appointed by the governor by August 1, 1997. The
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0019| terms of the initial voting members appointed shall be
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0020| staggered as follows: five members shall be appointed for a
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0021| term of four years; five members shall be appointed for a term
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0022| of three years; and five members shall be appointed for a term
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0023| of two years. Thereafter, all members shall be appointed for
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0024| terms of four years. After initial terms are served, no member
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0025| shall serve more than two consecutive four-year terms.
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0001| D. A voting member may be removed from the
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0002| commission only for incompetence, neglect of duty or
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0003| malfeasance in office. The governor shall initiate removal
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0004| proceedings. No voting member shall be removed without having
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0005| first been given notice of hearing and an opportunity to be
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0006| heard. The supreme court has exclusive original jurisdiction
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0007| over proceedings to remove a voting member. The supreme
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0008| court's decision on removal shall be final.
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0009| E. A majority of the commission's voting members
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0010| constitutes a quorum for the transaction of business. The
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0011| commission shall choose annually its chairman and any other
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0012| officers it deems necessary.
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0013| F. Voting members shall receive per diem and
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0014| mileage in accordance with the provisions of the Per Diem and
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0015| Mileage Act.
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0016| G. The commission is composed of the following nine
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0017| nonvoting members:
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0018| (1) the secretary of health;
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0019| (2) the secretary of human services;
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0020| (3) the secretary of children, youth and
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0021| families;
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0022| (4) the secretary of taxation and revenue;
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0023| (5) a person designated by the New Mexico
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0024| office of Indian affairs, after consultation with the federal
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0025| Indian health services;
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0001| (6) two members of the house of
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0002| representatives appointed by the speaker of the house,
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0003| including one member of the majority party and one member of
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0004| the minority party; and
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0005| (7) two members of the senate, including one
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0006| member of the majority party and one member of the minority
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0007| party appointed by the committees' committee of the senate, or,
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0008| if the senate appointments are made in the interim, by the
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0009| president pro tempore of the senate after consultation with and
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0010| agreement of a majority of the members of the committees'
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0011| committee.
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0012| H. The governor shall recommend to the legislature
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0013| by January 1, 1998 the need for compensation for commission
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0014| members.
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0015| Section 5. CONFLICT OF INTEREST.--
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0016| A. Except for nonvoting members and members
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0017| appointed to represent health care facilities or health care
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0018| providers, no commission member or a member of his immediate
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0019| family shall have any financial interest, direct or indirect,
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0020| in a person providing health care services or health care
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0021| insurance.
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0022| B. The commission shall adopt a conflict of
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0023| interest disclosure statement for use by all members that
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0024| specifies financial interests of the member or member of his
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0025| immediate family in a person providing the health care services
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0001| or health care insurance.
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0002| C. No member of the commission shall vote on any
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0003| matter in which he or a member of his immediate family has a
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0004| financial interest.
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0005| D. If there is a question about a conflict of
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0006| interest of a member, the commission shall vote on whether to
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0007| allow the member to vote.
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0008| Section 6. DIRECTOR--STAFF--CONTRACTS--BUDGETS.--
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0009| A. To assist in carrying out its duties, the
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0010| commission shall appoint and set the salary of a "director".
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0011| The director shall serve at the pleasure of the commission.
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0012| B. The director may employ those persons necessary
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0013| to carry out the purposes of the Health Care Act. Employees
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0014| are subject to the provisions of the Personnel Act.
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0015| C. The director and his staff shall implement the
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0016| Health Care Act in accordance with that act and the policies
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0017| and regulations adopted by the commission.
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0018| D. If the director determines that commission staff
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0019| or another state agency does not have the resources or
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0020| expertise to perform a necessary task, the commission may
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0021| contract with a person that has a demonstrated capability to
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0022| perform the task. If claims processing is provided by
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0023| contract, that contract shall require that all work shall be
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0024| performed entirely in New Mexico. All contracts shall be
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0025| reviewed at least every two years to ensure that they continue
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0001| to meet the criteria and performance standards of the contract
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0002| and the needs of the commission.
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0003| E. The director may contract with consultants that
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0004| the director deems necessary to advise him or the commission in
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0005| carrying out the provisions of the Health Care Act.
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0006| F. The director shall prepare an annual budget and
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0007| plan of operation for the commission. He shall submit both to
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0008| the commission for its approval before implementation.
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0009| Section 7. COMMISSION--GENERAL POWERS AND DUTIES.--The
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0010| commission shall:
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0011| A. adopt a five-year program of operation to
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0012| implement the provisions of the Health Care Act;
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0013| B. provide a program to educate the public, health
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0014| care providers and health care facilities about the health care
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0015| plan and the persons eligible to receive its benefits;
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0016| C. study and adopt the most cost-effective methods
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0017| of providing health care services to all eligible persons,
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0018| according high priority to increased reliance on:
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0019| (1) preventive and primary care, including
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0020| immunization and screening examinations;
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0021| (2) providing health care services in rural or
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0022| underserved areas of the state;
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0023| (3) in-home and community-based alternatives
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0024| to institutional care; and
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0025| (4) case management services when appropriate;
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0001| D. establish fee schedules and other compensation
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0002| for health care providers and adopt standards and procedures
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0003| for negotiating and entering into contracts with participating
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0004| health care providers;
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0005| E. establish global budgets for health care
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0006| facilities and adopt:
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0007| (1) standards and procedures for determining
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0008| base budgets and annual global budgets for health care
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0009| facilities; and
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0010| (2) a capital expenditure program that
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0011| requires prior approval for major capital expenditures by
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0012| health care facilities;
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0013| F. negotiate and enter into health care reciprocity
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0014| agreements with other states and foreign countries and
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0015| negotiate and enter into health care agreements with out-of-
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0016| state health care providers and health care facilities;
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0017| G. develop a payment system for health care
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0018| providers and health care facilities that affords continuity of
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0019| payments;
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0020| H. collect and analyze health care data and other
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0021| data necessary to improve the efficiency and effectiveness of
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0022| health care services and to control costs of health care
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0023| services in New Mexico, and shall include data on:
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0024| (1) mortality and natality, including
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0025| accidental causes of death;
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0001| (2) morbidity;
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0002| (3) health behavior;
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0003| (4) disability;
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0004| (5) health care services system costs,
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0005| availability, utilization and revenues;
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0006| (6) environmental factors;
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0007| (7) availability, adequacy and training of
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0008| health care services personnel;
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0009| (8) demographic factors;
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0010| (9) social and economic conditions affecting
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0011| health; and
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0012| (10) other factors determined by the
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0013| commission;
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0014| I. standardize data collection and specific methods
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0015| of measurement across databases and use scientific sampling or
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0016| complete enumeration for reporting health information;
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0017| J. establish a health care delivery system that is
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0018| efficient to administer and that eliminates unnecessary
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0019| administrative costs;
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0020| K. adopt rules and regulations necessary to
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0021| implement and monitor a state formulary to provide prescription
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0022| drugs, medicine, durable medical equipment and supplies,
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0023| eyeglasses, hearing aids, oxygen and related services;
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0024| L. study and evaluate the adequacy and quality of
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0025| health care services furnished pursuant to the Health Care Act,
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0001| the cost of each type of service and the effectiveness of cost-
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0002| containment measures in the health plan;
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0003| M. study and monitor the migration of persons to
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0004| New Mexico to determine if persons with costly health care
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0005| needs are moving to New Mexico to receive health care services.
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0006| If migration appears to threaten the financial stability of the
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0007| health plan, the commission shall recommend to the legislature
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0008| changes in eligibility requirements, premiums or other
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0009| statutory changes that may be necessary to maintain the
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0010| financial stability of the health plan;
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0011| N. study and evaluate the cost of medical
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0012| professional liability and medical professional liability
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0013| insurance and recommend statutory changes to the legislature as
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0014| necessary;
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0015| O. set or approve changes in benefit standards
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0016| covered by the health plan;
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0017| P. conduct necessary investigations and inquiries
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0018| and compel by subpoena the submission of information and
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0019| documents that the commission considers necessary to carry out
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0020| its duties;
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0021| Q. adopt rules and regulations necessary to
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0022| implement, administer and monitor the operation of the health
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0023| plan;
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0024| R. meet as needed, but no less than once every
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0025| three months; and
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0001| S. report annually to the legislature and the
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0002| governor on the commission's activities and the operation of
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0003| the health plan and include in the annual report:
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0004| (1) a summary of information about health care
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0005| needs, health care services, health care expenditures, revenues
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0006| and other relevant issues relating to the health plan and the
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0007| five-year program; and
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0008| (2) recommendations on methods to control
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0009| health care costs and improve access to and the quality of
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0010| health care for state residents, as well as recommendations for
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0011| legislative action if any are found to be necessary.
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0012| Section 8. ADVISORY BOARDS.--
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0013| A. The commission may establish advisory boards to
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0014| assist it in performing its duties.
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0015| B. The commission shall establish a "health care
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0016| provider advisory board" to advise and assist the commission in
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0017| all decisions requiring the expertise of health care providers.
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0018| Each noncommission member shall represent a different licensed
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0019| health profession.
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0020| C. The commission may appoint commission members
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0021| and up to five additional persons to serve on each advisory
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0022| board it creates. Advisory board members who are not
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0023| commission members may be paid per diem and mileage in
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0024| accordance with the provisions of the Per Diem and Mileage Act.
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0025| D. Staff and technical assistance for the advisory
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0001| boards shall be provided by the commission as necessary.
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0002| Section 9. HEALTH CARE DELIVERY REGIONS.--The commission
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0003| shall establish health care delivery regions in the state,
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0004| based on geography and health care resources. The regions may
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0005| have differential fee schedules, global budgets, capital
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0006| allocations or other features to encourage the provision of
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0007| health care services in rural and other underserved areas.
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0008| Section 10. REGIONAL COUNCILS.--
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0009| A. The commission shall create regional councils in
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0010| the health care delivery regions of the state.
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0011| B. The regional councils shall be composed of at
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0012| least one of the commission members who live in the region and
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0013| five other members appointed by the commission. No more than
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0014| two council members shall have any financial interest, direct
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0015| or indirect, in a person providing health care services or a
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0016| person providing health care insurance.
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0017| C. Members of a regional council may be paid per
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0018| diem and mileage in accordance with the provisions of the Per
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0019| Diem and Mileage Act.
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0020| D. The regional councils shall hold public hearings
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0021| to receive comments, suggestions and recommendations from the
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0022| public regarding regional health care needs. The councils
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0023| shall report to the commission so that regional concerns are
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0024| considered in the development and update of the five-year
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0025| program, fee schedules and global budgets.
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0001| E. Staff and technical assistance for the regional
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0002| councils shall be provided by the commission as necessary.
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0003| Section 11. COMMISSION, COUNCILS AND ADVISORY BOARDS--
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0004| MEETINGS.--All meetings of the commission, councils and
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0005| advisory boards shall be conducted pursuant to the provisions
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0006| of the Open Meetings Act.
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0007| Section 12. RULES AND REGULATIONS.--
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0008| A. The commission shall adopt reasonable
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0009| regulations necessary to carry out the duties of the commission
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0010| and the provisions of the Health Care Act.
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0011| B. No regulation affecting any person or agency
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0012| outside the commission shall be adopted, amended or repealed
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0013| without a public hearing on the proposed action before the
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0014| commission or a hearing officer designated by the commission.
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0015| The hearing officer may be a member of the commission's staff.
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0016| The hearing shall be held in Santa Fe unless the commission
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0017| determines that it would be in the interest of those affected
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0018| to hold the hearing elsewhere in the state. Notice of the
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0019| subject matter of the regulation, the action proposed to be
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0020| taken, the time and place of the hearing, the manner in which
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0021| interested persons may present their views and the method by
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0022| which copies of the proposed regulation, proposed amendment or
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0023| repeal of an existing regulation may be obtained shall be
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0024| published once at least thirty days prior to the hearing date
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0025| in a newspaper of general circulation and mailed at least
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0001| thirty days prior to the hearing date to all persons who have
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0002| made a written request for advance notice of hearing.
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0003| C. All rules and regulations adopted by the
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0004| commission shall be filed in accordance with the State Rules
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0005| Act.
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0006| Section 13. HEALTH PLAN.--
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0007| A. After notice and public hearing, including
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0008| taking public comment and the reports of the regional councils,
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0009| the commission shall adopt a health plan.
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0010| B. The health plan shall be designed to provide
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0011| comprehensive, necessary and appropriate health care benefits,
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0012| including preventive health care and primary, secondary and
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0013| tertiary health care for acute and chronic conditions. The
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0014| health plan may provide for certain health care services to be
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0015| phased in as the health plan budget allows.
