0001|                            HOUSE BILL 350
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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|                          EDWARD C. SANDOVAL
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0005|                                   
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0006|     
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0007|            FOR THE HEALTH CARE REFORM COMMITTEE
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0008|             AND THE HEALTH AND HUMAN SERVICES COMMITTEE
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0009|     
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0010|                                AN ACT
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0011|     RELATING TO INSURANCE; ENACTING THE PATIENT PROTECTION ACT;
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0012|     PROVIDING PROTECTIONS FOR PERSONS IN MANAGED HEALTH CARE PLANS; 
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0013|     APPLYING PATIENT PROTECTIONS TO MEDICAID MANAGED CARE; IMPOSING
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0014|     A CIVIL PENALTY; AMENDING AND ENACTING SECTIONS OF THE NMSA
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0015|     1978; MAKING AN APPROPRIATION.
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0016|     
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0017|     BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0018|          Section 1.  A new section of the New Mexico Insurance Code
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0019|     is enacted to read:  
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0020|          "[<u>NEW MATERIAL</u>]  SHORT TITLE.--Sections 1 through 11 of
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0021|     this act may be cited as the "Patient Protection Act"."
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0022|          Section 2.  A new section of the New Mexico Insurance Code
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0023|     is enacted to read:
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0024|          "[<u>NEW MATERIAL</u>]  PURPOSE OF ACT.--The purpose of the
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0025|     Patient Protection Act is to regulate aspects of health
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0001|     insurance by specifying patient and provider rights and
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0002|     confirming and clarifying the authority of the department to
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0003|     adopt regulations to provide protections to persons enrolled in
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0004|     managed health care plans.  The insurance protections should
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0005|     ensure that managed health care plans treat patients fairly and
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0006|     fulfill their primary obligation to deliver good quality health
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0007|     care services."     
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0008|          Section 3.  A new section of the New Mexico Insurance Code
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0009|     is enacted to read:
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0010|          "[<u>NEW MATERIAL</u>]  DEFINITIONS.--As used in the Patient
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0011|     Protection Act:
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0012|               A.  "continuous quality improvement" means an
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0013|     ongoing and systematic effort to measure, evaluate and improve
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0014|     a managed health care plan's operations in order to improve
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0015|     continually the quality of health care services provided to
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0016|     enrollees; 
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0017|               B.  "covered person", "enrollee", "patient" or
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0018|     "consumer" means an individual who is entitled to receive
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0019|     health care benefits from a managed health care plan; 
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0020|               C.  "department" means the insurance department;
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0021|               D.  "emergency care" means a health care procedure,
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0022|     treatment or service delivered to a covered person after the
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0023|     sudden onset of what appears to be a medical condition that
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0024|     manifests itself by symptoms of sufficient severity that the
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0025|     absence of immediate medical attention could be expected by a
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0001|     reasonable layperson to result in jeopardy to a person's
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0002|     health, serious impairment of bodily functions, serious
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0003|     dysfunction of a body part or disfigurement to a person;
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0004|               E.  "health care facility" means an institution
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0005|     providing health care services, including a hospital or other
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0006|     licensed inpatient center; an ambulatory surgical or treatment
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0007|     center; a skilled nursing center; a residential treatment
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0008|     center; a home health agency; a diagnostic, laboratory or
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0009|     imaging center; and a rehabilitation or other therapeutic
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0010|     health setting;
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0011|               F.  "health care insurer" means a person that has a
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0012|     valid certificate of authority in good standing under the New
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0013|     Mexico Insurance Code to act as an insurer, health maintenance
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0014|     organization, nonprofit health care plan or prepaid dental
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0015|     plan;
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0016|               G.  "health care professional" means a physician or
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0017|     other health care practitioner, including a pharmacist, who is
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0018|     licensed, certified or otherwise authorized by the state to
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0019|     provide health care services consistent with state law; 
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0020|               H.  "health care provider" or "provider" means a
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0021|     person that is licensed or otherwise authorized by the state to
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0022|     furnish health care services and includes health care
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0023|     professionals and health care facilities; 
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0024|               I.  "health care services" includes physical health
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0025|     or community-based mental health or developmental disability
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0001|     services, including services for developmental delay;
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0002|               J.  "managed health care plan" or "plan" means a
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0003|     health benefit plan of a health care insurer or a provider
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0004|     service network that either requires a covered person to use,
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0005|     or creates incentives, including financial incentives, for a
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0006|     covered person to use health care providers managed, owned,
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0007|     under contract with or employed by the health care insurer.  A
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0008|     managed health care plan includes a plan that provides health
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0009|     care services to enrollees on a prepaid, capitated basis and
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0010|     includes the health care services offered by a health
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0011|     maintenance organization, preferred provider organization,
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0012|     individual practice organization, a competitive medical plan,
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0013|     an exclusive provider organization, an integrated delivery
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0014|     system, an independent physician-provider organization, a
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0015|     physician hospital-provider organization or a managed care
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0016|     services organization.  "Managed health care plan" or "plan"
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0017|     does not include a traditional fee-for-service indemnity plan
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0018|     or a plan that covers only short-term travel, accident-only,
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0019|     limited benefit or specified disease policies;
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0020|               K.  "person" means an individual or other legal
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0021|     entity;
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0022|               L.  "point-of-service plan" or "open plan" means a
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0023|     managed health care plan that allows enrollees to use health
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0024|     care providers other than providers under direct contract with
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0025|     the plan, even if the plan provides incentives, including
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0001|     financial incentives, for covered persons to use the plan's
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0002|     designated participating providers; 
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0003|               M.  "primary health care clinic" means a nonprofit
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0004|     community-based entity established to provide the first level
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0005|     of basic or general health care needs, including diagnostic and
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0006|     treatment services, for residents of a health care underserved
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0007|     area as that area is defined in regulation adopted by the
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0008|     department of health and includes an entity that serves
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0009|     primarily low-income populations; 
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0010|               N.  "provider service network" means two or more
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0011|     health care providers affiliated for the purpose of providing
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0012|     health care services to covered persons on a capitated or
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0013|     similar prepaid flat-rate basis;
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0014|               O.  "superintendent" means the superintendent of
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0015|     insurance; and
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0016|               P.  "utilization review" means a system for
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0017|     reviewing the appropriate and efficient allocation of health
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0018|     care services, including hospitalization, given or proposed to
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0019|     be given to a patient or group of patients." 
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0020|          Section 4.  A new section of the New Mexico Insurance Code
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0021|     is enacted to read:
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0022|          "[<u>NEW MATERIAL</u>]  PATIENT RIGHTS--DISCLOSURES--RIGHTS TO
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0023|     BASIC AND COMPREHENSIVE HEALTH CARE SERVICES--GRIEVANCE
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0024|     PROCEDURE--UTILIZATION REVIEW PROGRAM--CONTINUOUS QUALITY
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0025|     PROGRAM.--
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0001|               A.  Each covered person enrolled in a managed health
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0002|     care plan has the right to be treated fairly.  A managed health
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0003|     care plan shall deliver good quality and appropriate health
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0004|     care services to enrollees.  The department shall adopt
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0005|     regulations to implement the provisions of the Patient
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0006|     Protection Act and shall monitor and oversee a managed health
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0007|     care plan to ensure that each covered person enrolled in a plan
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0008|     is treated fairly and is accorded the rights necessary or
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0009|     appropriate to protect patient interests.  In adopting
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0010|     regulations to implement the provisions of Subparagraphs (a)
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0011|     and (b) of Paragraph (3) and Paragraphs (5) and (6) of
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0012|     Subsection B of this section regarding health care standards
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0013|     and specialists, utilization review programs and continuous
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0014|     quality improvement programs, the department shall cooperate
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0015|     with and seek advice from the department of health. 
