46th legislature - STATE OF NEW MEXICO - first session, 2003

RELATING TO HEALTH INSURANCE; ENACTING THE RURAL HEALTH CARE PROVIDER ACCESS ACT; PROVIDING CRIMINAL AND CIVIL PENALTIES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

Section 1. A new section of the New Mexico Insurance Code is enacted to read:

"[NEW MATERIAL] SHORT TITLE.--This act may be cited as the

"Rural Health Care Provider Access Act"."

Section 2. A new section of the New Mexico Insurance code is enacted to read:

"[NEW MATERIAL] DEFINITIONS.--As used in the Rural Health Care Provider Access Act:

A. "health care facility" means an institution located outside the boundaries of a class A county that provides health care services, and includes a hospital or other licensed inpatient center, an ambulatory surgical or treatment center, a skilled nursing center, a residential treatment center, a home health agency, a diagnostic, laboratory or imaging center and a rehabilitation or other therapeutic health setting;

B. "health care insurer" means a person that has a valid certificate of authority in good standing pursuant to the Insurance Code to act as an insurer, health maintenance organization, nonprofit health care plan or prepaid dental plan;

C. "health care professional" means a physician, pharmacist or other health care practitioner:

(1) who is licensed, certified or otherwise authorized by the state to provide health care services or medical equipment consistent with state law; and

(2) whose principal practice is located outside the boundaries of a class A county;

D. "health care provider" means a health care professional, health care facility or supplier of medical equipment;

E. "health care services" includes physical health services or community-based mental health or developmental disability services;

F. "medical equipment" mean any device, item or supply furnished to a patient, whether on a rental or purchase basis, that has been prescribed by a health care provider for use in a patient's home or long-term care setting to meet the patient's medical and physical needs in connection with a medical condition; and

G. "provider service network" means two or more health care providers affiliated for the purpose of providing health care services to enrollees on a capitated or similar prepaid flat-rate basis."

Section 3. A new section of the New Mexico Insurance Code is enacted to read:

"[NEW MATERIAL] RURAL HEALTH CARE PROVIDER RULE.--A health care insurer or provider service network shall not:

A. deny a health care provider the right to participate as a provider under a policy, plan or certificate, if the type of services or medical equipment offered by the health care provider are covered, under the same terms and conditions of the policy, plan or certificate as those offered to any other health care provider;

B. prevent a person who is a party to or a member of a policy, plan or certificate from choosing a health care provider to furnish the health care services or medical equipment offered under the policy, plan or certificate under the same terms and conditions of the policy, plan or certificate as those offered to any other health care provider; or

C. permit or mandate any difference in coverage or impose any different conditions or disincentives that would cause a party to or a member of a policy, plan or certificate to choose one health care provider over another for health care services or medical equipment that are covered under the policy, plan or certificate."

Section 4. A new section of the New Mexico Insurance Code is enacted to read:

"[NEW MATERIAL] CRIMINAL PENALTY AND ENFORCEMENT.-- A. A health care insurer or provider service network that violates the provisions of the Rural Health Care Provider Access Act is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) and not more than one thousand dollars ($1,000).

B. Each violation of the provisions of the Rural Health Care Provider Access Act, as to each health care provider and each refusal to comply, constitutes a separate and distinct offense."

Section 5. A new section of the New Mexico Insurance Code is enacted to read:

"[NEW MATERIAL] PRIVATE CIVIL ENFORCEMENT.--

A. A person who suffers a loss as a result of a violation of a provision in the Rural Health Care Provider Access Act may bring an action to recover actual damages or the sum of one hundred dollars ($100), whichever is greater. When the trier of fact finds that the party charged with the violation acted willfully, the court may award up to three times actual damages or three hundred dollars ($300), whichever is greater, to the party complaining of the violation.

B. A person likely to be injured by a violation of the Rural Health Care Provider Access Act may seek and be granted an injunction on terms that the court considers reasonable. Proof of monetary damage or intent to violate a right is not required.

C. The court shall award attorney fees and costs to the party complaining of a violation of the Rural Health Care Provider Access Act if the party prevails substantially in the lawsuit.

D. The relief provided in this section is in addition to other remedies available against the same conduct under the common law or other statutes of this state. E. In a class action filed pursuant to this section, the court may award damages to the named plaintiffs as provided in this section and may award members of the class the actual damages suffered by each member of the class as a result of the unlawful practice."

Section 6. EFFECTIVE DATE.--The effective date of the provisions of this act is July 1, 2003.