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0016| C. The commission shall specify the health care
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0017| services to be included as covered by the health plan and shall
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0018| include:
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0019| (1) preventive health services;
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0020| (2) provider services;
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0021| (3) inpatient and outpatient medical services;
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0022| (4) laboratory tests and imaging procedures;
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0023| (5) in-home, community-based and institutional
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0024| long-term care services;
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0025| (6) prescription drugs;
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0001| (7) inpatient and outpatient mental health
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0002| services;
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0003| (8) drug and substance abuse services;
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0004| (9) preventive and prophylactic dental
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0005| services, including an annual dental examination and cleaning,
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0006| but not including orthodontic services;
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0007| (10) vision appliances, including medically
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0008| necessary contact lenses;
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0009| (11) medical supplies, durable medical
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0010| equipment and selected assistive devices, including hearing and
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0011| speech assistance devices; and
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0012| (12) experimental treatment services as
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0013| specified on a case-by-case basis by the commission.
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0014| D. Covered services shall not include:
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0015| (1) surgery for cosmetic purposes other than
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0016| for reconstructive purposes;
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0017| (2) medical examinations and medical reports
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0018| prepared for purchasing or renewing life insurance or
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0019| participating as a plaintiff or defendant in a civil action for
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0020| the recovery or settlement of damages; and
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0021| (3) cosmetic dental services except for
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0022| reconstructive purposes.
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0023| E. The health plan shall specify the services to be
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0024| covered and the amount, scope and duration of benefits. The
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0025| plan shall include a maximum amount or percentage for
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0001| administrative costs, and this maximum may be variable in
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0002| relation to total costs of services provided under the health
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0003| plan.
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0004| F. The commission shall specify the terms and
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0005| conditions for participation of health care providers and
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0006| health care facilities in the health plan.
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0007| G. The commission shall control health care costs
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0008| so that eligible persons receive comprehensive health services,
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0009| consistent with budget constraints, including needed health
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0010| care services in rural and other underserved areas.
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0011| H. The health plan shall phase in eligible persons
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0012| as their participation becomes possible through agreements,
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0013| waivers or federal legislation. The health plan may provide
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0014| for certain preventive health care services to be offered to
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0015| all New Mexicans regardless of eligibility.
|
0016| I. The five-year program shall be reviewed by the
|
0017| regional councils and the commission annually and revised as
|
0018| necessary. Revisions shall be adopted by the commission in
|
0019| accordance with Section 12 of the Health Care Act. In
|
0020| projecting services under the health plan, the commission shall
|
0021| take all reasonable steps to ensure that long-term care, mental
|
0022| health services and dental care are provided at the earliest
|
0023| practical times consistent with budget constraints.
|
0024| J. Any changes in health care services offered by
|
0025| the health plan shall be approved by the commission.
|
0001| Section 14. LONG-TERM CARE.--
|
0002| A. Long-term care may include:
|
0003| (1) home- and community-based services,
|
0004| including personal assistance and attendant care;
|
0005| (2) hospice care; and
|
0006| (3) institutional care.
|
0007| B. No later than one year after appointment of the
|
0008| director, the commission shall appoint a "long-term care
|
0009| committee" made up of representatives of health care consumers,
|
0010| providers and administrators to develop a plan for integrating
|
0011| long-term care into the health plan. The committee shall
|
0012| report its plan to the commission no later than one year from
|
0013| its appointment. Committee members may receive per diem and
|
0014| mileage as provided in the Per Diem and Mileage Act.
|
0015| C. The long-term care component of the health plan
|
0016| shall provide for service coordination, case management and
|
0017| noninstitutional services where appropriate.
|
0018| D. Nothing in this section affects long-term care
|
0019| services paid through federal programs or private insurance.
|
0020| E. Nothing in this section precludes the commission
|
0021| from including long-term care services from the inception of
|
0022| the health plan.
|
0023| Section 15. MENTAL HEALTH SERVICES.--
|
0024| A. Mental health services may include:
|
0025| (1) services for acute and chronic conditions;
|
0001| (2) home- and community-based services; and
|
0002| (3) institutional care.
|
0003| B. No later than one year after appointment of the
|
0004| director, the commission shall appoint a "mental health
|
0005| services committee" made up of representatives of mental health
|
0006| care consumers, providers and administrators to develop a plan
|
0007| for integrating mental health services into the health plan.
|
0008| The committee shall report its plan to the commission no later
|
0009| than one year from its appointment. Committee members may
|
0010| receive per diem and mileage as provided in the Per Diem and
|
0011| Mileage Act.
|
0012| C. The mental health services component of the
|
0013| health plan shall provide for service coordination, case
|
0014| management and noninstitutional services where appropriate.
|
0015| D. Nothing in this section affects mental health
|
0016| services paid through federal programs or private insurance.
|
0017| E. Nothing in this section precludes the commission
|
0018| from including mental health services from the inception of the
|
0019| health care plan.
|
0020| Section 16. MEDICAID COVERAGE--JOINT POWERS AGREEMENTS.--
|
0021| The commission may enter into joint powers agreements with the
|
0022| human services department in accordance with the Joint Powers
|
0023| Agreements Act for the purpose of furthering the goals of the
|
0024| Health Care Act. These agreements may transfer certain
|
0025| medicaid functions to the commission to allow the commission to
|
0001| implement the health plan.
|
0002| Section 17. HEALTH PLAN COVERAGE--ELIGIBLE PERSONS--
|
0003| NONRESIDENT STUDENTS--ELIGIBILITY CARD--PENALTIES.--
|
0004| A. An eligible person shall be covered by the
|
0005| health plan, but a person who has not resided in New Mexico for
|
0006| at least one year may become an eligible person upon payment of
|
0007| a premium as determined by the commission.
|
0008| B. State educational institutions shall purchase
|
0009| coverage under the health plan for its out-of-state and
|
0010| emancipated students through fees assessed to students. The
|
0011| board of regents or other governing body of a state educational
|
0012| institution shall set the fees at the amount determined by the
|
0013| commission.
|
0014| C. A student at a state educational institution who
|
0015| has not resided in the state for one year may demonstrate proof
|
0016| of health insurance coverage by a policy in another state that
|
0017| is acceptable to the commission, and his fee shall be reduced
|
0018| as provided by the commission.
|
0019| D. The commission shall adopt regulations to
|
0020| determine proof of a person's eligibility for the health plan
|
0021| or a student's proof of nonresident insurance coverage. The
|
0022| regulations shall provide a method for the purging of
|
0023| eligibility when a person is no longer eligible for coverage.
|
0024| E. An eligible person shall receive a card as proof
|
0025| of eligibility. The card shall be electronically readable and
|
0001| shall contain a picture or electronic image, information that
|
0002| identifies the person for treatment and electronic billing and
|
0003| payment and any other information the commission deems
|
0004| necessary.
|
0005| F. The eligibility card is not transferable. A
|
0006| person who lends his card to another and a person who uses
|
0007| another's card shall each be liable to the commission for the
|
0008| full cost of the health care services provided to the user.
|
0009| Each person shall pay the liability in full within ten days of
|
0010| being billed. If either person does not pay his liability, the
|
0011| other person shall be liable for that share. Liabilities
|
0012| pursuant to this section shall be collected by the taxation and
|
0013| revenue department in the same manner as delinquent taxes are
|
0014| collected pursuant to the Tax Administration Act.
|
0015| G. A person who lends his card to another or a
|
0016| person who uses another's card a second time is guilty of a
|
0017| misdemeanor and shall be sentenced pursuant to the provisions
|
0018| of Section 31-19-1 NMSA 1978. A third or subsequent conviction
|
0019| is a fourth degree felony and the offender shall be sentenced
|
0020| pursuant to the provisions of Section 31-18-15 NMSA 1978.
|
0021| Persons convicted pursuant to this subsection are also liable
|
0022| for the amounts specified in Subsection F of this section.
|
0023| Section 18. PRIMARY CARE PROVIDER--RIGHT TO CHOOSE--
|
0024| ACCESS TO SERVICES.--
|
0025| A. Except as provided in the Workers' Compensation
|
0001| Act, an eligible person has the right to choose a primary care
|
0002| provider. If an eligible person does not choose a primary care
|
0003| provider, one shall be assigned by procedures pursuant to
|
0004| regulations of the commission.
|
0005| B. The primary care provider shall be responsible
|
0006| for providing medical treatment, other than medical
|
0007| emergencies. If the expertise of another health care provider
|
0008| is needed, the primary care provider shall make a referral to
|
0009| the appropriate specialty. Except as provided in Subsections C
|
0010| and E of this section, health care provider specialists shall
|
0011| be paid only if the patient has been referred by the patient's
|
0012| primary care provider.
|
0013| C. The commission shall by regulation specify the
|
0014| conditions under which an eligible person may select a
|
0015| specialist as a primary care provider. The commission shall
|
0016| set primary care provider rates for specialists when serving as
|
0017| primary care providers.
|
0018| D. The commission shall by regulation specify how
|
0019| often and under what conditions an eligible person may change
|
0020| his primary care provider.
|
0021| E. The commission shall by regulation specify when
|
0022| and under what circumstances an eligible person may self-refer,
|
0023| including self-referral to chiropractors, acupuncturists,
|
0024| mental health professionals and other health care providers who
|
0025| are not primary care providers.
|
0001| Section 19. DISCRIMINATION PROHIBITED.--No health care
|
0002| provider or health care facility shall discriminate against or
|
0003| refuse to furnish health care services to a person covered by
|
0004| the plan on the basis of race, color, income level, national
|
0005| origin, religion, gender, sexual orientation, disabling
|
0006| condition or payment status. Nothing in this section shall
|
0007| require a health care provider or health care facility to care
|
0008| for a patient if it is not qualified to provide the needed care
|
0009| and it does not offer that needed care to the general public.
|
0010| Section 20. UTILIZATION REVIEW--MONITORING--EFFICIENCY
|
0011| OF OPERATIONS--PENALTIES.--
|
0012| A. The commission shall implement an evaluation and
|
0013| monitoring program that considers, at a minimum, access to
|
0014| care, quality of care and utilization of care provided by the
|
0015| health plan, including geographic distribution of health care
|
0016| resources.
|
0017| B. The commission shall set standards and review
|
0018| benefits to ensure that effective, cost-efficient and
|
0019| appropriate health care services are rendered.
|
0020| C. The commission shall establish an ongoing system
|
0021| for monitoring patterns of practice and peer review. The
|
0022| system shall include the appointment of an advisory group
|
0023| consisting of health care providers, health care facilities and
|
0024| other knowledgeable persons to advise the commission and staff
|
0025| on health care practice issues.
|
0001| D. The commission shall establish a system of peer
|
0002| education for health care providers or health care facilities
|
0003| engaging in aberrant patterns of practice. If the commission
|
0004| determines that peer education efforts have failed, the
|
0005| commission may refer the matter to the appropriate licensing or
|
0006| certifying board.
|
0007| E. The commission shall provide by regulation the
|
0008| procedures for recouping payments or withholding payments for
|
0009| health care services determined by the commission to be
|
0010| medically unnecessary. In addition, the commission may provide
|
0011| by regulation for the assessment of administrative penalties
|
0012| for up to three times the amount of excess payments if it finds
|
0013| that excessive billings were part of an aberrant pattern of
|
0014| practice. Administrative penalties shall be deposited in the
|
0015| current school fund.
|
0016| F. After consultation with the peer review advisory
|
0017| group, the commission may suspend or revoke a health care
|
0018| provider's or health care facility's privilege to provide
|
0019| health care services under the health plan for aberrant
|
0020| patterns of practice, including overutilization, unnecessary
|
0021| referrals, attempts to unbundle health care services or other
|
0022| practices that the commission deems a violation of the Health
|
0023| Care Act or regulations adopted pursuant to that act. As used
|
0024| in this section, "unbundle" means to divide a service into
|
0025| components in an attempt to increase or with the effect of
|
0001| increasing compensation from the health plan.
|
0002| G. The commission shall report a suspension or
|
0003| revocation to practice under the Health Care Act to the
|
0004| appropriate licensing or certifying board.
|
0005| H. The commission shall report cases of suspected
|
0006| fraud by a health care provider or a health care facility to
|
0007| the attorney general or to the district attorney of the county
|
0008| where the health care provider or health care facility operates
|
0009| for investigation and prosecution.
|
0010| I. The commission shall review and adopt
|
0011| professional practice guidelines developed by state and
|
0012| national medical and specialty organizations, the United States
|
0013| agencies for health care policy and research and other
|
0014| organizations as it deems necessary to promote the quality and
|
0015| cost-effectiveness of health care services provided through the
|
0016| health plan.
|
0017| Section 21. HEALTH PLAN BUDGET.--
|
0018| A. Each year, the commission shall develop a health
|
0019| plan budget. The budget shall establish the total amount to be
|
0020| spent by the plan for covered health care services in the next
|
0021| year. The budget shall include provider budgets and global
|
0022| budgets.
|
0023| B. Unless otherwise provided in the general
|
0024| appropriation act or other act of the legislature, the health
|
0025| plan budget shall be within projected annual revenues.
|
0001| C. In developing the health plan budget, the
|
0002| commission shall provide that credit be taken in that budget
|
0003| for all revenues produced for health care services and
|
0004| facilities in the state pursuant to any law other than the
|
0005| Health Care Act.