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0016|               B.  The regulations adopted by the department to
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0017|     protect patient rights shall provide at a minimum that:
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0018|                    (1)  a managed health care plan shall provide
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0019|     oral and written summaries, policies and procedures that
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0020|     explain, prior to or at the time of enrollment and at
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0021|     subsequent periodic times as appropriate, in a clear,
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0022|     conspicuous and readily understandable form, full and fair
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0023|     disclosure of the plan's benefits, terms, conditions, prior
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0024|     authorization requirements, enrollee financial responsibility
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0025|     for payments,   grievance procedures, appeal rights and the
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0001|     patient rights generally available to all covered persons; 
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0002|                    (2)  a managed health care plan shall provide
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0003|     each covered person with appropriate basic and comprehensive
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0004|     health care services that are reasonably accessible and
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0005|     available in a timely manner to each covered person; 
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0006|                    (3)  in providing the right to reasonably
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0007|     accessible health care services that are available in a timely
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0008|     manner, a managed health care plan shall ensure that:
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0009|                         (a)  the plan offers sufficient numbers
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0010|     and types of safe and adequately staffed health care providers
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0011|     at reasonable hours of service to meet the health needs of the
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0012|     enrollee population, including providers that are culturally
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0013|     appropriate for the enrollee population; 
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0014|                         (b)  health care providers that are
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0015|     specialists may act as primary care providers for patients with
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0016|     special health needs; 
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0017|                         (c)  reasonable access is provided to 
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0018|     out-of-network health care providers; and 
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0019|                         (d)  emergency care is immediately
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0020|     available without prior authorization requirements, and
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0021|     appropriate out-of-network emergency care is not subject to
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0022|     additional costs; 
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0023|                    (4)  a managed health care plan shall adopt and
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0024|     implement a prompt and fair grievance procedure for resolving 
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0025|     patient complaints and addressing patient questions and
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0001|     concerns regarding any aspect of the plan, including the
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0002|     quality of and access to health care, the choice of health care
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0003|     provider or treatment and the adequacy of the plan's provider
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0004|     network.  The grievance procedures shall notify patients of
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0005|     their statutory appeal rights, including the option of seeking
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0006|     immediate relief in court, and shall provide for a prompt and
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0007|     fair appeal of a plan's decision to the superintendent,
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0008|     including special provisions to govern emergency appeals to the
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0009|     superintendent in health emergencies;
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0010|                    (5)  a managed health care plan shall adopt and
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0011|     implement a comprehensive utilization review program.  The
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0012|     procedures and standards used in a plan's utilization review
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0013|     program to approve or deny care shall be disclosed to an
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0014|     affected enrollee.  The decision to approve or deny care to a
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0015|     patient shall be made in a timely manner, and the final
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0016|     decision shall be made by a qualified health care professional. 
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0017|     A plan's utilization review program shall ensure that enrollees
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0018|     have proper access to health care services, including referrals
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0019|     to necessary specialists.  A decision made in a plan's
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0020|     utilization review program shall be subject to the plan's
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0021|     grievance procedure and appeal to the superintendent; and 
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0022|                    (6)  a managed health care plan shall adopt and
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0023|     implement a continuous quality improvement program that
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0024|     monitors the quality and appropriateness of the health care
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0025|     services provided by the plan." 
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0001|          Section 5.  A new section of the New Mexico Insurance Code
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0002|     is enacted to read:
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0003|          "[<u>NEW MATERIAL</u>]  CONSUMER ASSISTANCE--CONSUMER ADVISORY
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0004|     BOARDS--OMBUDSMAN OFFICE--REPORTS TO CONSUMERS--
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0005|     SUPERINTENDENT'S ORDERS TO PROTECT CONSUMERS.-- 
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0006|               A.  Each health care insurer that offers a managed
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0007|     health care plan shall establish and adequately staff a
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0008|     consumer assistance office.  The purpose of the consumer
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0009|     assistance office is to respond to consumer questions and
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0010|     concerns and assist patients in exercising their rights and
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0011|     protecting their interests as consumers of health care.  
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0012|               B.  Each health care insurer that offers a managed
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0013|     health care plan shall establish a consumer advisory board. 
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0014|     The board shall meet at least quarterly and shall advise the
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0015|     insurer about the plan's general operations from the
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0016|     perspective of the enrollee as a consumer of health care.  The
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0017|     board shall also oversee the plan's consumer assistance office. 
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0018|               C.  The department shall establish and adequately
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0019|     staff a managed care ombudsman office.  The purpose of the 
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0020|     managed care ombudsman office shall be to assist patients in
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0021|     exercising their rights and help advocate for and protect
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0022|     patient interests.  The department's managed care ombudsman
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0023|     office shall work in conjunction with each insurer's consumer
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0024|     assistance office and shall independently evaluate the
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0025|     effectiveness of the insurer's consumer assistance office.  The
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0001|     department's managed care ombudsman office may require an
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0002|     insurer's consumer assistance office to adopt measures to
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0003|     ensure that the plan operates effectively to protect patient
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0004|     rights and inform consumers of the information to which they
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0005|     are entitled. 
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0006|               D.  The department shall prepare an annual report
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0007|     assessing the operations of managed health care plans subject
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0008|     to the department's oversight, including information about
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0009|     consumer complaints.
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0010|               E.  A person may file a complaint with the
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0011|     superintendent regarding a violation of the Patient Protection
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0012|     Act.  Prior to issuing any remedial order regarding violations
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0013|     of the Patient Protection Act or its regulations, the
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0014|     superintendent shall hold a hearing in accordance with the
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0015|     provisions of Chapter 59A, Article 4 NMSA 1978.  The
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0016|     superintendent may issue any order he deems necessary or
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0017|     appropriate, including ordering the delivery of appropriate
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0018|     care, to protect consumers and enforce the provisions of the
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0019|     Patient Protection Act.  The superintendent shall adopt special
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0020|     procedures to govern the submission of emergency appeals to him
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0021|     in health emergencies."
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0022|          Section 6.  A new section of the New Mexico Insurance Code
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0023|     is enacted to read:
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0024|          "[<u>NEW MATERIAL</u>]  FAIRNESS TO HEALTH CARE PROVIDERS--GAG
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0025|     RULES PROHIBITED--GRIEVANCE PROCEDURE FOR PROVIDERS.--
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0001|               A.  No managed health care plan may:
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0002|                    (1)  adopt a gag rule or practice that
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0003|     prohibits a health care provider from discussing a treatment
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0004|     option with an enrollee even if the plan does not approve of
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0005|     the option; 
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0006|                    (2)  offer a health care provider inducements,
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0007|     other than those inherent in a capitation payment system, to
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0008|     reduce or limit medically necessary health care services; or
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0009|                    (3)  require a health care provider to violate
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0010|     the ethical duties of his profession or place his license in
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0011|     jeopardy.
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0012|               B.  A health care insurer that proposes to terminate
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0013|     a health care provider from the insurer's managed health care
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0014|     plan shall explain in writing the rationale for its proposed
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0015|     termination and deliver reasonable advance written notice to
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0016|     the provider prior to the proposed effective date of the
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0017|     termination.  
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0018|               C.  A managed health care plan shall adopt and
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0019|     implement a prompt and fair grievance procedure for resolving
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0020|     health care provider complaints and addressing provider
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0021|     questions and concerns regarding any aspect of the plan,
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0022|     including the quality of and access to health care, the choice
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0023|     of health care provider or treatment and the adequacy of the
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0024|     plan's provider network.  The grievance procedures shall notify
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0025|     providers of their statutory appeal rights, including the
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0001|     option of seeking immediate relief in court, and shall provide
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0002|     for a prompt and fair appeal of a plan's decision to the
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0003|     superintendent, including special provisions to govern
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0004|     emergency appeals to the superintendent in health emergencies." 
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0005|          Section 7.  A new section of the New Mexico Insurance Code
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0006|     is enacted to read:
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0007|          "[<u>NEW MATERIAL</u>]  POINT-OF-SERVICE OPTION PLAN.--The
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0008|     department may require a health care insurer that offers a
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0009|     managed health care plan to include a point-of-service or open
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0010|     plan option."
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0011|          Section 8.  A new section of the New Mexico Insurance Code
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0012|     is enacted to read:
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0013|          "[<u>NEW MATERIAL</u>]  ADMINISTRATIVE COSTS AND BENEFIT COSTS
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0014|     DISCLOSURES.--The department shall adopt regulations to ensure
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0015|     that both the administrative costs and the direct costs of
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0016|     providing health care services of each managed health care plan
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0017|     are fully and fairly disclosed to consumers in a uniform manner
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0018|     that allows meaningful cost comparisons among plans."
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0019|          Section 9.  A new section of the New Mexico Insurance Code
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0020|     is enacted to read:
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0021|          "[<u>NEW MATERIAL</u>]  PRIVATE REMEDIES TO ENFORCE PATIENT AND
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0022|     PROVIDER INSURANCE RIGHTS--ENROLLEE AND PROVIDER AS THIRD-PARTY
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0023|     BENEFICIARIES TO ENFORCE THEIR RIGHTS--EXHAUSTION OF REMEDIES
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0024|     NOT REQUIRED.--
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0025|               A.  A violation of a patient's rights to health care
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0001|     services in the regulation of insurance as protected pursuant
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0002|     to the provisions of the Patient Protection Act shall be deemed
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0003|     an act of professional malpractice.
