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

RELATING TO HEALTH INSURANCE; ENACTING THE RURAL HEALTH CARE PROVIDER ACCESS ACT.

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

B. "health care provider" means a person licensed pursuant to:

(1) Section 61-3-23.2 NMSA 1978;

(2) the Dental Health Care Act;

(3) the Medical Practice Act; and

(4) Chapter 61, Article 10 NMSA 1978;

C. "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; and

D. "rural area" means a class B or class C county but does not include the area of a class B county within fifteen miles of a municipality having a population in excess of three hundred thousand."

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

"[NEW MATERIAL] RURAL HEALTH CARE PROVIDER PARTICIPATION.--

A. Except as provided in Subsections B and C of this section, a health care insurer or provider service network shall not deny a health care provider who provides services in a rural area the right to participate as a provider of services in that area under a policy, plan or certificate, under the same credentialing criteria and contractual terms and conditions as other similar providers, if the type of services offered by the health care provider is covered under the policy, plan or certificate.

B. A health care insurer may refuse to allow a health care provider the right to participate as a provider pursuant to a policy, plan or certificate if:

(1) the health care provider does not meet the credentialing criteria or is unwilling to accept the same contractual terms and conditions as other similar providers; or

(2) the health care insurer has a provider network that provides reasonable access to insured individuals, members or enrollees without contracting with the additional health care provider and the health care insurer is not acting unreasonably or arbitrarily to avoid a contract with the health care provider.

C. If a health care provider believes that a health care insurer has refused to contract with the health care provider in violation of the Rural Health Care Provider Access Act, the health care provider may file a complaint with the superintendent. If the superintendent finds that there is reasonable cause to believe that the health care insurer has refused to contract with the health care provider in violation of the Rural Health Care Provider Access Act, the superintendent shall hold a hearing and shall enter an order as he deems necessary."

Section 4. EFFECTIVE DATE.--The effective date of the provisions of this act is January 1, 2004.