|
0006| Section 22. PROVIDER BUDGET--PAYMENTS TO HEALTH CARE
|
0007| PROVIDER--CO-PAYMENTS.--
|
0008| A. Consistent with budget constraints, the health
|
0009| plan shall provide payment for all covered health care services
|
0010| rendered by health care providers. A variety of payment plans,
|
0011| including fee-for-service, compensation caps and capitated
|
0012| payments may be adopted by the commission. Payment plans shall
|
0013| be negotiated with providers as provided by regulation.
|
0014| B. Different or supplemental payment rates may be
|
0015| adopted to provide incentives to help ensure the delivery of
|
0016| needed health care services in rural and other underserved
|
0017| areas throughout the state.
|
0018| C. The annual percentage increase in provider
|
0019| budgets shall be no greater than the percentage increase in the
|
0020| implicit price deflator using one year prior to implementation
|
0021| of the health plan as the baseline year.
|
0022| D. Payment, or the offer of payment whether or not
|
0023| that offer is accepted, to a health care provider for services
|
0024| covered by the health plan shall be payment in full for those
|
0025| services. A health care provider shall not charge a patient
|
0001| covered under the health plan any additional amounts for
|
0002| services covered by the plan.
|
0003| E. The commission may set co-payments if co-payment
|
0004| is determined to be an effective cost-control measure. No co-
|
0005| payment shall be required for preventive care or if it creates
|
0006| a barrier to medically necessary care. When a co-payment is
|
0007| required, the health care provider or health care facility
|
0008| shall not waive the co-payment.
|
0009| Section 23. GLOBAL BUDGET--PAYMENTS TO HEALTH CARE
|
0010| FACILITIES.--
|
0011| A. A health care facility shall negotiate an annual
|
0012| global budget with the commission. The global budget shall be
|
0013| based on a base budget of past performance and projected
|
0014| changes upward or downward in costs and services anticipated
|
0015| for the next year. If a negotiated agreement is not reached,
|
0016| the commission shall set the global budget for the health care
|
0017| facility. The initial base budget for a health care facility
|
0018| shall be based on a twelve-month period that is no later than
|
0019| the year the health plan is implemented, appropriately adjusted
|
0020| by the implicit price deflator not to exceed five percent a
|
0021| year from 1995 to the first global budget. Thereafter,
|
0022| increases in global budgets are limited by the implicit price
|
0023| deflator.
|
0024| B. Different or supplemental payment rates may be
|
0025| adopted to provide incentives to help ensure the delivery of
|
0001| needed health care services in rural and other underserved
|
0002| areas throughout the state.
|
0003| C. Each health care provider employed by a globally
|
0004| budgeted health care facility shall be paid from the budget
|
0005| allocation in a manner determined by the health care facility.
|
0006| Section 24. CAPITAL BUDGETS--COMMISSION APPROVAL REQUIRED
|
0007| FOR MAJOR CAPITAL EXPENDITURE.--
|
0008| A. The commission shall adopt an annual capital
|
0009| budget.
|
0010| B. Allocations to geographic areas and to
|
0011| individual health care facilities and health care providers
|
0012| shall be based on need and shall be calculated so that the
|
0013| minimum access standards adopted by the commission are
|
0014| considered for all areas of the state, and shall ensure the
|
0015| efficient development and operation of necessary facilities.
|
0016| C. No major capital expenditure shall be made by a
|
0017| health care provider or health care facility without prior
|
0018| approval. The director of the commission has approval
|
0019| authority for major capital expenditures between fifty thousand
|
0020| dollars ($50,000) and five hundred thousand dollars ($500,000),
|
0021| based on regulations adopted by the commission. The commission
|
0022| has approval authority for major capital expenditures over five
|
0023| hundred thousand dollars ($500,000).
|
0024| D. The approval of any proposed major capital
|
0025| expenditure shall be based on efforts to do all of the
|
0001| following:
|
0002| (1) fulfill unmet needs;
|
0003| (2) preclude unnecessary expansion of
|
0004| facilities and services;
|
0005| (3) ensure the efficient development of health
|
0006| care facilities that are appropriate to the services provided;
|
0007| (4) ensure sufficient access to health care
|
0008| facilities; and
|
0009| (5) ensure access to efficacious new
|
0010| technologies.
|
0011| E. No health care facility or health care provider
|
0012| shall engage in component purchasing to avoid restrictions on
|
0013| major capital expenditures. The commission may deduct the
|
0014| total cost of component purchases in the next year's capital
|
0015| budget or the appropriate operating budget. As used in this
|
0016| subsection, "component purchasing" means the purchase of
|
0017| component parts or other purchasing practice with the effect of
|
0018| circumventing major capital expenditure restrictions.
|
0019| F. There is a two-year moratorium on major capital
|
0020| expenditures beginning July 1, 1997. The commission may grant
|
0021| waivers to the moratorium in emergencies.
|
0022| G. No later than January 1, 1998, the commission
|
0023| shall report to the appropriate committees of the legislature
|
0024| on the capital needs of health care facilities, including
|
0025| facilities of state and local governments, with a focus on
|
0001| underserved geographic areas with substantially below-average
|
0002| health care facilities and investment per capita as compared to
|
0003| the state average. The report shall also describe geographic
|
0004| areas where the distance to health care facilities imposes a
|
0005| barrier to care. The report shall include a section on health
|
0006| care transportation needs, including capital, personnel and
|
0007| training needs.
|
0008| Section 25. ACTUARIAL REVIEW--AUDITS.--
|
0009| A. The commission shall provide for an annual
|
0010| independent actuarial review of the health plan and any funds
|
0011| of the commission or the plan.
|
0012| B. The commission shall provide by regulation for
|
0013| independent financial audits of health care providers and
|
0014| health care facilities.
|
0015| C. The commission, through its staff or by
|
0016| contract, shall perform announced and unannounced audits,
|
0017| including financial, operational, management and electronic
|
0018| data processing audits of health care providers and health care
|
0019| facilities. The auditor shall report directly to the
|
0020| commission. A copy of the audit report shall be given to the
|
0021| state auditor.
|
0022| D. Actuarial reviews, financial audits and internal
|
0023| audits are public documents after they have been released by
|
0024| the commission.
|
0025| Section 26. STANDARD CLAIM FORMS FOR INSURANCE PAYMENT.--
|
0001| The commission shall adopt standard claim forms that shall be
|
0002| used by all health care providers and health care facilities
|
0003| that seek payment through the health plan or from private
|
0004| persons, including private insurance companies, for health care
|
0005| services rendered in the state. Each claim form may indicate
|
0006| whether a person is eligible for federal or other insurance
|
0007| programs for payment. Each claim form shall include data
|
0008| elements required by the commission.
|
0009| Section 27. COMPUTERIZED SYSTEM.--The commission shall
|
0010| require that all health care providers and health care
|
0011| facilities participate in the health plan's computer network
|
0012| that provides for electronic transfer of payments to health
|
0013| care providers and health care facilities; transmittal of
|
0014| reports, including patient data and other statistical reports;
|
0015| billing data, with specificity as to procedures or services
|
0016| provided to individual patients; and any other information
|
0017| required or requested by the commission.
|
0018| Section 28. REPORTS REQUIRED--CONFIDENTIAL INFORMATION.--
|
0019| A. The commission, through the state health
|
0020| information system, shall require reports by all health care
|
0021| providers and health care facilities of information needed to
|
0022| allow the commission to evaluate the health plan, cost-
|
0023| containment measures, utilization review, health care facility
|
0024| global budgets, health care provider fees and any other
|
0025| information the commission deems necessary to carry out its
|
0001| duties under the Health Care Act.
|
0002| B. The commission shall establish uniform reporting
|
0003| requirements for health care providers and health care
|
0004| facilities.
|
0005| C. Information confidential pursuant to other
|
0006| provisions of law shall be confidential under the Health Care
|
0007| Act. Within the constraints of confidentiality, reports of the
|
0008| commission are public documents.
|
0009| Section 29. OMBUDSMAN PROGRAM.--
|
0010| A. The commission shall establish an ombudsman
|
0011| program to take complaints and to provide timely and
|
0012| knowledgeable assistance to:
|
0013| (1) eligible persons and applicants about
|
0014| their rights and responsibilities and the coverages provided in
|
0015| accordance with the Health Care Act; and
|
0016| (2) health care providers and health care
|
0017| facilities about status of claims, payments and other pertinent
|
0018| information relevant to the claims payment process.
|
0019| B. The commission shall establish a toll-free
|
0020| telephone line for the ombudsman programs and shall have
|
0021| ombudsmen available throughout the state to assist eligible
|
0022| persons, applicants, health care providers and health care
|
0023| facilities in person.
|
0024| Section 30. APPEALS--MEDIATION--FAIR HEARING.--
|
0025| A. An applicant for or recipient of a health care
|
0001| service may appeal a decision related to eligibility, covered
|
0002| services or a primary care provider's referral decision.
|
0003| B. A health care provider or health care facility
|
0004| may appeal a decision related to claims, budgets or right to
|
0005| practice.
|
0006| C. An appeal of a decision may be summarily settled
|
0007| by the director if the person filing for an appeal presents
|
0008| evidence satisfactory to the director that an erroneous
|
0009| decision had been made. If the summary appeal is unsuccessful,
|
0010| the person may request mediation or a hearing.
|
0011| D. The commission shall by regulation establish
|
0012| procedures for a mediation process. The regulations shall
|
0013| provide for the selection of a mediator that is acceptable to
|
0014| all parties.
|
0015| E. The commission shall by regulation establish
|
0016| procedures for the filing of a request for hearing and the time
|
0017| limits within which a request may be filed. The commission may
|
0018| grant reasonable extensions of the time limits. If the request
|
0019| for hearing is not filed within the specified time or within
|
0020| whatever extension the commission may grant, the initial
|
0021| decision shall be final. Upon receipt of a timely request, the
|
0022| commission shall give the appellant reasonable notice of an
|
0023| opportunity for a fair hearing in accordance with the
|
0024| regulations of the commission.
|
0025| F. The hearing shall be conducted by a hearing
|
0001| officer designated by the director. The hearing officer may be
|
0002| an employee of the commission if there is no conflict of
|
0003| interest in the appointment of the employee.
|
0004| G. The powers of the hearing officer include
|
0005| administering oaths or affirmations to witnesses called to
|
0006| testify, taking testimony, examining witnesses, admitting or
|
0007| excluding evidence and reopening any hearing to receive
|
0008| additional evidence. The technical rules of evidence and rules
|
0009| of civil procedure shall not apply. The hearing shall be
|
0010| conducted so that the contentions or defenses of each party to
|
0011| the hearing are amply and fairly presented. Either party may
|
0012| be represented by counsel or other representative of his
|
0013| designation, and he or his representative may conduct cross-
|
0014| examinations. Any oral or documentary evidence may be
|
0015| received, but the hearing officer may exclude irrelevant,
|
0016| immaterial or unduly repetitious evidence. A verbatim record
|
0017| by audio recording or other means shall be made.
|
0018| H. The commission shall review the verbatim record
|
0019| of the proceedings and shall make a decision based on the
|
0020| record. A written notice of decision shall be sent by
|
0021| certified mail to the person requesting the hearing.
|
0022| Section 31. REVIEW AND APPEAL.--
|
0023| A. Within thirty days after the date written notice
|
0024| of the decision of the commission is mailed, an applicant,
|
0025| recipient, health care provider or health care facility may
|
0001| file a notice of appeal with the court of appeals, together
|
0002| with a copy of the notice of the decision. The clerk of the
|
0003| court shall transmit a copy of the notice of appeal to the
|
0004| director.
|
0005| B. The filing of a notice of appeal shall not stay
|
0006| the enforcement of the decision of the commission, but the
|
0007| commission may grant, or the court upon motion and good cause
|
0008| shown may order, a stay.
|
0009| C. Appeals shall be taken as provided in the Rules
|
0010| of Appellate Procedure.
|
0011| D. The review of the court shall be made upon the
|
0012| decision and the record of the proceedings.
|
0013| E. The court shall set aside a decision and order
|
0014| of the commission only if found to be:
|
0015| (1) arbitrary, capricious or an abuse of
|
0016| discretion;
|
0017| (2) not supported by substantial evidence in
|
0018| the record as a whole; or
|
0019| (3) otherwise not in accordance with law or
|
0020| the rules and regulations of the commission.
|
0021| Section 32. REIMBURSEMENT FOR OUT-OF-STATE SERVICES--
|
0022| HEALTH PLAN'S RIGHT TO SUBROGATION AND PAYMENT FROM OTHER
|
0023| INSURANCE PLANS--CHARGES FOR NON-COVERED PERSONS.--
|
0024| A. If an eligible person needs health care services
|
0025| out of state, those services shall be covered at the same rate
|
0001| that would apply if the services were received in New Mexico.