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0004|               B.  A person who suffers a loss as a result of a
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0005|     violation of a right protected pursuant to the provisions of
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0006|     the Patient Protection Act, its regulations or a managed health
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0007|     care plan may bring an action to recover actual damages or the
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0008|     sum of one hundred dollars ($100), whichever is greater.  When
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0009|     the trier of fact finds that the party charged with the
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0010|     violation acted willfully, the court may award up to three
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0011|     times actual damages or three hundred dollars ($300), whichever
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0012|     is greater, to the party complaining of the violation.
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0013|               C.  A person likely to be damaged by a denial of a
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0014|     right protected pursuant to the provisions of the Patient
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0015|     Protection Act, its regulations or a managed health care plan
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0016|     may be granted an injunction under the principles of equity and
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0017|     on terms that the court considers reasonable.  Proof of
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0018|     monetary damage or intent to violate a right is not required.
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0019|               D.  To protect and enforce an enrollee's or a health
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0020|     care provider's rights in a managed health care plan, an
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0021|     individual enrollee and a health care provider participating in
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0022|     or eligible to participate in a managed health care plan shall
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0023|     each be treated as a third-party beneficiary of the managed
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0024|     health care plan contract between the health care insurer and
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0025|     the party with which the health care insurer directly
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0001|     contracts.  An individual enrollee or a health care provider
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0002|     may sue to enforce the rights provided in the contract that
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0003|     governs the managed health care plan. 
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0004|               E.  The court shall award attorney fees and costs to
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0005|     the party complaining of a violation of a right protected
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0006|     pursuant to the provisions of the Patient Protection Act, its
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0007|     regulations or a managed health care plan if the party
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0008|     substantially prevails in the lawsuit.
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0009|               F.  The relief provided pursuant to this section is
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0010|     in addition to other remedies available against the same
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0011|     conduct under the common law or other statutes of this state. 
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0012|               
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0013|               G.  In any class action filed pursuant to this
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0014|     section, the court may award damages to the named plaintiffs as
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0015|     provided in this section and may award members of the class the
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0016|     actual damages suffered by each member of the class as a result
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0017|     of the unlawful practice.
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0018|               H.  A person shall not be required to complete
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0019|     available grievance procedures or exhaust administrative
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0020|     remedies prior to seeking relief in court regarding a complaint
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0021|     that may be filed under this section."
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0022|          Section 10.  A new section of the New Mexico Insurance
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0023|     Code is enacted to read:
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0024|          "[<u>NEW MATERIAL</u>]  APPLICATION OF ACT TO MEDICAID
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0025|     PROGRAM.--The provisions of the Patient Protection Act apply to
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0001|     the medicaid program operation in the state.  A managed health
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0002|     care plan offered through the medicaid program shall grant
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0003|     enrollees and providers the same rights and protections as are
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0004|     granted to enrollees and providers in any other managed health
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0005|     care plan subject to the provisions of the Patient Protection
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0006|     Act."
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0007|          Section 11.  A new section of the New Mexico Insurance
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0008|     Code is enacted to read:
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0009|          "[<u>NEW MATERIAL</u>]  PENALTY.--In addition to any other
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0010|     penalties provided by law, a civil administrative penalty of up
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0011|     to twenty-five thousand dollars ($25,000) may be imposed for
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0012|     each violation of the Patient Protection Act.  An
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0013|     administrative penalty shall be imposed by written order of the
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0014|     superintendent made after holding a hearing as provided for in
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0015|     Chapter 59A, Article 4 NMSA 1978."
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0016|          Section 12.  Section 59A-1-16 NMSA 1978 (being Laws 1984,
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0017|     Chapter 127, Section 16) is amended to read:
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0018|          "59A-1-16.  EXEMPTED FROM CODE.--In addition to
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0019|     organizations and businesses otherwise exempt, the Insurance
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0020|     Code shall not apply <s>[as]</s> to:
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0021|               A.  a labor organization <s>[which]</s> <u>that</u>,
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0022|     incidental only to operations as a labor organization, issues
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0023|     benefit certificates to members or maintains funds to assist
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0024|     members and their families in times of illness, injury or need,
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0025|     and not for profit;
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0001|               B.  the credit union share insurance corporation, as
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0002|     identified in <s>[Article 58-12]</s> <u>Chapter 58, Article l2</u> NMSA
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0003|     1978, and similar corporations and funds for protection of
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0004|     depositors, shareholders or creditors of financial institutions
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0005|     and businesses other than insurers; or
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0006|               C.  the risk management division of the <u>general
</u>    |
<u></u>0007| <u>    services</u> department <s>[of finance and administration of New
</s>    |
<s></s>0008| <s>    Mexico]</s> or <s>[as]</s> to insurance of public property or public
    |
0009|     risks by any agency of government not otherwise engaged in the
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0010|     business of insurance, <u>except the provisions of the Patient
</u>    |
<u></u>0011| <u>    Protection Act shall apply to the risk management division and
</u>    |
<u></u>0012| <u>    any managed health care plan it offers</u>."
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0013|          Section 13.  Section 59A-46-30 NMSA 1978 (being Laws 1993,
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0014|     Chapter 266, Section 29) is amended to read:
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0015|          "59A-46-30.  STATUTORY CONSTRUCTION AND RELATIONSHIP TO
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0016|     OTHER LAWS.--
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0017|               A.  The provisions of the Insurance Code other than
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0018|     Chapter 59A, Article 46 NMSA 1978 shall not apply to health
    |
0019|     maintenance organizations except as expressly provided in the
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0020|     Insurance Code and that article.  To the extent reasonable and
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0021|     not inconsistent with the provisions of that article, the
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0022|     following articles and provisions of the Insurance Code shall
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0023|     also apply to health maintenance organizations, their
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0024|     promoters, sponsors, directors, officers, employees, agents,
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0025|     solicitors and other representatives <s>[and]</s>.  For the purposes
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0001|     of such applicability, a health maintenance organization may
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0002|     <s>[therein]</s> be referred to as an "insurer": 
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0003|                    (1)  Chapter 59A, Article 1 NMSA 1978; 
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0004|                    (2)  Chapter 59A, Article 2 NMSA 1978;
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0005|                    (3)  Chapter 59A, Article 3 NMSA 1978;
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0006|                    (4)  Chapter 59A, Article 4 NMSA 1978; 
    |
0007|                    (5)  Subsection C of Section 59A-5-22 NMSA
    |
0008|     1978;
    |
0009|                    (6)  Sections 59A-6-2 through 59A-6-4 and
    |
0010|     59A-6-6 NMSA 1978;
    |
0011|                    (7)  Chapter 59A, Article 8 NMSA 1978; 
    |
0012|                    (8)  Chapter 59A, Article 10 NMSA 1978; 
    |
0013|                    (9)  Section 59A-12-22 NMSA 1978; 
    |
0014|                    (10)  Chapter 59A, Article 16 NMSA 1978;
    |
0015|                    (11)  Chapter 59A, Article 18 NMSA 1978; 
    |
0016|                    (12)  Chapter 59A, Article 19 NMSA 1978; 
    |
0017|                    <u>(13)  Section 59A-22-14 NMSA 1978;</u>
    |
0018|                    <s>[(13)]</s> <u>(14)</u>  Chapter 59A, Article 23B NMSA
    |
0019|     1978;
    |
0020|                    <s>[(14)]</s> <u>(15)</u>  Sections 59A-34-9 through 
    |
0021|     59A-34-13, 59A-34-23, 59A-34-36 and 59A-34-37 NMSA 1978; <s>[and
</s>    |
<s></s>0022| <s>                   (15)]</s> <u>(16)</u>  Chapter 59A, Article 37 NMSA
    |
0023|     1978; <u>and</u>
    |
0024|                    <u>(17)  the Patient Protection Act</u>.     
    |
0025|               B.  Solicitation of enrollees by a health
    |
0001|     maintenance organization granted a certificate of authority, or
    |
0002|     its representatives, shall not be construed as violating any
    |
0003|     provision of law relating to solicitation or advertising by
    |
0004|     health professionals, but health professionals shall be
    |
0005|     individually subject to the laws, rules, regulations and
    |
0006|     ethical provisions governing their individual professions. 
    |
0007|               C.  Any health maintenance organization authorized
    |
0008|     under the provisions of the Health Maintenance Organization Law
    |
0009|     shall not be deemed to be practicing medicine and shall be
    |
0010|     exempt from the provisions of laws relating to the practice of
    |
0011|     medicine."

