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AN ACT

RELATING TO INSURANCE; INCLUDING PHARMACISTS AND PHARMACIST

CLINICIANS AS PROVIDERS OF SERVICE.

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

Section 1. Section 59A-46-2 NMSA 1978 (being Laws 1993,

Chapter 266, Section 2) is amended to read:

"59A-46-2. DEFINITIONS.--As used in the Health

Maintenance Organization Law:

A. "basic health care services":

(1) means medically necessary services

consisting of preventive care, emergency care, inpatient and

outpatient hospital and physician care, diagnostic laboratory,

diagnostic and therapeutic radiological services and services

of pharmacists and pharmacist clinicians; but

(2) does not include mental health services

or services for alcohol or drug abuse, dental or vision

services or long-term rehabilitation treatment;

B. "capitated basis" means fixed per member per

month payment or percentage of premium payment wherein the

provider assumes the full risk for the cost of contracted

services without regard to the type, value or frequency of

services provided and includes the cost associated with

operating staff model facilities;

C. "carrier" means a health maintenance

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organization, an insurer, a nonprofit health care plan or

other entity responsible for the payment of benefits or

provision of services under a group contract;

D. "copayment" means an amount an enrollee must

pay in order to receive a specific service that is not fully

prepaid;

E. "deductible" means the amount an enrollee is

responsible to pay out-of-pocket before the health maintenance

organization begins to pay the costs associated with

treatment;

F. "enrollee" means an individual who is covered

by a health maintenance organization;

G. "evidence of coverage" means a policy, contract

or certificate showing the essential features and services of

the health maintenance organization coverage that is given to

the subscriber by the health maintenance organization or by

the group contract holder;

H. "extension of benefits" means the continuation

of coverage under a particular benefit provided under a

contract or group contract following termination with respect

to an enrollee who is totally disabled on the date of

termination;

I. "grievance" means a written complaint submitted

in accordance with the health maintenance organization's

formal grievance procedure by or on behalf of the enrollee

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regarding any aspect of the health maintenance organization

relative to the enrollee;

J. "group contract" means a contract for health

care services that by its terms limits eligibility to members

of a specified group and may include coverage for dependents;

K. "group contract holder" means the person to

whom a group contract has been issued;

L. "health care services" means any services

included in the furnishing to any individual of medical,

mental, dental, pharmaceutical or optometric care or

hospitalization or nursing home care or incident to the

furnishing of such care or hospitalization, as well as the

furnishing to any person of any and all other services for the

purpose of preventing, alleviating, curing or healing human

physical or mental illness or injury;

M. "health maintenance organization" means any

person who undertakes to provide or arrange for the delivery

of basic health care services to enrollees on a prepaid basis,

except for enrollee responsibility for copayments or

deductibles;

N. "health maintenance organization agent" means a

person who solicits, negotiates, effects, procures, delivers,

renews or continues a policy or contract for health

maintenance organization membership or who takes or transmits

a membership fee or premium for such a policy or contract,

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other than for himself, or a person who advertises or

otherwise holds himself out to the public as such;

O. "individual contract" means a contract for

health care services issued to and covering an individual and

it may include dependents of the subscriber;

P. "insolvent" or "insolvency" means that the

organization has been declared insolvent and placed under an

order of liquidation by a court of competent jurisdiction;

Q. "managed hospital payment basis" means

agreements in which the financial risk is related primarily to

the degree of utilization rather than to the cost of services;

R. "net worth" means the excess of total admitted

assets over total liabilities, but the liabilities shall not

include fully subordinated debt;

S. "participating provider" means a provider as

defined in Subsection U of this section who, under an express

contract with the health maintenance organization or with its

contractor or subcontractor, has agreed to provide health care

services to enrollees with an expectation of receiving

payment, other than copayment or deductible, directly or

indirectly from the health maintenance organization;

T. "person" means an individual or other legal

entity;

U. "provider" means a physician, pharmacist,

pharmacist clinician, hospital or other person licensed or

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otherwise authorized to furnish health care services;

V. "replacement coverage" means the benefits

provided by a succeeding carrier;

W. "subscriber" means an individual whose

employment or other status, except family dependency, is the

basis for eligibility for enrollment in the health maintenance

organization or, in the case of an individual contract, the

person in whose name the contract is issued;

X. "uncovered expenditures" means the costs to the

health maintenance organization for health care services that

are the obligation of the health maintenance organization, for

which an enrollee may also be liable in the event of the

health maintenance organization's insolvency and for which no

alternative arrangements have been made that are acceptable to

the superintendent;

Y. "pharmacist" means a person licensed as a

pharmacist pursuant to the Pharmacy Act; and

Z. "pharmacist clinician" means a pharmacist who

exercises prescriptive authority pursuant to the Pharmacist

Prescriptive Authority Act."

Section 2. Section 59A-47-3 NMSA 1978 (being Laws 1984,

Chapter 127, Section 879.1, as amended) is amended to read:

"59A-47-3. DEFINITIONS.--As used in Chapter 59A,

Article 47 NMSA 1978:

A. "health care" means the treatment of persons

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for the prevention, cure or correction of any illness or

physical or mental condition, including optometric services;

B. "item of health care" includes any services or

materials used in health care;

C. "health care expense payment" means a payment

for health care to a purveyor on behalf of a subscriber, or

such a payment to the subscriber;

D. "purveyor" means a person who furnishes any

item of health care and charges for that item;

E. "service benefit" means a payment that the

purveyor has agreed to accept as payment in full for health

care furnished the subscriber;

F. "indemnity benefit" means a payment that the

purveyor has not agreed to accept as payment in full for

health care furnished the subscriber;

G. "subscriber" means any individual who, because

of a contract with a health care plan entered into by or for

the individual, is entitled to have health care expense

payments made on the individual's behalf or to the individual

by the health care plan;

H. "underwriting manual" means the health care

plan's written criteria, approved by the superintendent, that

defines the terms and conditions under which subscribers may

be selected. The underwriting manual may be amended from time

to time, but amendment will not be effective until approved by

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the superintendent. The superintendent shall notify the

health care plan filing the underwriting manual or the

amendment thereto of the superintendent's approval or

disapproval thereof in writing within thirty days after filing

or within sixty days after filing if the superintendent shall

so extend the time. If the superintendent fails to act within

such period, the filing shall be deemed to be approved;

I. "acquisition expenses" includes all expenses

incurred in connection with the solicitation and enrollment of

subscribers;

J. "administration expenses" means all expenses of

the health care plan other than the cost of health care

expense payments and acquisition expenses;

K. "health care plan" means a nonprofit

corporation authorized by the superintendent to enter into

contracts with subscribers and to make health care expense

payments;

L. "agent" means a person appointed by a health

care plan authorized to transact business in this state to act

as its representative in any given locality for soliciting

health care policies and other related duties as may be

authorized;

M. "solicitor" means a person employed by the

licensed agent of a health care plan for the purpose of

soliciting health care policies and other related duties in

connection with the handling of the business of the agent as

may be authorized and paid for the person's services either on

a commission basis or salary basis or part by commission and

part by salary;

N. "chiropractor" means any person holding a

license provided for in the Chiropractic Physician Practice

Act;

O. "doctor of oriental medicine" means any person

licensed as a doctor of oriental medicine under the

Acupuncture and Oriental Medicine Practice Act;

P. "pharmacist" means a person licensed as a

pharmacist pursuant to the Pharmacy Act; and

Q. "pharmacist clinician" means a pharmacist who

exercises prescriptive authority pursuant to the Pharmacist

Prescriptive Authority Act."

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