|
0002| Additional charges for those services shall not be paid by the
|
0003| health care plan unless the commission has negotiated a
|
0004| reciprocity or other agreement with the other state or foreign
|
0005| country or with the out-of-state health care provider or health
|
0006| care facility.
|
0007| B. If an otherwise eligible person has a separate
|
0008| health insurance plan that covers the same services, the health
|
0009| plan has the right of subrogation to receive payment from the
|
0010| separate health insurance plan for all covered services paid by
|
0011| the health plan. In those circumstances, the health plan shall
|
0012| be the payer of last resort. Any services provided by a
|
0013| separate health insurance plan not covered in the health plan
|
0014| shall not be affected.
|
0015| C. Nothing in this section affects an ineligible
|
0016| person's responsibility for payment of health care services.
|
0017| Section 33. PRIVATE HEALTH INSURANCE COVERAGE LIMITED--
|
0018| COMMUNITY RATING REQUIRED.--
|
0019| A. Except as provided in Subsection B of Section 32
|
0020| of the Health Care Act, no person shall provide private health
|
0021| insurance to an eligible person for a health care service that
|
0022| is covered by the health plan.
|
0023| B. Health insurance for a health care service that
|
0024| is not covered by the health plan shall be based on a system of
|
0025| community rating in which an insurer shall charge the same
|
0001| premium for the same coverage to each New Mexico resident,
|
0002| regardless of a person's individual circumstances for pre-
|
0003| existing condition, medical risk, job risk, age or gender.
|
0004| C. Nothing in this section shall be construed to
|
0005| affect insurance coverage pursuant to the federal Employee
|
0006| Retirement Income Security Act of 1974 unless the state obtains
|
0007| a congressional exemption or a waiver from the federal
|
0008| government. Businesses that are covered by the provisions of
|
0009| that act may elect to participate in the health plan.
|
0010| Section 34. FEDERAL HEALTH INSURANCE PROGRAM WAIVERS--
|
0011| REIMBURSEMENT TO PLAN FROM FEDERAL AND OTHER HEALTH INSURANCE
|
0012| PROGRAMS.--
|
0013| A. The commission, in conjunction with the human
|
0014| services department, shall:
|
0015| (1) apply to the United States department of
|
0016| health and human services for all waivers of requirements under
|
0017| health care programs established pursuant to the federal Social
|
0018| Security Act, as amended, that are necessary to enable the
|
0019| state to deposit federal payments for services covered by the
|
0020| health plan into the plan's fund and to be the supplemental
|
0021| payer of benefits for persons receiving medicare benefits;
|
0022| (2) identify other federal programs that
|
0023| provide federal funds for payment of health care services to
|
0024| individuals and apply for any waivers or enter into any
|
0025| agreements that are necessary to enable the state to deposit
|
0001| federal payments for health care services covered by the health
|
0002| plan into the plan's fund; provided, however, agreements
|
0003| negotiated with Indian health services shall not impair treaty
|
0004| obligations of the United States government and other
|
0005| agreements negotiated shall not impair portability or other
|
0006| aspects of the health care coverage; and
|
0007| (3) seek an amendment to the federal Employee
|
0008| Retirement Income Security Act of 1974 to exempt New Mexico
|
0009| from the provisions of that act that relate to health care
|
0010| services or health insurance, or the commission shall apply to
|
0011| the appropriate federal agency for waivers of any requirements
|
0012| of that act if congress provides for waivers to enable the
|
0013| commission to extend coverage through the Health Care Act to as
|
0014| many New Mexicans as possible.
|
0015| B. The commission shall seek payment to the health
|
0016| plan from medicaid, medicare or any other federal or other
|
0017| insurance program for any reimbursable payment provided under
|
0018| the plan.
|
0019| C. The commission shall seek to maximize federal
|
0020| contributions and payments for health care services provided in
|
0021| New Mexico and shall ensure that the contributions of the
|
0022| federal government for health care services in New Mexico will
|
0023| not decrease in relation to other states as a result of any
|
0024| waivers, exemptions or agreements.
|
0025| Section 35. INSURANCE--COMMISSION APPROVAL.--No person
|
0001| shall insure himself or his employees after July 1, 1997 unless
|
0002| the coverage terminates on the date that the insureds are
|
0003| eligible for coverage under the health plan. Nothing in this
|
0004| section prohibits insurance coverage for health care services
|
0005| not covered by the health plan or for people not eligible for
|
0006| coverage under the health plan.
|
0007| Section 36. [NEW MATERIAL] INSURANCE RATES--COMMISSION
|
0008| AND SUPERINTENDENT OF INSURANCE DUTIES.--
|
0009| A. The commission shall work closely with the
|
0010| superintendent of insurance to identify health care cost
|
0011| savings that have been achieved as a result of implementation
|
0012| of the health plan. The commission and the superintendent
|
0013| shall identify savings by insurance companies on payments made
|
0014| for medical services through motor vehicle liability insurance,
|
0015| homeowners' insurance, workers' compensation insurance or other
|
0016| insurance policies that have a medical payment component. The
|
0017| commission and the superintendent shall report their findings
|
0018| to the legislature.
|
0019| B. The superintendent shall lower insurance
|
0020| premiums associated with medical benefits on all types of
|
0021| insurance policies written in New Mexico that have a medical
|
0022| payment component as soon as data indicate health care savings
|
0023| have been achieved as a result of operation of the health plan.
|
0024| Section 37. TEMPORARY PROVISION--TRANSITION PERIOD
|
0025| ARRANGEMENTS--PUBLICLY FUNDED HEALTH CARE SERVICE PLANS.--
|
0001| A. A person who, on the date benefits are available
|
0002| under the Health Care Act health plan, receives health care
|
0003| benefits under private contract or collective bargaining
|
0004| agreement entered into prior to July 1, 1997 shall continue to
|
0005| receive those benefits until the contract or agreement expires
|
0006| or unless the contract or agreement is renegotiated to provide
|
0007| participation in the health plan.
|
0008| B. A person covered by a health care services plan
|
0009| that has its premiums paid for in any part by public money,
|
0010| including money from the state, a political subdivision, state
|
0011| educational institution, public school or other entity that
|
0012| receives public money to pay health insurance premiums, shall
|
0013| be covered by the Health Care Act health plan on the effective
|
0014| date that benefits are available under the plan.
|
0015| Section 38. EFFECTIVE DATE.--The effective date of the
|
0016| provisions of this act is July 1, 1997.
|
0017|
|
0018|
|
0019| FORTY-THIRD LEGISLATURE
|
0020| FIRST SESSION, 1997
|
0021|
|
0022|
|
0023| March 10, 1997
|
0024|
|
0025| Mr. President:
|
0001|
|
0002| Your PUBLIC AFFAIRS COMMITTEE, to whom has been
|
0003| referred
|
0004|
|
0005| SENATE BILL 1240
|
0006|
|
0007| has had it under consideration and reports same with
|
0008| recommendation that it DO NOT PASS, but that
|
0009|
|
0010| SENATE PUBLIC AFFAIRS COMMITTEE SUBSTITUTE FOR
|
0011| SENATE BILL 1240
|
0012|
|
0013| is reported WITHOUT RECOMMENDATION, and thence referred to
|
0014| the CORPORATIONS & TRANSPORTATION COMMITTEE.
|
0015|
|
0016| Respectfully submitted,
|
0017|
|
0018|
|
0019|
|
0020| __________________________________
|
0021| Shannon Robinson, Chairman
|
0022|
|
0023|
|
0024| Adopted_______________________ Not Adopted_______________________
|
0025| (Chief Clerk) (Chief Clerk)
|
0001|
|
0002| Date ________________________
|
0003|
|
0004|
|
0005| The roll call vote was 4 For 3 Against
|
0006| Yes: 4
|
0007| No: Adair, Boitano, Ingle
|
0008| Excused: Vernon
|
0009| Absent: None
|
0010|
|
0011| S1240PA1 SENATE PUBLIC AFFAIRS COMMITTEE SUBSTITUTE FOR
|
0012| SENATE BILL 1240
|
0013| 43rd legislature - STATE OF NEW MEXICO - first session, 1997
|
0014|
|
0015|
|
0016|
|
0017|
|
0018|
|
0019|
|
0020|
|
0021| AN ACT
|
0022| RELATING TO HEALTH CARE; ENACTING THE HEALTH CARE ACT TO
|
0023| PROVIDE FOR COMPREHENSIVE STATEWIDE HEALTH CARE; PROVIDING FOR
|
0024| HEALTH CARE PLANNING; ESTABLISHING PROCEDURES TO CONTAIN HEALTH
|
0025| CARE COSTS; CREATING A COMMISSION; PROVIDING ITS POWERS AND
|
0001| DUTIES; PROVIDING FOR HEALTH CARE DELIVERY REGIONS AND REGIONAL
|
0002| COUNCILS.
|
0003|
|
0004| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
|
0005| Section 1. SHORT TITLE.--This act may be cited as the
|
0006| "Health Care Act"
|
0007| Section 2. PURPOSE OF ACT.--The purposes of the Health
|
0008| Care Act are to create a publicly financed statewide health
|
0009| program to provide coverage for health care services for all
|
0010| state residents and to control escalating health care costs.
|
0011| Section 3. DEFINITIONS.--As used in the Health Care Act:
|
0012| A. "beneficiary" means a person eligible for coverage
|
0013| and benefits pursuant to the health plan;
|
0014| B. "capital budget" means that portion of a budget
|
0015| that establishes dollar amounts for expenditures for:
|
0016| (1) acquisition or addition of substantial
|
0017| improvements to real property; and
|
0018| (2) acquisition of tangible personal property;
|
0019| C. "capitation" means allocation of health plan funds
|
0020| to a health care provider based on the number of individuals
|
0021| whose health care must be covered by the provider, with respect
|
0022| to all benefits available under the health plan, for a calendar
|
0023| year or part of a calendar year;
|
0024| D. "commission" means the health care commission
|
0025| created pursuant to the Health Care Act;
|
0001| E. "director" means the director of the commission;
|
0002| F. "global budget" means the prospective operating
|
0003| budget of a health facility, excluding the capital budget;
|
0004| G. "group practice" means a health maintenance
|
0005| organization, an association of health care providers that
|
0006| provides one or more specialized health care services, such as
|
0007| laboratory services, x-ray services, emergency care and
|
0008| inpatient or outpatient hospital services, a tribally operated
|
0009| health care center or tribal coalitions in partnership or under
|
0010| contract with the Indian health service that is authorized
|
0011| under federal law to provide health care to Native American
|
0012| populations in the state;
|
0013| H. "health care provider" means:
|
0014| (1) a person licensed or certified in New Mexico
|
0015| as a:
|
0016| (a) physician;
|
0017| (b) osteopathic physician;
|
0018| (c) physician assistant or osteopathic
|
0019| physician's assistant;
|
0020| (d) chiropractic physician;
|
0021| (e) dentist;
|
0022| (f) psychologist, social worker; professional
|
0023| clinical mental health counselor, professional mental health
|
0024| counselor, marriage and family therapist or registered mental
|
0025| health counselor;
|
0001| (g) optometrist;
|
0002| (h) podiatrist;
|
0003| (i) pharmacist;
|
0004| (j) pharmacist clinician;
|
0005| (k) registered nurse or certified nurse
|
0006| practitioner;
|
0007| (l) visiting nurse service, private duty
|
0008| registry or other certified home health agency;
|
0009| (m) doctor of oriental medicine;
|
0010| (n) physical therapist;
|
0011| (o) massage therapist;
|
0012| (p) occupational therapist;
|
0013| (q) speech-language pathologist;
|
0014| (r) audiologist;
|
0015| (s) respiratory care practitioner;
|
0016| (t) midwife;
|
0017| (u) dietician or nutritionist;
|
0018| (v) transportation service; or
|
0019| (w) other practitioner of the healing arts
|
0020| designated as a health care provider by the commission;
|
0021| (2) a person licensed or certified by a nationally
|
0022| recognized professional organization and designated as a health
|
0023| care provider by the commission as a:
|
0024| (a) prosthetist;
|
0025| (b) orthotist; or
|
0001| (c) oculist; or
|
0002| (3) a group practice or transportation service for
|
0003| that portion of the group practice or transportation service that
|
0004| is paid pursuant to a fee schedule established by the commission;
|
0005| I. "health facility" means a clinic, general or special
|
0006| hospital, outpatient facility, psychiatric hospital, laboratory,
|
0007| skilled nursing facility or nursing facility. For the purpose of
|
0008| determining global budgets, "health facility" includes a group
|
0009| practice or transportation service;
|
0010| J. "health plan" means the mechanism developed by the
|
0011| commission for provision of health care services pursuant to the
|
0012| Health Care Act;
|
0013| K. "health plan budget" means all expenditures for the
|
0014| health plan, including the costs of services and benefits
|
0015| provided, administration, data gathering and other activities;
|
0016| L. "implicit price deflator" means a measure of
|
0017| inflation that is published in the United States department of
|
0018| commerce survey of current business;
|
0019| M. "major capital expenditure" means construction or
|
0020| renovation of facilities or the purchase of diagnostic, treatment
|
0021| or transportation equipment costing more than an amount
|
0022| established by the legislature after the commission completes a
|
0023| study and makes recommendations on this matter;
|
0024| N. "person" means a legal entity;
|
0025| O. "primary care provider" means a licensed physician,
|
0001| osteopathic physician, nurse practitioner, physician assistant,
|
0002| osteopathic physician's assistant, pharmacist clinician or other
|
0003| provider certified by the commission as a primary care provider
|
0004| after the commission's determination that the provider provides
|
0005| the first level of health care for a beneficiary's health needs;
|
0006| P. "provider budget" means the fee schedule established
|
0007| by the commission each year to pay for health care services
|
0008| provided by health care providers participating in the health
|
0009| plan; and
|
0010| Q. "transportation service" means the services of an
|
0011| ambulance, helicopter or other conveyance that is equipped with
|
0012| emergency supplies and equipment and is used to transport patients
|
0013| to health care providers or health facilities.