    |
0012|          Section 14.  Section 59A-47-33 NMSA 1978 (being Laws 1984,
    |
0013|     Chapter 127, Section 879.32, as amended by Laws 1994, Chapter
    |
0014|     64, Section 10 and also by Laws 1994, Chapter 75, Section 34)
    |
0015|     is amended to read:
    |
0016|          "59A-47-33.  OTHER PROVISIONS APPLICABLE.--The provisions
    |
0017|     of the Insurance Code other than Chapter 59A, Article 47 NMSA
    |
0018|     1978 shall not apply to health care plans except as expressly
    |
0019|     provided in the Insurance Code and that article.  To the extent
    |
0020|     reasonable and not inconsistent with the provisions of that
    |
0021|     article, the following articles and provisions of the Insurance
    |
0022|     Code shall also apply to health care plans, their promoters,
    |
0023|     sponsors, directors, officers, employees, agents, solicitors
    |
0024|     and other representatives; and, for the purposes of such
    |
0025|     applicability, a health care plan may <s>[therein]</s> be referred
    |
0001|     to as an "insurer":
    |
0002|               A.  Chapter 59A, Article 1 NMSA 1978;
    |
0003|               B.  Chapter 59A, Article 2 NMSA 1978;
    |
0004|               C.  Chapter 59A, Article 4 NMSA 1978;
    |
0005|               D.  Subsection C of Section 59A-5-22 NMSA 1978;
    |
0006|               E.  Sections 59A-6-2 through 59A-6-4 and 
    |
0007|     59A-6-6 NMSA 1978;
    |
0008|               F.  Section 59A-7-11 NMSA 1978;
    |
0009|               G.  Chapter 59A, Article 8 NMSA 1978;
    |
0010|               H.  Chapter 59A, Article 10 NMSA 1978;
    |
0011|               I.  Section 59A-12-22 NMSA 1978;
    |
0012|               J.  Chapter 59A, Article 16 NMSA 1978;
    |
0013|               K.  Chapter 59A, Article 18 NMSA 1978;
    |
0014|               L.  Chapter 59A, Article 19 NMSA 1978;
    |
0015|               M.  Subsections B through E of Section 
    |
0016|     59A-22-5 NMSA 1978;
    |
0017|               <u>N.  Section 59A-22-14 NMSA 1978</u>;
    |
0018|               <s>[N.]</s> <u>O.</u>  Section 59A-22-34.1 NMSA 1978; 
    |
0019|               <s>[O.]</s> <u>P.</u>  Section 59A-22-39 NMSA 1978;
    |
0020|               <s>[P.]</s> <u>Q.</u>  Section 59A-22-40 NMSA 1978;
    |
0021|               <s>[Q.]</s> <u>R.</u>  Sections 59A-34-9 through 59A-34-13
    |
0022|     <s>[NMSA 1978]</s> and <s>[Section]</s> 59A-34-23 NMSA 1978;
    |
0023|               <s>[R.]</s> <u>S.</u>  Chapter 59A, Article 37 NMSA 1978,
    |
0024|     except Section 59A-37-7 NMSA 1978; <s>[and
</s>    |
<s></s>0025| <s>              S.]</s> <u>T.</u>  Section 59A-46-15 NMSA 1978; <u>and</u>
    |
0001|               <u>U.  the Patient Protection Act</u>."
    |
0002|          Section 15.  APPROPRIATION.--Two hundred four thousand
    |
0003|     nine hundred dollars ($204,900) is appropriated from the
    |
0004|     general fund to the department of insurance for expenditure in
    |
0005|     fiscal year 1998 to pay salaries and benefits and other costs
    |
0006|     necessary to establish a managed care ombudsman office and
    |
0007|     administer the provisions of the Patient Protection Act.  Any
    |
0008|     unexpended or unencumbered balance remaining at the end of
    |
0009|     fiscal year 1998 shall revert to the general fund.
    |
0010|          Section 16.  EFFECTIVE DATE.--The effective date of the
    |
0011|     provisions of this act is July 1, 1997.
    |
0012|                                  
    |
0013|     
    |
0014|     
    |
0015|     
    |
0016|     
    |
0017|     
    |
0018|     
    |
0019|                            State of New Mexico
    |
0020|                      House of Representatives
    |
0021|   
    |
0022|                      FORTY-THIRD LEGISLATURE
    |
0023|                        FIRST SESSION, 1997
    |
0024|   
    |
0025|   
    |
0001|                                               February 18, 1997
    |
0002|   
    |
0003|   
    |
0004|   Mr. Speaker:
    |
0005|   
    |
0006|        Your LABOR AND HUMAN RESOURCES COMMITTEE, to
    |
0007|   whom has been referred
    |
0008|   
    |
0009|                        HOUSE BILL 350
    |
0010|   
    |
0011|   has had it under consideration and reports same with
    |
0012|   recommendation that it DO NOT PASS, but that
    |
0013|   
    |
0014|          HOUSE LABOR AND HUMAN RESOURCES COMMITTEE
    |
0015|                SUBSTITUTE FOR HOUSE BILL 350
    |
0016|   
    |
0017|   DO PASS, and thence referred to the JUDICIARY
    |
0018|   COMMITTEE.
    |
0019|   
    |
0020|                                 Respectfully submitted,
    |
0021|   
    |
0022|   
    |
0023|   
    |
0024|                                 <u>                                
</u>    |
<u></u>0025| <u>  
</u>    |
<u></u>0001| <u>                                </u>                             Rick Miera, Chairman
    |
0002|   
    |
0003|   
    |
0004|   Adopted <u>                    </u>     Not Adopted <u>                    
</u>    |
<u></u>0005| <u>   </u>
    |
0006|             (Chief Clerk)                       (Chief Clerk)
    |
0007|   
    |
0008|                        Date <u>            </u>
    |
0009|   
    |
0010|   The roll call vote was<u> 7 </u> For<u> 0 </u> Against
    |
0011|   Yes:      7
    |
0012|             Excused:  Marquardt
    |
0013|             Absent:   None
    |
0014|   
    |
0015|   G:\BILLTEXT\BILLW_97\H0350      HOUSE LABOR AND HUMAN RESOURCES COMMITTEE SUBSTITUTE FOR
    |
0016|                            HOUSE BILL 350
    |
0017|     43rd legislature - STATE OF NEW MEXICO - first session, 1997
    |
0018|                                   
    |
0019|     
    |
0020|                                   
    |
0021|     
    |
0022|                              
    |
0023|                              
    |
0024|     
    |
0025|                                AN ACT
    |
0001|     RELATING TO INSURANCE; ENACTING THE PATIENT PROTECTION ACT;
    |
0002|     PROVIDING PROTECTIONS FOR PERSONS IN MANAGED HEALTH CARE PLANS; 
    |
0003|     APPLYING PATIENT PROTECTIONS TO MEDICAID MANAGED CARE; IMPOSING
    |
0004|     A CIVIL PENALTY; AMENDING AND ENACTING SECTIONS OF THE NMSA
    |
0005|     1978; MAKING AN APPROPRIATION.
    |
0006|     
    |
0007|     BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
    |
0008|          Section 1.  A new section of the New Mexico Insurance Code
    |
0009|     is enacted to read:  
    |
0010|          "[NEW MATERIAL<u>]  SHORT TITLE.--Sections 1 through 11 of
</u>    |
<u></u>0011| <u>    this act may be cited as the "Patient Protection Act"."
</u>    |
<u></u>0012| <u>         Section 2.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0013| <u>    is enacted to read:
</u>    |
<u></u>0014| <u>         "[</u>NEW MATERIAL<u>]  PURPOSE OF ACT.--The purpose of the
</u>    |
<u></u>0015| <u>    Patient Protection Act is to regulate aspects of health
</u>    |
<u></u>0016| <u>    insurance by specifying patient and provider rights and
</u>    |
<u></u>0017| <u>    confirming and clarifying the authority of the department to
</u>    |
<u></u>0018| <u>    adopt regulations to provide protections to persons enrolled in
</u>    |
<u></u>0019| <u>    managed health care plans.  The insurance protections should
</u>    |
<u></u>0020| <u>    ensure that managed health care plans treat patients fairly and
</u>    |
<u></u>0021| <u>    fulfill their primary obligation to deliver good quality health
</u>    |
<u></u>0022| <u>    care services."     
</u>    |
<u></u>0023| <u>         Section 3.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0024| <u>    is enacted to read:
</u>    |
<u></u>0025| <u>         "[</u>NEW MATERIAL<u>]  DEFINITIONS.--As used in the Patient
</u>    |
<u></u>0001| <u>    Protection Act:
</u>    |
<u></u>0002| <u>              A.  "continuous quality improvement" means an
</u>    |
<u></u>0003| <u>    ongoing and systematic effort to measure, evaluate and improve
</u>    |
<u></u>0004| <u>    a managed health care plan's operations in order to improve
</u>    |
<u></u>0005| <u>    continually the quality of health care services provided to
</u>    |
<u></u>0006| <u>    enrollees; 
</u>    |
<u></u>0007| <u>              B.  "covered person", "enrollee", "patient" or
</u>    |
<u></u>0008| <u>    "consumer" means an individual who is entitled to receive
</u>    |
<u></u>0009| <u>    health care benefits from a managed health care plan; 
</u>    |
<u></u>0010| <u>              C.  "department" means the insurance department;
</u>    |
<u></u>0011| <u>              D.  "emergency care" means a health care procedure,
</u>    |
<u></u>0012| <u>    treatment or service delivered to a covered person after the
</u>    |
<u></u>0013| <u>    sudden onset of what appears to be a medical condition that
</u>    |
<u></u>0014| <u>    manifests itself by symptoms of sufficient severity that the
</u>    |
<u></u>0015| <u>    absence of immediate medical attention could be expected by a
</u>    |
<u></u>0016| <u>    reasonable layperson to result in jeopardy to a person's
</u>    |
<u></u>0017| <u>    health, serious impairment of bodily functions, serious
</u>    |
<u></u>0018| <u>    dysfunction of a body part or disfigurement to a person;
</u>    |
<u></u>0019| <u>              E.  "health care facility" means an institution
</u>    |
<u></u>0020| <u>    providing health care services, including a hospital or other
</u>    |
<u></u>0021| <u>    licensed inpatient center; an ambulatory surgical or treatment
</u>    |
<u></u>0022| <u>    center; a skilled nursing center; a residential treatment center;
</u>    |
<u></u>0023| <u>    a home health agency; a diagnostic, laboratory or imaging center;
</u>    |
<u></u>0024| <u>    and a rehabilitation or other therapeutic health setting;
</u>    |
<u></u>0025| <u>              F.  "health care insurer" means a person that has a
</u>    |
<u></u>0001| <u>    valid certificate of authority in good standing under the New
</u>    |
<u></u>0002| <u>    Mexico Insurance Code to act as an insurer, health maintenance
</u>    |
<u></u>0003| <u>    organization, nonprofit health care plan or prepaid dental plan;
</u>    |
<u></u>0004| <u>              G.  "health care professional" means a physician or
</u>    |
<u></u>0005| <u>    other health care practitioner, including a pharmacist, who is
</u>    |
<u></u>0006| <u>    licensed, certified or otherwise authorized by the state to
</u>    |
<u></u>0007| <u>    provide health care services consistent with state law; 
</u>    |
<u></u>0008| <u>              H.  "health care provider" or "provider" means a person
</u>    |
<u></u>0009| <u>    that is licensed or otherwise authorized by the state to furnish
</u>    |
<u></u>0010| <u>    health care services and includes health care professionals and
</u>    |
<u></u>0011| <u>    health care facilities; 
</u>    |
<u></u>0012| <u>              I.  "health care services" includes physical health or
</u>    |
<u></u>0013| <u>    community-based mental health or developmental disability
</u>    |
<u></u>0014| <u>    services, including services for developmental delay;
</u>    |
<u></u>0015| <u>              J.  "managed health care plan" or "plan" means a health
</u>    |
<u></u>0016| <u>    benefit plan of a health care insurer or a provider service
</u>    |
<u></u>0017| <u>    network that either requires a covered person to use, or creates
</u>    |
<u></u>0018| <u>    incentives, including financial incentives, for a covered person
</u>    |
<u></u>0019| <u>    to use health care providers managed, owned, under contract with
</u>    |
<u></u>0020| <u>    or employed by the health care insurer.  "Managed health care
</u>    |
<u></u>0021| <u>    plan" or "plan" does not include a traditional fee-for-service
</u>    |
<u></u>0022| <u>    indemnity plan or a plan that covers only short-term travel,
</u>    |
<u></u>0023| <u>    accident-only, limited benefit, student health plan or specified
</u>    |
<u></u>0024| <u>    disease policies;
</u>    |
<u></u>0025| <u>              K.  "person" means an individual or other legal entity;
</u>    |
<u></u>0001| <u>              L.  "point-of-service plan" or "open plan" means a
</u>    |
<u></u>0002| <u>    managed health care plan that allows enrollees to use health care
</u>    |
<u></u>0003| <u>    providers other than providers under direct contract with the
</u>    |
<u></u>0004| <u>    plan, even if the plan provides incentives, including financial
</u>    |
<u></u>0005| <u>    incentives, for covered persons to use the plan's designated
</u>    |
<u></u>0006| <u>    participating providers; 
</u>    |
<u></u>0007| <u>              M.  "primary health care clinic" means a nonprofit
</u>    |
<u></u>0008| <u>    community-based entity established to provide the first level of
</u>    |
<u></u>0009| <u>    basic or general health care needs, including diagnostic and
</u>    |
<u></u>0010| <u>    treatment services, for residents of a health care underserved
</u>    |
<u></u>0011| <u>    area as that area is defined in regulation adopted by the
</u>    |
<u></u>0012| <u>    department of health and includes an entity that serves primarily
</u>    |
<u></u>0013| <u>    low-income populations; 
</u>    |
<u></u>0014| <u>              N.  "provider service network" means two or more health
</u>    |
<u></u>0015| <u>    care providers affiliated for the purpose of providing health care
</u>    |
<u></u>0016| <u>    services to covered persons on a capitated or similar prepaid
</u>    |
<u></u>0017| <u>    flat-rate basis;
</u>    |
<u></u>0018| <u>              O.  "superintendent" means the superintendent of
</u>    |
<u></u>0019| <u>    insurance; and
</u>    |
<u></u>0020| <u>              P.  "utilization review" means a system for reviewing
</u>    |
<u></u>0021| <u>    the appropriate and efficient allocation of health care services,
</u>    |
<u></u>0022| <u>    including hospitalization, given or proposed to be given to a
</u>    |
<u></u>0023| <u>    patient or group of patients." 
</u>    |
<u></u>0024| <u>         Section 4.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0025| <u>    is enacted to read:
</u>    |
<u></u>0001| <u>         "[</u>NEW MATERIAL<u>]  PATIENT RIGHTS--DISCLOSURES--RIGHTS TO
</u>    |
<u></u>0002| <u>    BASIC AND COMPREHENSIVE HEALTH CARE SERVICES--GRIEVANCE PROCEDURE-
</u>    |
<u></u>0003| <u>    -UTILIZATION REVIEW PROGRAM--CONTINUOUS QUALITY PROGRAM.--
</u>    |
<u></u>0004| <u>              A.  Each covered person enrolled in a managed health
</u>    |
<u></u>0005| <u>    care plan has the right to be treated fairly.  A managed health
</u>    |
<u></u>0006| <u>    care plan shall deliver good quality and appropriate health care
</u>    |
<u></u>0007| <u>    services to enrollees.  The department shall adopt regulations to
</u>    |
<u></u>0008| <u>    implement the provisions of the Patient Protection Act and shall
</u>    |
<u></u>0009| <u>    monitor and oversee a managed health care plan to ensure that each
</u>    |
<u></u>0010| <u>    covered person enrolled in a plan is treated fairly and is
</u>    |
<u></u>0011| <u>    accorded the rights necessary or appropriate to protect patient
</u>    |
<u></u>0012| <u>    interests.  In adopting regulations to implement the provisions of
</u>    |
<u></u>0013| <u>    Subparagraphs (a) and (b) of Paragraph (3) and Paragraphs (5) and
</u>    |
<u></u>0014| <u>    (6) of Subsection B of this section regarding health care
</u>    |
<u></u>0015| <u>    standards and specialists, utilization review programs and
</u>    |
<u></u>0016| <u>    continuous quality improvement programs, the department shall
</u>    |
<u></u>0017| <u>    cooperate with and seek advice from the department of health. 