|
0014| Section 4. HEALTH CARE COMMISSION CREATED--VOTING AND
|
0015| NONVOTING MEMBERS.--
|
0016| A. The "health care commission" is created as an adjunct
|
0017| agency pursuant to the Executive Reorganization Act. The general
|
0018| services department, the department of health and the human
|
0019| services department shall cooperate with the commission and assist
|
0020| it as needed. The commission consists of fifteen voting members
|
0021| and nine nonvoting members. The voting members, all of whom shall
|
0022| be appointed by the governor with the advice and consent of the
|
0023| senate, are:
|
0024| (1) four persons who represent consumer interests,
|
0025| at least one of whom represents elderly consumer interests;
|
0001| (2) two persons who represent persons with physical
|
0002| or mental impairments that limit one or more of their major life
|
0003| activities;
|
0004| (3) five persons who represent either health care
|
0005| providers or health facilities;
|
0006| (4) two persons who represent business ownership
|
0007| interests, with one person representing employers of more than
|
0008| fifteen persons and one person representing employers of fifteen
|
0009| persons or fewer; and
|
0010| (5) two persons who represent organized labor.
|
0011| B. The voting members appointed shall reflect the
|
0012| ethnic, gender, economic and geographic diversity of the state.
|
0013| To ensure fair geographic representation of all areas of the
|
0014| state, members shall be appointed from each of the state board of
|
0015| education districts established by the 1991 Educational
|
0016| Redistricting Act as follows:
|
0017| (1) two from state board of education district 1;
|
0018| (2) one from state board of education district 2;
|
0019| (3) one from state board of education district 3;
|
0020| (4) two from state board of education district 4;
|
0021| (5) two from state board of education district 5;
|
0022| (6) one from state board of education district 6;
|
0023| (7) two from state board of education district 7;
|
0024| (8) two from state board of education district 8;
|
0025| (9) one from state board of education district 9;
|
0001| and
|
0002| (10) one from state board of education district 10.
|
0003| C. The initial voting members of the commission shall be
|
0004| appointed by the governor by July 1, 1998. The terms of the
|
0005| initial voting members appointed shall be staggered as follows:
|
0006| five members shall be appointed for a term of four years; five
|
0007| members shall be appointed for a term of three years; and five
|
0008| members shall be appointed for a term of two years. Thereafter,
|
0009| all members shall be appointed for terms of four years. After
|
0010| initial terms are served, no member shall serve more than three
|
0011| consecutive four-year terms.
|
0012| D. A voting member may be removed from the commission
|
0013| only for incompetence, neglect of duty or malfeasance in office.
|
0014| No voting member shall be removed without having first been given
|
0015| notice of hearing and an opportunity to be heard. The supreme
|
0016| court has exclusive original jurisdiction over proceedings to
|
0017| remove a voting member. The supreme court's decision on removal
|
0018| shall be final.
|
0019| E. A majority of the commission's voting members
|
0020| constitutes a quorum for the transaction of business. Annually
|
0021| the commission shall elect its chairman and any other officers it
|
0022| deems necessary.
|
0023| F. Voting members shall receive per diem and mileage in
|
0024| accordance with the provisions of the Per Diem and Mileage Act.
|
0025| G. The commission is composed of the following nine
|
0001| nonvoting members:
|
0002| (1) the secretary of health;
|
0003| (2) the secretary of human services;
|
0004| (3) the secretary of children, youth and families;
|
0005| (4) the secretary of taxation and revenue;
|
0006| (5) a person designated by the New Mexico office of
|
0007| Indian affairs, after consultation with the federal Indian health
|
0008| service;
|
0009| (6) two members of the house of representatives,
|
0010| including one member of the majority party and one member of the
|
0011| minority party, appointed by the speaker of the house; and
|
0012| (7) two members of the senate, including one member
|
0013| of the majority party and one member of the minority party,
|
0014| appointed by the committees' committee of the senate, or, if the
|
0015| senate appointments are made in the interim, by the president pro
|
0016| tempore of the senate after consultation with and agreement of a
|
0017| majority of the members of the committees' committee.
|
0018| H. The governor shall recommend to the legislature by
|
0019| January 1, 1998 whether or not the members of the commission
|
0020| should be compensated.
|
0021| Section 5. CONFLICT OF INTEREST.--
|
0022| A. Except for nonvoting members and members appointed to
|
0023| represent health facilities or health care providers, no
|
0024| commission member or a member of his immediate family shall have
|
0025| any financial interest, direct or indirect, in a person providing
|
0001| health care services or health insurance.
|
0002| B. The commission shall adopt a conflict of interest
|
0003| disclosure statement for use by all members that requires
|
0004| disclosure of financial interests of the member or a member of his
|
0005| immediate family in a person providing the health care services or
|
0006| health insurance.
|
0007| C. No member of the commission shall vote on any matter
|
0008| in which he or a member of his immediate family has a financial
|
0009| interest, except that members representing health facilities or
|
0010| health care providers may vote on matters that pertain generally
|
0011| to health facilities or health care providers.
|
0012| D. If there is a question about a conflict of interest
|
0013| of a member, the commission shall vote on whether to allow the
|
0014| member to vote.
|
0015| Section 6. DIRECTOR--STAFF--CONTRACTS--BUDGETS.--
|
0016| A. To assist in carrying out its duties, the commission
|
0017| shall appoint and set the salary of a "director", subject to the
|
0018| provisions of Section 10-9-5 NMSA 1978. The director shall serve
|
0019| at the pleasure of the commission.
|
0020| B. The director may employ those persons necessary to
|
0021| administer and implement the provisions of the Health Care Act.
|
0022| Employees are subject to the provisions of the Personnel Act.
|
0023| C. The director and his staff shall implement the Health
|
0024| Care Act in accordance with that act and the policies and
|
0025| regulations adopted by the commission. The director may delegate
|
0001| authority to employees and may organize the staff into units to
|
0002| facilitate its work.
|
0003| D. If the director determines that commission staff or
|
0004| another state agency does not have the resources or expertise to
|
0005| perform a necessary task, the commission may contract with a
|
0006| person that has a demonstrated capability to perform the task. If
|
0007| claims processing is provided by contract, that contract shall
|
0008| require that all work shall be performed entirely in New Mexico.
|
0009| All contracts shall be reviewed at least every two years to ensure
|
0010| that they continue to meet the criteria and performance standards
|
0011| of the contract and the needs of the commission.
|
0012| E. The director may contract with consultants that the
|
0013| director deems necessary to advise him or the commission in
|
0014| carrying out the provisions of the Health Care Act.
|
0015| F. The director shall prepare an annual budget and plan
|
0016| of operation for the commission. He shall submit both to the
|
0017| commission for its approval before implementation.
|
0018| Section 7. COMMISSION--GENERAL POWERS AND DUTIES.--The
|
0019| commission shall:
|
0020| A. adopt a five-year program of operation to implement
|
0021| the provisions of the Health Care Act;
|
0022| B. provide a program to educate the public, health care
|
0023| providers and health facilities about the health plan and the
|
0024| persons eligible to receive its benefits;
|
0025| C. study and adopt the most cost-effective methods of
|
0001| providing health care services to all beneficiaries, according
|
0002| high priority to increased reliance on:
|
0003| (1) preventive and primary care that shall include
|
0004| immunization and screening examinations;
|
0005| (2) providing health care services in rural or
|
0006| undeserved areas of the state;
|
0007| (3) in-home and community-based alternatives to
|
0008| institutional care; and
|
0009| (4) case management services when appropriate;
|
0010| D. establish compensation mechanisms for health care
|
0011| providers and adopt standards and procedures for negotiating and
|
0012| entering into contracts with participating health care providers;
|
0013| E. establish a health plan budget;
|
0014| F. establish global budgets for health facilities and
|
0015| adopt:
|
0016| (1) standards and procedures for determining base
|
0017| budgets and annual global budgets for health facilities; and
|
0018| (2) a capital expenditure program that requires
|
0019| prior approval for major capital expenditures by health
|
0020| facilities;
|
0021| G. negotiate and enter into health care reciprocity
|
0022| agreements with other states and foreign countries and negotiate
|
0023| and enter into health care agreements with out-of-state health
|
0024| care providers and health facilities;
|
0025| H. develop a payment system for health care providers
|
0001| and health facilities that ensures continuity of payments to
|
0002| enable the providers and facilities to meet their financial
|
0003| obligations as they become due;
|
0004| I. establish a system to collect and analyze health care
|
0005| data and other data necessary to improve the quality, efficiency
|
0006| and effectiveness of health care services and to control costs of
|
0007| health care services in New Mexico, and at a minimum the system
|
0008| shall include data on:
|
0009| (1) mortality, including accidental causes of
|
0010| death, and natality;
|
0011| (2) morbidity;
|
0012| (3) health behavior;
|
0013| (4) physical and psychological impairment and
|
0014| disability;
|
0015| (5) health care services system costs and health
|
0016| care services availability, utilization and revenues;
|
0017| (6) environmental factors;
|
0018| (7) availability, adequacy and training of health
|
0019| care services personnel;
|
0020| (8) demographic factors;
|
0021| (9) social and economic conditions affecting
|
0022| health; and
|
0023| (10) other factors determined by the commission;
|
0024| J. standardize data collection and specific methods of
|
0025| measurement across databases and use scientific sampling or
|
0001| complete enumeration for reporting health information;
|
0002| K. establish a health care services delivery system that
|
0003| is efficient to administer and that eliminates unnecessary
|
0004| administrative costs;
|
0005| L. adopt rules and regulations necessary to implement
|
0006| and monitor a state formulary to provide prescription drugs,
|
0007| medicine, durable medical equipment and supplies, eyeglasses,
|
0008| hearing aids, oxygen and related services;
|
0009| M. study and evaluate the adequacy and quality of health
|
0010| care services furnished pursuant to the Health Care Act, the cost
|
0011| of each type of service and the effectiveness of cost-containment
|
0012| measures in the health plan;
|
0013| N. study and monitor the migration of persons to New
|
0014| Mexico to determine if persons with costly health care needs are
|
0015| moving to New Mexico to receive health care services, and if
|
0016| migration appears to threaten the financial stability of the
|
0017| health plan, recommend to the legislature changes in eligibility
|
0018| requirements, premiums or other statutory changes that may be
|
0019| necessary to maintain the financial integrity of the health plan;
|
0020| O. study and evaluate the cost of health care provider
|
0021| professional liability and health care provider professional
|
0022| liability insurance and recommend statutory changes to the
|
0023| legislature as necessary;
|
0024| P. establish and approve changes in coverage benefits
|
0025| and benefit standards in the health plan;
|
0001| Q. conduct necessary investigations and inquiries and
|
0002| compel by subpoena the submission of testimony, information and
|
0003| documents that the commission considers necessary to carry out its
|
0004| duties;
|
0005| R. adopt rules and regulations necessary to implement,
|
0006| administer and monitor the operation of the health plan;
|
0007| S. meet as needed, but no less than once every three
|
0008| months; and
|
0009| T. report annually to the legislature and the governor
|
0010| on the commission's activities and the operation of the health
|
0011| plan and include in the annual report:
|
0012| (1) a summary of information about health care
|
0013| needs, health care services, health care expenditures, revenues
|
0014| received and projected revenues and other relevant issues relating
|
0015| to the health plan and the five-year program; and
|
0016| (2) recommendations on methods to control health
|
0017| care costs and improve access to and the quality of health care
|
0018| for state residents, as well as recommendations for legislative
|
0019| action if any are found to be necessary.