</u>    |
<u></u>0018| <u>              B.  The regulations adopted by the department to
</u>    |
<u></u>0019| <u>    protect patient rights shall provide at a minimum that:
</u>    |
<u></u>0020| <u>                   (1)  a managed health care plan shall provide
</u>    |
<u></u>0021| <u>    oral and written summaries, policies and procedures that explain,
</u>    |
<u></u>0022| <u>    prior to or at the time of enrollment and at subsequent periodic
</u>    |
<u></u>0023| <u>    times as appropriate, in a clear, conspicuous and readily
</u>    |
<u></u>0024| <u>    understandable form, full and fair disclosure of the plan's
</u>    |
<u></u>0025| <u>    benefits, terms, conditions, prior authorization requirements,
</u>    |
<u></u>0001| <u>    enrollee financial responsibility for payments, grievance
</u>    |
<u></u>0002| <u>    procedures, appeal rights and the patient rights generally
</u>    |
<u></u>0003| <u>    available to all covered persons; 
</u>    |
<u></u>0004| <u>                   (2)  a managed health care plan shall provide
</u>    |
<u></u>0005| <u>    each covered person with appropriate basic and comprehensive
</u>    |
<u></u>0006| <u>    health care services that are reasonably accessible and available
</u>    |
<u></u>0007| <u>    in a timely manner to each covered person; 
</u>    |
<u></u>0008| <u>                   (3)  in providing the right to reasonably
</u>    |
<u></u>0009| <u>    accessible health care services that are available in a timely
</u>    |
<u></u>0010| <u>    manner, a managed health care plan shall ensure that:
</u>    |
<u></u>0011| <u>                        (a)  the plan offers sufficient numbers and
</u>    |
<u></u>0012| <u>    types of safe and adequately staffed health care providers at
</u>    |
<u></u>0013| <u>    reasonable hours of service to meet the health needs of the
</u>    |
<u></u>0014| <u>    enrollee population, and takes into account cultural aspects of
</u>    |
<u></u>0015| <u>    the enrollee population; 
</u>    |
<u></u>0016| <u>                        (b)  health care providers that are
</u>    |
<u></u>0017| <u>    specialists may act as primary care providers for patients with
</u>    |
<u></u>0018| <u>    chronic medical conditions, provided the specialists offer all
</u>    |
<u></u>0019| <u>    reasonable primary care services required by a managed health care
</u>    |
<u></u>0020| <u>    plan; 
</u>    |
<u></u>0021| <u>                        (c)  reasonable access is provided to 
</u>    |
<u></u>0022| <u>    out-of-network health care providers; and 
</u>    |
<u></u>0023| <u>                        (d)  emergency care is immediately available
</u>    |
<u></u>0024| <u>    without prior authorization requirements, and appropriate out-of-
</u>    |
<u></u>0025| <u>    network emergency care is not subject to additional costs; 
</u>    |
<u></u>0001| <u>                   (4)  a managed health care plan shall adopt and
</u>    |
<u></u>0002| <u>    implement a prompt and fair grievance procedure for resolving 
</u>    |
<u></u>0003| <u>    patient complaints and addressing patient questions and concerns
</u>    |
<u></u>0004| <u>    regarding any aspect of the plan, including the quality of and
</u>    |
<u></u>0005| <u>    access to health care, the choice of health care provider or
</u>    |
<u></u>0006| <u>    treatment and the adequacy of the plan's provider network.  The
</u>    |
<u></u>0007| <u>    grievance procedures shall notify patients of their statutory
</u>    |
<u></u>0008| <u>    appeal rights, including the option of seeking immediate relief in
</u>    |
<u></u>0009| <u>    court, and shall provide for a prompt and fair appeal of a plan's
</u>    |
<u></u>0010| <u>    decision to the superintendent, including special provisions to
</u>    |
<u></u>0011| <u>    govern emergency appeals to the superintendent in health
</u>    |
<u></u>0012| <u>    emergencies;
</u>    |

<u></u>0013| <u>                   (5)  a managed health care plan shall adopt and
</u>    |
<u></u>0014| <u>    implement a comprehensive utilization review program.  The basis
</u>    |
<u></u>0015| <u>    of a decision to approve or deny care shall be disclosed to an
</u>    |
<u></u>0016| <u>    affected enrollee.  The decision to approve or deny care to a
</u>    |
<u></u>0017| <u>    patient shall be made in a timely manner, and the final decision
</u>    |
<u></u>0018| <u>    shall be made by a qualified health care professional.  A plan's
</u>    |
<u></u>0019| <u>    utilization review program shall ensure that enrollees have proper
</u>    |
<u></u>0020| <u>    access to health care services, including referrals to necessary
</u>    |
<u></u>0021| <u>    specialists.  A decision made in a plan's utilization review
</u>    |
<u></u>0022| <u>    program shall be subject to the plan's grievance procedure and
</u>    |
<u></u>0023| <u>    appeal to the superintendent; and 
</u>    |
<u></u>0024| <u>                   (6)  a managed health care plan shall adopt and
</u>    |
<u></u>0025| <u>    implement a continuous quality improvement program that monitors
</u>    |
<u></u>0001| <u>    the quality and appropriateness of the health care services
</u>    |
<u></u>0002| <u>    provided by the plan." 
</u>    |
<u></u>0003| <u>         Section 5.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0004| <u>    is enacted to read:
</u>    |
<u></u>0005| <u>         "[</u>NEW MATERIAL<u>]  CONSUMER ASSISTANCE--CONSUMER ADVISORY
</u>    |
<u></u>0006| <u>    BOARDS--OMBUDSMAN OFFICE--REPORTS TO CONSUMERS--SUPERINTENDENT'S
</u>    |
<u></u>0007| <u>    ORDERS TO PROTECT CONSUMERS.-- 
</u>    |
<u></u>0008| <u>              A.  Each health care insurer that offers a managed
</u>    |
<u></u>0009| <u>    health care plan shall establish and adequately staff a consumer
</u>    |
<u></u>0010| <u>    assistance office.  The purpose of the consumer assistance office
</u>    |
<u></u>0011| <u>    is to respond to consumer questions and concerns and assist
</u>    |
<u></u>0012| <u>    patients in exercising their rights and protecting their interests
</u>    |
<u></u>0013| <u>    as consumers of health care.  
</u>    |
<u></u>0014| <u>              B.  Each health care insurer that offers a managed
</u>    |
<u></u>0015| <u>    health care plan shall establish a consumer advisory board.  The
</u>    |
<u></u>0016| <u>    board shall meet at least quarterly and shall advise the insurer
</u>    |
<u></u>0017| <u>    about the plan's general operations from the perspective of the
</u>    |
<u></u>0018| <u>    enrollee as a consumer of health care.  The board shall also
</u>    |
<u></u>0019| <u>    oversee the plan's consumer assistance office. 
</u>    |
<u></u>0020| <u>              C.  The department shall establish and adequately staff
</u>    |
<u></u>0021| <u>    a managed care ombudsman office, either within the department or
</u>    |
<u></u>0022| <u>    by contract.  The purpose of the  managed care ombudsman office
</u>    |
<u></u>0023| <u>    shall be to assist patients in exercising their rights and help
</u>    |
<u></u>0024| <u>    advocate for and protect patient interests.  The department's
</u>    |
<u></u>0025| <u>    managed care ombudsman office shall work in conjunction with each
</u>    |
<u></u>0001| <u>    insurer's consumer assistance office and shall independently
</u>    |
<u></u>0002| <u>    evaluate the effectiveness of the insurer's consumer assistance
</u>    |
<u></u>0003| <u>    office.  The department's managed care ombudsman office may
</u>    |
<u></u>0004| <u>    require an insurer's consumer assistance office to adopt measures
</u>    |
<u></u>0005| <u>    to ensure that the plan operates effectively to protect patient
</u>    |
<u></u>0006| <u>    rights and inform consumers of the information to which they are
</u>    |
<u></u>0007| <u>    entitled. 
</u>    |
<u></u>0008| <u>              D.  The department shall prepare an annual report
</u>    |
<u></u>0009| <u>    assessing the operations of managed health care plans subject to
</u>    |
<u></u>0010| <u>    the department's oversight, including information about consumer
</u>    |
<u></u>0011| <u>    complaints.
</u>    |
<u></u>0012| <u>              E.  A person may file a complaint with the
</u>    |
<u></u>0013| <u>    superintendent regarding a violation of the Patient Protection
</u>    |
<u></u>0014| <u>    Act.  Prior to issuing any remedial order regarding violations of
</u>    |
<u></u>0015| <u>    the Patient Protection Act or its regulations, the superintendent
</u>    |
<u></u>0016| <u>    shall hold a hearing in accordance with the provisions of Chapter
</u>    |
<u></u>0017| <u>    59A, Article 4 NMSA 1978.  The superintendent may issue any order
</u>    |
<u></u>0018| <u>    he deems necessary or appropriate, including ordering the delivery
</u>    |
<u></u>0019| <u>    of appropriate care, to protect consumers and enforce the
</u>    |
<u></u>0020| <u>    provisions of the Patient Protection Act.  The superintendent
</u>    |
<u></u>0021| <u>    shall adopt special procedures to govern the submission of
</u>    |
<u></u>0022| <u>    emergency appeals to him in health emergencies."