|
0020| Section 8. COMMISSION--AUTHORITY.--The commission has the
|
0021| authority necessary to carry out all duties and responsibilities
|
0022| required of it pursuant to the Health Care Act, whether that
|
0023| authority is expressly provided in that act or is necessarily
|
0024| implied. The commission may delegate its general authority to the
|
0025| director except for specific authority or direction that is
|
0001| granted to the commission by a provision of the Health Care Act
|
0002| and authority, which is expressly reserved in the commission, to
|
0003| take the following actions:
|
0004| A. sue and defend suits brought against it, subject to
|
0005| the provisions of the Tort Claims Act;
|
0006| B. enter into contracts;
|
0007| C. approve its budget and plan of operation;
|
0008| D. approve the health plan and make changes in the
|
0009| health plan;
|
0010| E. adopt regulations, written policies and procedures to
|
0011| implement the health plan and the provisions of the Health Care
|
0012| Act;
|
0013| F. issue subpoenas to persons to appear and testify
|
0014| before the commission and to produce documents and other
|
0015| information, and enforce this subpoena power through an action in
|
0016| the district court of Santa Fe county;
|
0017| G. make reports and recommendations to the legislature;
|
0018| H. apply for program waivers from any governmental
|
0019| entity; and
|
0020| I. accept grants, apply for and receive loans and accept
|
0021| donations.
|
0022| Section 9. ADVISORY BOARDS.--
|
0023| A. The commission may establish advisory boards to
|
0024| assist it in performing its duties.
|
0025| B. The commission shall establish a "health care
|
0001| provider advisory board" to advise and assist the commission in
|
0002| all decisions requiring the expertise of health care providers.
|
0003| Each noncommission member shall represent a different licensed
|
0004| health profession.
|
0005| C. No more than two advisory board members shall have
|
0006| any financial interest, direct or indirect, in a person providing
|
0007| health care services or a person providing health insurance.
|
0008| D. The commission may appoint commission members and up
|
0009| to five additional persons to serve on an advisory board it
|
0010| creates. Advisory board members who are not commission members
|
0011| may be paid per diem and mileage in accordance with the provisions
|
0012| of the Per Diem and Mileage Act.
|
0013| E. Staff and technical assistance for an advisory board
|
0014| shall be provided by the commission as necessary.
|
0015| Section 10. HEALTH CARE DELIVERY REGIONS.--The commission
|
0016| shall establish health care delivery regions in the state, based
|
0017| on geography and health care resources. The regions may have
|
0018| differential fee schedules, global budgets, capital expenditure
|
0019| allocations or other features to encourage the provision of health
|
0020| care services in rural and other underserved areas.
|
0021| Section 11. REGIONAL COUNCILS.--
|
0022| A. The commission shall create regional councils in the
|
0023| health care delivery regions of the state.
|
0024| B. The regional councils shall be composed of at least
|
0025| one of the commission members who lives in the region and five
|
0001| other members appointed by the commission. No more than two
|
0002| council members shall have any financial interest, direct or
|
0003| indirect, in a person providing health care services or a person
|
0004| providing health insurance.
|
0005| C. Members of a regional council may be paid per diem
|
0006| and mileage in accordance with the provisions of the Per Diem and
|
0007| Mileage Act.
|
0008| D. The regional councils shall hold public hearings to
|
0009| receive comments, suggestions and recommendations from the public
|
0010| regarding regional health care needs. The councils shall report
|
0011| to the commission at times specified by the commission to ensure
|
0012| that regional concerns are considered in the development and
|
0013| update of the five-year program, fee schedules, global budgets and
|
0014| capital expenditure allocations.
|
0015| E. Staff and technical assistance for the regional
|
0016| councils shall be provided by the commission.
|
0017| Section 12. COMMISSION, COUNCILS AND ADVISORY BOARDS--
|
0018| MEETINGS.--All meetings of the commission, councils and advisory
|
0019| boards shall be conducted pursuant to the provisions of the Open
|
0020| Meetings Act.
|
0021| Section 13. RULES AND REGULATIONS.--
|
0022| A. The commission shall adopt regulations necessary to
|
0023| carry out the duties of the commission and the provisions of the
|
0024| Health Care Act.
|
0025| B. No regulation affecting any person outside the
|
0001| commission shall be adopted, amended or repealed without a public
|
0002| hearing on the proposed action before the commission or a hearing
|
0003| officer designated by the commission. The hearing officer may be
|
0004| a member of the commission's staff. The hearing shall be held in
|
0005| Santa Fe unless the commission determines that it would be in the
|
0006| interest of those affected to hold the hearing elsewhere in the
|
0007| state. Notice of the subject matter of the regulation, the action
|
0008| proposed to be taken, the time and place of the hearing, the
|
0009| manner in which interested persons may present their views and the
|
0010| method by which copies of the proposed regulation or an amendment
|
0011| or repeal of an existing regulation may be obtained shall be
|
0012| published once at least thirty days prior to the hearing date in a
|
0013| newspaper of general circulation and mailed at least thirty days
|
0014| prior to the hearing date to all persons who have made a written
|
0015| request for advance notice of hearing.
|
0016| C. All rules and regulations adopted by the commission
|
0017| shall be filed in accordance with the State Rules Act.
|
0018| Section 14. HEALTH PLAN.--
|
0019| A. After notice and public hearing, including taking
|
0020| public comment and the reports of the regional councils, the
|
0021| commission shall adopt a health plan.
|
0022| B. The health plan shall be designed to provide
|
0023| comprehensive, necessary and appropriate health care benefits,
|
0024| including preventive health care and primary, secondary and
|
0025| tertiary health care for acute and chronic conditions. The health
|
0001| plan may provide for certain health care services to be phased in
|
0002| as the health plan budget allows.
|
0003| C. The commission shall specify the health care services
|
0004| to be included as covered by the health plan but shall include:
|
0005| (1) preventive health services;
|
0006| (2) health care provider services;
|
0007| (3) health facility inpatient and outpatient
|
0008| services;
|
0009| (4) laboratory tests and imaging procedures;
|
0010| (5) in-home, community-based and institutional
|
0011| long-term care services;
|
0012| (6) prescription drugs;
|
0013| (7) inpatient and outpatient mental health
|
0014| services;
|
0015| (8) drug and substance abuse services;
|
0016| (9) preventive and prophylactic dental services,
|
0017| including an annual dental examination and cleaning;
|
0018| (10) vision appliances, including medically
|
0019| necessary contact lenses;
|
0020| (11) medical supplies, durable medical equipment
|
0021| and selected assistive devices, including hearing and speech
|
0022| assistance devices; and
|
0023| (12) experimental or investigational procedures or
|
0024| treatments as specified by the commission.
|
0025| D. Covered services shall not include:
|
0001| (1) surgery for cosmetic purposes other than for
|
0002| reconstructive purposes;
|
0003| (2) medical examinations and medical reports
|
0004| prepared for purchasing or renewing life insurance or
|
0005| participating as a plaintiff or defendant in a civil action for
|
0006| the recovery or settlement of damages; and
|
0007| (3) orthodontic services and cosmetic dental
|
0008| services except those cosmetic dental services necessary for
|
0009| reconstructive purposes.
|
0010| E. The health plan shall specify the services to be
|
0011| covered and the amount, scope and duration of benefits. The plan
|
0012| shall include a maximum amount or percentage for administrative
|
0013| costs, and this maximum, if a percentage, may change in relation
|
0014| to the total costs of services provided under the health plan.
|
0015| F. The commission shall specify the terms and conditions
|
0016| for participation of health care providers and health facilities
|
0017| in the health plan.
|
0018| G. The health plan shall contain provisions to control
|
0019| health care costs so that beneficiaries receive comprehensive
|
0020| health services, consistent with budget constraints, including
|
0021| needed health care services in rural and other underserved areas.
|
0022| H. The health plan shall phase in beneficiaries as their
|
0023| participation becomes possible through contracts, waivers or
|
0024| federal legislation. The health plan may provide for certain
|
0025| preventive health care services to be offered to all New Mexicans
|
0001| regardless of eligibility.
|
0002| I. The five-year program shall be reviewed by the
|
0003| regional councils and the commission annually and revised as
|
0004| necessary. Revisions shall be adopted by the commission in
|
0005| accordance with Section 13 of the Health Care Act. In projecting
|
0006| services under the health plan, the commission shall take all
|
0007| reasonable steps to ensure that long-term care, mental health
|
0008| services and dental care are provided at the earliest practical
|
0009| times consistent with budget constraints.
|
0010| Section 15. LONG-TERM CARE.--
|
0011| A. Long-term care may include:
|
0012| (1) home- and community-based services, including
|
0013| personal assistance and attendant care;
|
0014| (2) hospice care; and
|
0015| (3) institutional care.
|
0016| B. No later than one year after appointment of the
|
0017| director, the commission shall appoint an advisory "long-term care
|
0018| committee" made up of representatives of health care consumers,
|
0019| providers and administrators to develop a plan for integrating
|
0020| long-term care into the health plan. The committee shall report
|
0021| its plan to the commission no later than one year from its
|
0022| appointment. Committee members may receive per diem and mileage
|
0023| as provided in the Per Diem and Mileage Act.
|
0024| C. The long-term care component of the health plan
|
0025| shall provide for service coordination, case management and
|
0001| noninstitutional services where appropriate.
|
0002| D. Nothing in this section affects long-term care
|
0003| services paid through federal programs or private insurance
|
0004| subject to the provisions of Sections 34 and 35 of the Health Care
|
0005| Act.
|
0006| E. Nothing in this section precludes the commission from
|
0007| including long-term care services from the inception of the health
|
0008| plan.
|
0009| Section 16. MENTAL HEALTH SERVICES.--
|
0010| A. Mental health services may include:
|
0011| (1) services for acute and chronic conditions;
|
0012| (2) home- and community-based services; and
|
0013| (3) institutional care.
|
0014| B. No later than one year after appointment of the
|
0015| director, the commission shall appoint an advisory "mental health
|
0016| services committee" made up of representatives of mental health
|
0017| care consumers, providers and administrators to develop a plan for
|
0018| integrating mental health services into the health plan. The
|
0019| committee shall report its plan to the commission no later than
|
0020| one year from its appointment. Committee members may receive per
|
0021| diem and mileage as provided in the Per Diem and Mileage Act.
|
0022| C. The mental health services component of the health
|
0023| plan shall provide for service coordination, case management and
|
0024| noninstitutional services where appropriate.
|
0025| D. Nothing in this section affects mental health
|
0001| services paid through federal programs or private insurance
|
0002| subject to the provisions of Sections 34 and 35 of the Health Care
|
0003| Act.
|
0004| E. Nothing in this section precludes the commission from
|
0005| including mental health services from the inception of the health
|
0006| plan.
|
0007| Section 17. MEDICAID COVERAGE--JOINT POWERS AGREEMENTS.--The
|
0008| commission may enter into joint powers agreements with the human
|
0009| services department in accordance with the Joint Powers Agreements
|
0010| Act for the purpose of furthering the goals of the Health Care
|
0011| Act. These agreements may provide for certain medicaid functions
|
0012| to be administered by the commission to allow the commission to
|
0013| implement the health plan.
|
0014| Section 18. HEALTH PLAN COVERAGE--CONDITIONS OF ELIGIBILITY
|
0015| FOR BENEFICIARIES--NONRESIDENT STUDENTS--ELIGIBILITY CARD--
|
0016| PENALTIES.--
|
0017| A. An individual is eligible as a beneficiary of the
|
0018| health plan if the individual has been physically present in New
|
0019| Mexico for one year prior to the date of application for
|
0020| enrollment in the health plan and if the individual has a present
|
0021| intention to remain in New Mexico and not to reside elsewhere. A
|
0022| dependent of an eligible individual is included as a beneficiary.
|
0023| An individual is not eligible for coverage if he is covered for
|
0024| the same or similar benefits pursuant to a private or governmental
|
0025| health insurance policy or plan, but he becomes eligible when that
|
0001| coverage terminates or agreements or waivers are accomplished
|
0002| under which coverage under the health plan is available.
|
0003| Individuals covered under the following governmental programs
|
0004| shall not be brought into coverage through agreements or waivers:
|
0005| (1) federal retiree health plan beneficiaries;
|
0006| (2) Indian health service beneficiaries, but
|
0007| individuals who are covered by tribal providers that are in
|
0008| partnership with or have contracts with the Indian health service
|
0009| may be brought under coverage through agreement between the tribal
|
0010| providers and the commission;
|
0011| (3) active duty military personnel; and
|
0012| (4) individuals covered by the federal civilian
|
0013| health and medical plan for the uniformed services.
|
0014| B. An educational institution shall purchase coverage
|
0015| under the health plan for its nonresident students through fees
|
0016| assessed to these students. The governing body of an educational
|
0017| institution shall set the fees at the amount determined by the
|
0018| commission.
|
0019| C. A nonresident student at an educational institution
|
0020| may demonstrate health insurance or plan coverage by proof of
|
0021| coverage under a policy or plan in another state that is
|
0022| acceptable to the commission. The fee that students shall be
|
0023| assessed shall be specified by the commission.
|
0024| D. The commission shall adopt regulations to determine
|
0025| proof of an individual's eligibility for the health plan or a
|
0001| student's proof of nonresident health insurance or plan coverage.
|
0002| E. The commission shall adopt regulations to provide a
|
0003| method for the purging of eligibility when a beneficiary is no
|
0004| longer eligible for coverage.
|
0005| F. A beneficiary shall receive a card as proof of
|
0006| eligibility. The card shall be electronically readable and shall
|
0007| contain a picture or electronic image, information that identifies
|
0008| the beneficiary for treatment and electronic billing and payment
|
0009| and any other information the commission deems necessary.
|
0010| G. The eligibility card is not transferable. A
|
0011| beneficiary who lends his card to another and an individual who
|
0012| uses another's card shall be jointly and severally be liable to
|
0013| the commission for the full cost of the health care services
|
0014| provided to the user. The liability shall be paid in full within
|
0015| ten days of billing. Liabilities created pursuant to this section
|
0016| shall be collected by the taxation and revenue department in the
|
0017| same manner as delinquent taxes are collected pursuant to the Tax
|
0018| Administration Act.
|
0019| H. A beneficiary who lends his card to another or an
|
0020| individual who uses another's card a second time is guilty of a
|
0021| misdemeanor and shall be sentenced pursuant to the provisions of
|
0022| Section 31-19-1 NMSA 1978. A third or subsequent conviction is a
|
0023| fourth degree felony and the offender shall be sentenced pursuant
|
0024| to the provisions of Section 31-18-15 NMSA 1978.
|
0025| Section 19. PRIMARY CARE PROVIDER--RIGHT TO CHOOSE--ACCESS
|
0001| TO SERVICES.--
|
0002| A. Except as provided in the Workers' Compensation Act,
|
0003| a beneficiary has the right to choose a primary care provider. If
|
0004| he does not choose a primary care provider, one shall be assigned
|
0005| to him under procedures in regulations adopted by the commission.
|
0006| B. The primary care provider shall be responsible for
|
0007| providing health care services other than services in medical
|
0008| emergencies. If the expertise of another health care provider is
|
0009| needed, the primary care provider shall make a referral to the
|
0010| appropriate specialty. Except as provided in Subsections C and E
|
0011| of this section, health care provider specialists shall be paid
|
0012| pursuant to the health plan only if the patient has been referred
|
0013| by the patient's primary care provider. Nothing in this
|
0014| subsection prevents a beneficiary from obtaining the services of a
|
0015| health care provider specialist and paying the specialist for
|
0016| services provided.
|
0017| C. The commission shall by regulation specify the
|
0018| conditions under which a beneficiary may select a specialist as a
|
0019| primary care provider. The commission shall set primary care
|
0020| provider rates for specialists when serving as primary care
|
0021| providers.
|
0022| D. The commission shall by regulation specify how often
|
0023| and under what conditions a beneficiary may change his primary
|
0024| care provider.
|
0025| E. The commission shall by regulation specify when and
|
0001| under what circumstances a beneficiary may self-refer, including
|
0002| self-referral to chiropractors, acupuncturists, mental health
|
0003| professionals and other health care providers who are not primary
|
0004| care providers.
|
0005| Section 20. DISCRIMINATION PROHIBITED.--No health care
|
0006| provider or health facility shall discriminate against or refuse
|
0007| to furnish health care services to a beneficiary on the basis of
|
0008| race, color, income level, national origin, religion, gender,
|
0009| sexual orientation, disabling condition or payment status.
|
0010| Nothing in this section shall require a health care provider or
|
0011| health facility to provide services to a beneficiary if the
|
0012| provider or facility is not qualified to provide the needed
|
0013| services and does not offer them to the general public.
|
0014| Section 21. GRIEVANCE PROCEDURES.--The commission shall
|
0015| adopt regulations to cover and shall implement a prompt and fair
|
0016| grievance procedure to respond to complaints of applicants,
|
0017| beneficiaries, health care providers and health facilities.
|
0018| Section 22. UTILIZATION REVIEW.--
|
0019| A. The commission shall adopt regulations to cover and
|
0020| shall implement a comprehensive utilization review program. The
|
0021| procedures and standards used in the program shall be disclosed in
|
0022| writing to applicants, beneficiaries, health care providers and
|
0023| health facilities at the time of application to or participation
|
0024| in the health plan.
|
0025| B. The decision of the health plan to approve or deny
|
0001| health care services for payment shall be made in a timely manner.
|
0002| A final decision to deny payment for services shall be made by a
|
0003| health care professional having appropriate and adequate
|
0004| qualifications to make the decision. The utilization review
|
0005| program shall be designed to ensure that beneficiaries have proper
|
0006| access to health care services, including referrals to necessary
|
0007| specialists. A decision made in the utilization review program
|
0008| shall be subject to the grievance procedures under regulations
|
0009| adopted pursuant to Section 21 of the Health Care Act.
|
0010| Section 23. MONITORING HEALTH CARE PROVIDER PRACTICES.--
|
0011| A. The commission shall adopt regulations to establish
|
0012| and implement a continuous quality improvement program that
|
0013| monitors the quality and appropriateness of health care services
|
0014| provided by the health plan. The commission shall set standards
|
0015| and review benefits to ensure that effective, cost-efficient and
|
0016| appropriate health care services are rendered.
|
0017| B. The commission shall review and adopt professional
|
0018| practice guidelines developed by state and national medical and
|
0019| specialty organizations, the United States agencies for health
|
0020| care policy and research and other organizations as it deems
|
0021| necessary to promote the quality and cost-effectiveness of health
|
0022| care services provided through the health plan.
|
0023| C. The quality improvement program shall include an
|
0024| ongoing system for monitoring patterns of practice. The
|
0025| commission shall appoint an advisory group consisting of health
|
0001| care providers, representatives of health facilities and other
|
0002| knowledgeable persons to advise the commission and staff on health
|
0003| care practice issues. The advisory group shall provide to the
|
0004| commission recommended standards and guidelines to be followed in
|
0005| making determinations on practice issues.
|
0006| D. The commission shall establish a system of peer
|
0007| education for health care providers or health facilities
|
0008| determined to be engaging in aberrant patterns of practice. If
|
0009| the commission determines that peer education efforts have failed,
|
0010| the commission may refer the matter to the appropriate licensing
|
0011| or certifying board.
|
0012| E. The commission shall provide by regulation the
|
0013| procedures for recouping payments or withholding payments for
|
0014| health care services determined by the commission to be medically
|
0015| unnecessary. In addition, the commission may provide by
|
0016| regulation for the assessment of administrative penalties for up
|
0017| to three times the amount of excess payments if it finds that
|
0018| excessive billings were part of an aberrant pattern of practice.
|
0019| Administrative penalties shall be deposited in the current school
|
0020| fund.
|
0021| F. After consultation with the peer review advisory
|
0022| group, the commission may suspend or revoke a health care
|
0023| provider's or health facility's privilege to provide health care
|
0024| services under the health plan for aberrant patterns of practice,
|
0025| including overutilization, unnecessary referrals, attempts to
|
0001| unbundle health care services or other practices that the
|
0002| commission deems a violation of the Health Care Act or regulations
|
0003| adopted pursuant to that act. As used in this section, "unbundle"
|
0004| means to divide a service into components in an attempt to
|
0005| increase or with the effect of increasing compensation from the
|
0006| health plan.
|
0007| G. The commission shall report a suspension or
|
0008| revocation to practice under the Health Care Act to the
|
0009| appropriate licensing or certifying board.
|
0010| H. The commission shall report cases of suspected fraud
|
0011| by a health care provider or a health facility to the attorney
|
0012| general or to the district attorney of the county where the health
|
0013| care provider or health facility operates for investigation and
|
0014| prosecution.
|
0015| Section 24. HEALTH PLAN BUDGET.--
|
0016| A. Each year, the commission shall develop a health plan
|
0017| budget. The budget shall establish the total amount to be spent
|
0018| by the plan for covered health care services in the next year.
|
0019| The budget shall include administrative budgets, provider budgets
|
0020| and global budgets.
|
0021| B. Unless otherwise provided in the general
|
0022| appropriation act or other act of the legislature, the health plan
|
0023| budget shall be within projected annual revenues.
|
0024| C. In developing the health plan budget, the commission
|
0025| shall provide that credit be taken in that budget for all revenues
|
0001| produced for health care services and facilities in the state
|
0002| pursuant to any law other than the Health Care Act.
|
0003| Section 25. PROVIDER BUDGET--PAYMENTS TO HEALTH CARE
|
0004| PROVIDER--CO-PAYMENTS.--
|
0005| A. Consistent with budget constraints, the health plan
|
0006| shall provide payment for all covered health care services
|
0007| rendered by health care providers. A variety of payment plans,
|
0008| including fee-for-service, compensation caps and capitated
|
0009| payments may be adopted by the commission. Payment plans shall be
|
0010| negotiated with providers as provided by regulation. In the event
|
0011| that negotiation fails to develop an acceptable payment plan, the
|
0012| disputing parties shall submit the payment plan to mediation. The
|
0013| commission shall adopt regulations governing the procedures for
|
0014| mediation. If the disputed payment plan is not resolved in
|
0015| mediation, the disputing parties shall submit the payment plan to
|
0016| binding arbitration pursuant to the Uniform Arbitration Act and
|
0017| regulations to be adopted by the commission.
|
0018| B. Different or supplemental payment rates may be
|
0019| adopted to provide incentives to help ensure the delivery of
|
0020| needed health care services in rural and other underserved areas
|
0021| throughout the state.
|
0022| C. The annual percentage increase in provider budgets
|
0023| shall be no greater than the percentage increase in the implicit
|
0024| price deflator using one year prior to implementation of the
|
0025| health plan as the baseline year.
|
0001| D. Payment, or the offer of payment whether or not that
|
0002| offer is accepted, to a health care provider for services covered
|
0003| by the health plan shall be payment in full for those services. A
|
0004| health care provider shall not charge a beneficiary any additional
|
0005| amounts for services covered by the plan.
|
0006| E. The commission may set co-payments if co-payment is
|
0007| determined to be an effective cost-control measure. No co-payment
|
0008| shall be required for preventive care or if it creates a barrier
|
0009| to medically necessary care. When a co-payment is required, the
|
0010| health care provider shall not waive the co-payment.
|
0011| Section 26. GLOBAL BUDGET--PAYMENTS TO HEALTH FACILITIES--
|
0012| CO-PAYMENTS.--
|
0013| A. A health facility shall negotiate an annual global
|
0014| budget with the commission. The global budget shall be based on a
|
0015| base budget of past performance and projected changes upward or
|
0016| downward in costs and services anticipated for the next year. If
|
0017| a negotiated annual global budget is not reached, a health
|
0018| facility shall submit the budget to mediation. The commission
|
0019| shall adopt regulations governing the procedures for mediation.
|
0020| If the disputed budget is not resolved in mediation, the health
|
0021| facility shall submit the budget to binding arbitration pursuant
|
0022| to the Uniform Arbitration Act and regulations adopted by the
|
0023| commission. The initial base budget for a health facility shall
|
0024| be based on a twelve-month period that is no later than the year
|
0025| the health plan is implemented, appropriately adjusted by the
|
0001| implicit price deflator not to exceed five percent a year from
|
0002| 1996 to the first global budget. Thereafter, increases in global
|
0003| budgets are limited by the implicit price deflator.
|
0004| B. Different or supplemental payment rates may be
|
0005| adopted to provide incentives to help ensure the delivery of
|
0006| needed health care services in rural and other underserved areas
|
0007| throughout the state.
|
0008| C. Each health care provider employed by a globally
|
0009| budgeted health facility shall be paid from the budget allocation
|
0010| in a manner determined by the health facility.
|
0011|
|
0012| D. The commission may set co-payments if co-payment is
|
0013| determined to be an effective cost-control measure. No co-payment
|
0014| shall be required for preventive care or if it creates a barrier
|
0015| to medically necessary care. When a co-payment is required, the
|
0016| health facility shall not waive the co-payment.
|
0017| Section 27. HEALTH RESOURCE CERTIFICATE--COMMISSION
|
0018| REGULATIONS--REQUIREMENT FOR REVIEW.--
|
0019| A. The commission shall adopt regulations pertaining to
|
0020| when a health facility or health care provider must apply for a
|
0021| health resource certificate, how the application will be reviewed,
|
0022| how the certificate will be granted, how an expedited review is
|
0023| conducted and other matters relating to health resource projects.
|
0024| B. No health facility or health care provider shall
|
0025| undertake a capital project or obligate a health facility or
|
0001| health care provider to undertake a project without first
|
0002| obtaining a health resource certificate, except as provided in
|
0003| Subsection F of this section.
|
0004| C. No health facility or health care provider shall
|
0005| acquire through rental, lease or comparable arrangement or through
|
0006| donation all or a part of a capital project that would have
|
0007| required review if the acquisition had been by purchase unless the
|
0008| project is granted a health resource certificate.
|
0009| D. No health facility or health care provider shall
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0010| engage in component purchasing in order to avoid the provisions of
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0011| this section.
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0012| E. The commission shall grant a health resource
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0013| certificate for a capital project only when the project is
|
0014| determined to be needed.