</u>    |
<u></u>0023| <u>         Section 6.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0024| <u>    is enacted to read:
</u>    |
<u></u>0025| <u>         "[</u>NEW MATERIAL<u>]  FAIRNESS TO HEALTH CARE PROVIDERS--GAG
</u>    |
<u></u>0001| <u>    RULES PROHIBITED--GRIEVANCE PROCEDURE FOR PROVIDERS.--
</u>    |
<u></u>0002| <u>              A.  No managed health care plan may:
</u>    |
<u></u>0003| <u>                   (1)  adopt a gag rule or practice that prohibits
</u>    |
<u></u>0004| <u>    a health care provider from discussing a treatment option with an
</u>    |
<u></u>0005| <u>    enrollee even if the plan does not approve of the option; 
</u>    |
<u></u>0006| <u>                   (2)  offer a health care provider inducements,
</u>    |
<u></u>0007| <u>    other than those inherent in a capitation payment system, to
</u>    |
<u></u>0008| <u>    reduce or limit medically necessary health care services; or
</u>    |
<u></u>0009| <u>                   (3)  require a health care provider to violate
</u>    |
<u></u>0010| <u>    the ethical duties of his profession or place his license in
</u>    |
<u></u>0011| <u>    jeopardy.
</u>    |
<u></u>0012| <u>              B.  A health care insurer that proposes to terminate a
</u>    |
<u></u>0013| <u>    health care provider from the insurer's managed health care plan
</u>    |
<u></u>0014| <u>    shall explain in writing the rationale for its proposed
</u>    |
<u></u>0015| <u>    termination and deliver reasonable advance written notice to the
</u>    |
<u></u>0016| <u>    provider prior to the proposed effective date of the termination.  
</u>    |
<u></u>0017| <u>              C.  A managed health care plan shall adopt and
</u>    |
<u></u>0018| <u>    implement a prompt and fair grievance procedure for resolving
</u>    |
<u></u>0019| <u>    health care provider complaints and addressing provider questions
</u>    |
<u></u>0020| <u>    and concerns regarding any aspect of the plan, including the
</u>    |
<u></u>0021| <u>    quality of and access to health care, the choice of health care
</u>    |
<u></u>0022| <u>    provider or treatment and the adequacy of the plan's provider
</u>    |
<u></u>0023| <u>    network.  The grievance procedures shall notify providers of their
</u>    |
<u></u>0024| <u>    statutory appeal rights, including the option of seeking immediate
</u>    |
<u></u>0025| <u>    relief in court, and shall provide for a prompt and fair appeal of
</u>    |
<u></u>0001| <u>    a plan's decision to the superintendent, including special
</u>    |
<u></u>0002| <u>    provisions to govern emergency appeals to the superintendent in
</u>    |
<u></u>0003| <u>    health emergencies." 
</u>    |
<u></u>0004| <u>         Section 7.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0005| <u>    is enacted to read:
</u>    |
<u></u>0006| <u>         "[</u>NEW MATERIAL<u>]  POINT-OF-SERVICE OPTION PLAN.--The
</u>    |
<u></u>0007| <u>    department may require a health care insurer that offers a
</u>    |
<u></u>0008| <u>    point-of-service plan or open plan to include in any managed
</u>    |
<u></u>0009| <u>    health care plan it offers an option for a point-of-service plan
</u>    |
<u></u>0010| <u>    or open plan."
</u>    |
<u></u>0011| <u>         Section 8.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0012| <u>    is enacted to read:
</u>    |
<u></u>0013| <u>         "[</u>NEW MATERIAL<u>]  ADMINISTRATIVE COSTS AND BENEFIT COSTS
</u>    |
<u></u>0014| <u>    DISCLOSURES.--The department shall adopt regulations to ensure
</u>    |
<u></u>0015| <u>    that both the administrative costs and the direct costs of
</u>    |
<u></u>0016| <u>    providing health care services of each managed health care plan
</u>    |
<u></u>0017| <u>    are fully and fairly disclosed to consumers in a uniform manner
</u>    |
<u></u>0018| <u>    that allows meaningful cost comparisons among plans."
</u>    |
<u></u>0019| <u>         Section 9.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0020| <u>    is enacted to read:
</u>    |
<u></u>0021| <u>         "[</u>NEW MATERIAL<u>]  PRIVATE REMEDIES TO ENFORCE PATIENT AND
</u>    |
<u></u>0022| <u>    PROVIDER INSURANCE RIGHTS--ENROLLEE AS THIRD-PARTY BENEFICIARY TO
</u>    |
<u></u>0023| <u>    ENFORCE RIGHTS.--
</u>    |
<u></u>0024| <u>              A.  A person who suffers a loss as a result of a
</u>    |
<u></u>0025| <u>    violation of a right protected pursuant to the provisions of the
</u>    |
<u></u>0001| <u>    Patient Protection Act, its regulations or a managed health care
</u>    |
<u></u>0002| <u>    plan may bring an action to recover actual damages or the sum of
</u>    |
<u></u>0003| <u>    one hundred dollars ($100), whichever is greater. 
</u>    |
<u></u>0004| <u>              B.  A person likely to be damaged by a denial of a
</u>    |
<u></u>0005| <u>    right protected pursuant to the provisions of the Patient
</u>    |
<u></u>0006| <u>    Protection Act, its regulations or a managed health care plan may
</u>    |
<u></u>0007| <u>    be granted an injunction under the principles of equity and on
</u>    |
<u></u>0008| <u>    terms that the court considers reasonable.  Proof of monetary
</u>    |
<u></u>0009| <u>    damage or intent to violate a right is not required.
</u>    |
<u></u>0010| <u>              C.  To protect and enforce an enrollee's rights in a
</u>    |
<u></u>0011| <u>    managed health care plan, an individual enrollee participating in
</u>    |
<u></u>0012| <u>    or eligible to participate in a managed health care plan shall be
</u>    |
<u></u>0013| <u>    treated as a third-party beneficiary of the managed health care
</u>    |
<u></u>0014| <u>    plan contract between the health care insurer and the party with
</u>    |
<u></u>0015| <u>    which the health care insurer directly contracts.  An individual
</u>    |
<u></u>0016| <u>    enrollee may sue to enforce the rights provided in the contract
</u>    |
<u></u>0017| <u>    that governs the managed health care plan. 
</u>    |
<u></u>0018| <u>              D.  The relief provided pursuant to this section is in
</u>    |
<u></u>0019| <u>    addition to other remedies available against the same conduct
</u>    |
<u></u>0020| <u>    under the common law or other statutes of this state.       
</u>    |
<u></u>0021| <u>              E.  In any class action filed pursuant to this section,
</u>    |
<u></u>0022| <u>    the court may award damages to the named plaintiffs as provided in
</u>    |
<u></u>0023| <u>    this section and may award members of the class the actual damages
</u>    |
<u></u>0024| <u>    suffered by each member of the class as a result of the unlawful
</u>    |
<u></u>0025| <u>    practice."
</u>    |
<u></u>0001| <u>         Section 10.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0002| <u>    is enacted to read:
</u>    |
<u></u>0003| <u>         "[</u>NEW MATERIAL<u>]  APPLICATION OF ACT TO MEDICAID PROGRAM.--
</u>    |
<u></u>0004| <u>    The provisions of the Patient Protection Act apply to the medicaid
</u>    |
<u></u>0005| <u>    program operation in the state.  A managed health care plan
</u>    |
<u></u>0006| <u>    offered through the medicaid program shall grant enrollees and
</u>    |
<u></u>0007| <u>    providers the same rights and protections as are granted to
</u>    |
<u></u>0008| <u>    enrollees and providers in any other managed health care plan
</u>    |
<u></u>0009| <u>    subject to the provisions of the Patient Protection Act."
</u>    |
<u></u>0010| <u>         Section 11.  A new section of the New Mexico Insurance Code
</u>    |
<u></u>0011| <u>    is enacted to read:
</u>    |
<u></u>0012| <u>         "[</u>NEW MATERIAL<u>]  PENALTY.--In addition to any other
</u>    |
<u></u>0013| <u>    penalties provided by law, a civil administrative penalty of up to
</u>    |
<u></u>0014| <u>    twenty-five thousand dollars ($25,000) may be imposed for each
</u>    |
<u></u>0015| <u>    violation of the Patient Protection Act.  An administrative
</u>    |
<u></u>0016| <u>    penalty shall be imposed by written order of the superintendent
</u>    |
<u></u>0017| <u>    made after holding a hearing as provided for in Chapter 59A,
</u>    |
<u></u>0018| <u>    Article 4 NMSA 1978."