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0015| F. This section does not apply to:
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0016| (1) the purchase, construction or renovation of
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0017| office space for health care providers;
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0018| (2) a capital project for which a binding
|
0019| contractual obligation was incurred prior to the effective date of
|
0020| this section;
|
0021| (3) expenditures incurred solely in preparation for
|
0022| a capital project, including architectural design, surveys, plans,
|
0023| working drawings and specifications and other related activities,
|
0024| but those expenditures shall be included in the cost of a project
|
0025| for the purpose of determining whether a health resource
|
0001| certificate is required;
|
0002| (4) acquisition of an existing health facility,
|
0003| equipment or practice of a health care provider that does not
|
0004| result in a new service being provided or in increased bed
|
0005| capacity;
|
0006| (5) capital expenditures for nonclinical services
|
0007| when the nonclinical services are the primary purpose of the
|
0008| expenditure; and
|
0009| (6) the replacement of equipment with equipment
|
0010| that has the same function and that does not result in the
|
0011| offering of new services.
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0012| G. No later than January 1, 1999, the commission shall
|
0013| report to the appropriate committees of the legislature on the
|
0014| capital needs of health facilities, including facilities of state
|
0015| and local governments, with a focus on underserved geographic
|
0016| areas with substantially below-average health facilities and
|
0017| investment per capita as compared to the state average. The
|
0018| report shall also describe geographic areas where the distance to
|
0019| health facilities imposes a barrier to care. The report shall
|
0020| include a section on health care transportation needs, including
|
0021| capital, personnel and training needs. The report shall make
|
0022| recommendations for legislation to amend the Health Care Act by
|
0023| adding to that act dollar limitations to apply in denying or
|
0024| approving capital expenditures.
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0025| Section 28. ACTUARIAL REVIEW--AUDITS.--
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0001| A. The commission shall provide for an annual
|
0002| independent actuarial review of the health plan and any funds of
|
0003| the commission or the plan.
|
0004| B. The commission shall provide by regulation for
|
0005| independent financial audits of health care providers and health
|
0006| facilities.
|
0007| C. The commission, through its staff or by contract,
|
0008| shall perform announced and unannounced audits, including
|
0009| financial, operational, management and electronic data processing
|
0010| audits of health care providers and health facilities. The
|
0011| auditor shall report directly to the commission. A copy of the
|
0012| audit report shall be given to the state auditor.
|
0013| D. Actuarial reviews, financial audits and internal
|
0014| audits are public documents after they have been released by the
|
0015| commission.
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0016| Section 29. STANDARD CLAIM FORMS FOR INSURANCE PAYMENT.--The
|
0017| commission shall adopt standard claim forms that shall be used by
|
0018| all health care providers and health facilities that seek payment
|
0019| through the health plan or from private persons, including private
|
0020| insurance companies, for health care services rendered in the
|
0021| state. Each claim form may indicate whether a person is eligible
|
0022| for federal or other insurance programs for payment. Each claim
|
0023| form shall include data elements required by the commission.
|
0024| Section 30. COMPUTERIZED SYSTEM.--The commission shall
|
0025| require that all health care providers and health facilities
|
0001| participate in the health plan's computer network that provides
|
0002| for electronic transfer of payments to health care providers and
|
0003| health facilities; transmittal of reports, including patient data
|
0004| and other statistical reports; billing data, with specificity as
|
0005| to procedures or services provided to individual patients; and any
|
0006| other information required or requested by the commission.
|
0007| Section 31. REPORTS REQUIRED--CONFIDENTIAL INFORMATION.--
|
0008| A. The commission, through the state health information
|
0009| system, shall require reports by all health care providers and
|
0010| health facilities of information needed to allow the commission to
|
0011| evaluate the health plan, cost-containment measures, utilization
|
0012| review, health facility global budgets, health care provider fees
|
0013| and any other information the commission deems necessary to carry
|
0014| out its duties under the Health Care Act.
|
0015| B. The commission shall establish uniform reporting
|
0016| requirements for health care providers and health facilities.
|
0017| C. Information confidential pursuant to other provisions
|
0018| of law shall be confidential under the Health Care Act. Within
|
0019| the constraints of confidentiality, reports of the commission are
|
0020| public documents.
|
0021| Section 32. OMBUDSMAN PROGRAM.--
|
0022| A. The commission shall establish an ombudsman program
|
0023| to take complaints and to provide timely and knowledgeable
|
0024| assistance to:
|
0025| (1) eligible persons and applicants about their
|
0001| rights and responsibilities and the coverages provided in
|
0002| accordance with the Health Care Act; and
|
0003| (2) health care providers and health facilities
|
0004| about status of claims, payments and other pertinent information
|
0005| relevant to the claims payment process.
|
0006| B. The commission shall establish a toll-free telephone
|
0007| line for the ombudsman programs and shall have ombudsmen available
|
0008| throughout the state to assist beneficiaries, applicants, health
|
0009| care providers and health facilities in person.
|
0010| Section 33. REIMBURSEMENT FOR OUT-OF-STATE SERVICES--HEALTH
|
0011| PLAN'S RIGHT TO SUBROGATION AND PAYMENT FROM OTHER INSURANCE
|
0012| PLANS--CHARGES FOR NON-COVERED PERSONS.--
|
0013| A. If a beneficiary needs health care services out of
|
0014| state, those services shall be covered at the same rate that would
|
0015| apply if the services were received in New Mexico. Additional
|
0016| charges for those services shall not be paid by the health plan
|
0017| unless the commission has negotiated a reciprocity or other
|
0018| agreement with the other state or foreign country or with the out-
|
0019| of-state health care provider or health facility.
|
0020| B. The health plan shall make reasonable efforts to
|
0021| ascertain any legal liability of third parties who are or may be
|
0022| liable to pay all or part of the health care services costs of
|
0023| injury, disease or disability of a beneficiary.
|
0024| C. When the health plan makes payments on behalf of a
|
0025| beneficiary, the health plan is subrogated to any right of the
|
0001| beneficiary against a third party for recovery of amounts paid by
|
0002| the health plan.
|
0003| D. By operation of law, an assignment to the health plan
|
0004| of the rights of a beneficiary:
|
0005| (1) is conclusively presumed to be made of:
|
0006| (a) a payment for health care services from any
|
0007| person, firm or corporation, including an insurance carrier; and
|
0008| (b) a monetary recovery for damages for bodily
|
0009| injury, whether by judgment, contract for compromise or
|
0010| settlement;
|
0011| (2) shall be effective to the extent of the amount
|
0012| of payments by the health plan; and
|
0013| (3) shall be effective as to the rights of any
|
0014| other beneficiaries whose rights can legally be assigned by the
|
0015| beneficiary.
|
0016| Section 34. PRIVATE HEALTH INSURANCE COVERAGE LIMITED.--
|
0017| A. After the health plan is effective, no person shall
|
0018| provide private health insurance to a beneficiary for a health
|
0019| care service that is covered by the health plan except for retiree
|
0020| health insurance plans that do not enter into contracts with the
|
0021| health plan.
|
0022| B. Nothing in this section shall be construed to affect
|
0023| insurance coverage pursuant to the federal Employee Retirement
|
0024| Income Security Act of 1974 unless the state obtains a
|
0025| congressional exemption or a waiver from the federal government.
|
0001| Businesses that are covered by the provisions of that act may
|
0002| elect to participate in the health plan.
|
0003| Section 35. FEDERAL HEALTH INSURANCE PROGRAM WAIVERS--
|
0004| REIMBURSEMENT TO HEALTH PLAN FROM FEDERAL AND OTHER HEALTH
|
0005| INSURANCE PROGRAMS.--
|
0006| A. The commission, in conjunction with the human
|
0007| services department, shall:
|
0008| (1) apply to the United States department of health
|
0009| and human services for all waivers of requirements under health
|
0010| care programs established pursuant to the federal Social Security
|
0011| Act, as amended, that are necessary to enable the state to deposit
|
0012| federal payments for services covered by the health plan into the
|
0013| plan's fund and to be the supplemental payer of benefits for
|
0014| persons receiving medicare benefits;
|
0015| (2) identify other federal programs that provide
|
0016| federal funds for payment of health care services to individuals
|
0017| and apply for any waivers or enter into any agreements that are
|
0018| necessary to enable the state to deposit federal payments for
|
0019| health care services covered by the health plan into the plan's
|
0020| fund; provided, however, agreements negotiated with the Indian
|
0021| health service shall not impair treaty obligations of the United
|
0022| States government and other agreements negotiated shall not impair
|
0023| portability or other aspects of the health care coverage; and
|
0024| (3) seek an amendment to the federal Employee
|
0025| Retirement Income Security Act of 1974 to exempt New Mexico from
|
0001| the provisions of that act that relate to health care services or
|
0002| health insurance, or the commission shall apply to the appropriate
|
0003| federal agency for waivers of any requirements of that act if
|
0004| congress provides for waivers to enable the commission to extend
|
0005| coverage through the Health Care Act to as many New Mexicans as
|
0006| possible.
|
0007| B. The commission shall seek payment to the health plan
|
0008| from medicaid, medicare or any other federal or other insurance
|
0009| program for any reimbursable payment provided under the plan.
|
0010| C. The commission shall seek to maximize federal
|
0011| contributions and payments for health care services provided in
|
0012| New Mexico and shall ensure that the contributions of the federal
|
0013| government for health care services in New Mexico will not
|
0014| decrease in relation to other states as a result of any waivers,
|
0015| exemptions or agreements.
|
0016| Section 36. INSURANCE--COMMISSION APPROVAL.--No person shall
|
0017| insure himself or his employees after July 1, 1999 unless the
|
0018| coverage terminates on the date that the insureds are eligible for
|
0019| coverage under the health plan. Nothing in this section prohibits
|
0020| insurance coverage for health care services not covered by the
|
0021| health plan or for individuals not eligible for coverage under the
|
0022| health plan.
|
0023| Section 37. INSURANCE RATES--COMMISSION AND SUPERINTENDENT
|
0024| OF INSURANCE DUTIES.--
|
0025| A. The commission shall work closely with the
|
0001| superintendent of insurance to identify health care cost savings
|
0002| that have been achieved as a result of implementation of the
|
0003| health plan. The commission and the superintendent shall identify
|
0004| savings by insurance companies on payments made for medical
|
0005| services through motor vehicle liability insurance, homeowners'
|
0006| insurance, workers' compensation insurance or other insurance
|
0007| policies that have a medical payment component. The commission
|
0008| and the superintendent shall report their findings to the
|
0009| legislature.
|
0010| B. The superintendent shall lower insurance premiums
|
0011| associated with medical benefits on all types of insurance
|
0012| policies written in New Mexico that have a medical payment
|
0013| component as soon as data indicate health care savings have been
|
0014| achieved as a result of operation of the health plan.
|
0015| Section 38. FINANCING THE HEALTH PLAN.--
|
0016| A. The legislative finance committee, in cooperation
|
0017| with the New Mexico health policy commission, shall determine
|
0018| financing options for the health plan. In making its
|
0019| determinations the committee shall be guided by the following
|
0020| requirements and assumptions:
|
0021| (1) the health plan budget shall be no greater than
|
0022| the health care expenditures projected for the 1998 calendar year
|
0023| would have been had the health plan been in effect;
|
0024| (2) benefits to be costed in determining the
|
0025| financing options shall be equivalent to basic health care
|
0001| coverage afforded state employees; and
|
0002| (3) options shall set minimum and maximum levels of
|
0003| premium payments and employer contributions and include a system
|
0004| for reasonable co-payments except for preventive care and for
|
0005| those beneficiaries at or below one hundred percent of the poverty
|
0006| level.
|
0007| B. The legislative finance committee shall prepare a
|
0008| report of its determinations with the specific options and
|
0009| recommendations no later than December 15, 1997. The report shall
|
0010| be submitted for consideration for legislative implementation to
|
0011| the second session of the forty-third legislature.
|
0012| Section 39. TEMPORARY PROVISION--TRANSITION PERIOD
|
0013| ARRANGEMENTS--PUBLICLY FUNDED HEALTH CARE SERVICE PLANS.--
|
0014| A. A person who, on the date benefits are available
|
0015| under the Health Care Act health plan, receives health care
|
0016| benefits under private contract or collective bargaining agreement
|
0017| entered into prior to July 1, 1999 shall continue to receive those
|
0018| benefits until the contract or agreement expires or unless the
|
0019| contract or agreement is renegotiated to provide participation in
|
0020| the health plan.
|
0021| B. A person covered by a health care services plan that
|
0022| has its premiums paid for in any part by public money, including
|
0023| money from the state, a political subdivision, state educational
|
0024| institution, public school or other entity that receives public
|
0025| money to pay health insurance premiums, shall be covered by the
|
0001| Health Care Act health plan on the effective date that benefits
|
0002| are available under the plan.
|
0003| Section 40. EFFECTIVE DATE.--The effective date of the
|
0004| provisions of this act is July 1, 1997.
|
0005|
|