</u>    |
<u></u>0019| <u>         Section 12.  Section 59A-1-16 NMSA 1978 (being Laws 1984,
</u>    |
<u></u>0020| <u>    Chapter 127, Section 16) is amended to read:
</u>    |
<u></u>0021| <u>         "59A-1-16.  EXEMPTED FROM CODE.--In addition to
</u>    |
<u></u>0022| <u>    organizations and businesses otherwise exempt, the Insurance Code
</u>    |
<u></u>0023| <u>    shall not apply <s>[as]</s> to:
</u>    |
<u></u>0024| <u>              A.  a labor organization <s>[which]</s> </u>that<u>, incidental
</u>    |
<u></u>0025| <u>    only to operations as a labor organization, issues benefit
</u>    |
<u></u>0001| <u>    certificates to members or maintains funds to assist members and
</u>    |
<u></u>0002| <u>    their families in times of illness, injury or need, and not for
</u>    |
<u></u>0003| <u>    profit;
</u>    |
<u></u>0004| <u>              B.  the credit union share insurance corporation, as
</u>    |
<u></u>0005| <u>    identified in <s>[Article 58-12]</s> </u>Chapter 58, Article 12<u> NMSA
</u>    |
<u></u>0006| <u>    1978, and similar corporations and funds for protection of
</u>    |
<u></u>0007| <u>    depositors, shareholders or creditors of financial institutions
</u>    |
<u></u>0008| <u>    and businesses other than insurers; or
</u>    |
<u></u>0009| <u>              C.  the risk management division of the </u>general
    |
0010|     services<u> department <s>[of finance and administration of New
</u></s>    |
<u><s></u></s>0011| <u><s>    Mexico]</s> or <s>[as]</s> to insurance of public property or public risks
</u>    |
<u></u>0012| <u>    by any agency of government not otherwise engaged in the business
</u>    |
<u></u>0013| <u>    of insurance, </u>except the provisions of the Patient Protection Act
    |
0014|     shall apply to the risk management division and any managed health
    |
0015|     care plan it offers<u>."
</u>    |
<u></u>0016| <u>         Section 13.  Section 59A-46-30 NMSA 1978 (being Laws 1993,
</u>    |
<u></u>0017| <u>    Chapter 266, Section 29) is amended to read:
</u>    |
<u></u>0018| <u>         "59A-46-30.  STATUTORY CONSTRUCTION AND RELATIONSHIP TO
</u>    |
<u></u>0019| <u>    OTHER LAWS.--
</u>    |
<u></u>0020| <u>              A.  The provisions of the Insurance Code other than
</u>    |
<u></u>0021| <u>    Chapter 59A, Article 46 NMSA 1978 shall not apply to health
</u>    |
<u></u>0022| <u>    maintenance organizations except as expressly provided in the
</u>    |
<u></u>0023| <u>    Insurance Code and that article.  To the extent reasonable and not
</u>    |
<u></u>0024| <u>    inconsistent with the provisions of that article, the following
</u>    |
<u></u>0025| <u>    articles and provisions of the Insurance Code shall also apply to
</u>    |
<u></u>0001| <u>    health maintenance organizations, their promoters, sponsors,
</u>    |
<u></u>0002| <u>    directors, officers, employees, agents, solicitors and other
</u>    |
<u></u>0003| <u>    representatives <s>[and]</s>.  For the purposes of such applicability,
</u>    |
<u></u>0004| <u>    a health maintenance organization may <s>[therein]</s> be referred to
</u>    |
<u></u>0005| <u>    as an "insurer": 
</u>    |
<u></u>0006| <u>                   (1)  Chapter 59A, Article 1 NMSA 1978; 
</u>    |
<u></u>0007| <u>                   (2)  Chapter 59A, Article 2 NMSA 1978;
</u>    |
<u></u>0008| <u>                   (3)  Chapter 59A, Article 3 NMSA 1978;
</u>    |
<u></u>0009| <u>                   (4)  Chapter 59A, Article 4 NMSA 1978; 
</u>    |
<u></u>0010| <u>                   (5)  Subsection C of Section 59A-5-22 NMSA 1978;
</u>    |
<u></u>0011| <u>                   (6)  Sections 59A-6-2 through 59A-6-4 and 59A-6-6
</u>    |
<u></u>0012| <u>    NMSA 1978;
</u>    |
<u></u>0013| <u>                   (7)  Chapter 59A, Article 8 NMSA 1978; 
</u>    |
<u></u>0014| <u>                   (8)  Chapter 59A, Article 10 NMSA 1978; 
</u>    |
<u></u>0015| <u>                   (9)  Section 59A-12-22 NMSA 1978; 
</u>    |
<u></u>0016| <u>                   (10)  Chapter 59A, Article 16 NMSA 1978;
</u>    |
<u></u>0017| <u>                   (11)  Chapter 59A, Article 18 NMSA 1978; 
</u>    |
<u></u>0018| <u>                   (12)  Chapter 59A, Article 19 NMSA 1978; 
</u>    |
<u></u>0019| <u>                   </u>(13)  Section 59A-22-14 NMSA 1978;<u>
</u>    |
<u></u>0020| <u>                   <s>[(13)]</s> </u>(14)<u>  Chapter 59A, Article 23B NMSA
</u>    |
<u></u>0021| <u>    1978;
</u>    |
<u></u>0022| <u>                   <s>[(14)]</s> </u>(15)<u>  Sections 59A-34-9 through 
</u>    |
<u></u>0023| <u>    59A-34-13, 59A-34-23, 59A-34-36 and 59A-34-37 NMSA 1978; <s>[and
</u></s>    |
<u><s></u></s>0024| <u><s>                   (15)]</s> </u>(16)<u>  Chapter 59A, Article 37 NMSA 1978;
</u>    |
<u></u>0025| <u>    </u>and<u>
</u>    |
<u></u>0001| <u>                   </u>(17)  the Patient Protection Act<u>.     
</u>    |
<u></u>0002| <u>              B.  Solicitation of enrollees by a health maintenance
</u>    |
<u></u>0003| <u>    organization granted a certificate of authority, or its
</u>    |
<u></u>0004| <u>    representatives, shall not be construed as violating any provision
</u>    |
<u></u>0005| <u>    of law relating to solicitation or advertising by health
</u>    |
<u></u>0006| <u>    professionals, but health professionals shall be individually
</u>    |
<u></u>0007| <u>    subject to the laws, rules, regulations and ethical provisions
</u>    |
<u></u>0008| <u>    governing their individual professions. 
</u>    |
<u></u>0009| <u>              C.  Any health maintenance organization authorized
</u>    |
<u></u>0010| <u>    under the provisions of the Health Maintenance Organization Law
</u>    |
<u></u>0011| <u>    shall not be deemed to be practicing medicine and shall be exempt
</u>    |
<u></u>0012| <u>    from the provisions of laws relating to the practice of medicine."
</u>    |
<u></u>0013| <u>         Section 14.  Section 59A-47-33 NMSA 1978 (being Laws 1984,
</u>    |
<u></u>0014| <u>    Chapter 127, Section 879.32, as amended by Laws 1994, Chapter 64,
</u>    |
<u></u>0015| <u>    Section 10 and also by Laws 1994, Chapter 75, Section 34) is
</u>    |
<u></u>0016| <u>    amended to read:
</u>    |
<u></u>0017| <u>         "59A-47-33.  OTHER PROVISIONS APPLICABLE.--The provisions of
</u>    |
<u></u>0018| <u>    the Insurance Code other than Chapter 59A, Article 47 NMSA 1978
</u>    |
<u></u>0019| <u>    shall not apply to health care plans except as expressly provided
</u>    |
<u></u>0020| <u>    in the Insurance Code and that article.  To the extent reasonable
</u>    |
<u></u>0021| <u>    and not inconsistent with the provisions of that article, the
</u>    |
<u></u>0022| <u>    following articles and provisions of the Insurance Code shall also
</u>    |
<u></u>0023| <u>    apply to health care plans, their promoters, sponsors, directors,
</u>    |
<u></u>0024| <u>    officers, employees, agents, solicitors and other representatives;
</u>    |
<u></u>0025| <u>    and, for the purposes of such applicability, a health care plan
</u>    |
<u></u>0001| <u>    may <s>[therein]</s> be referred to as an "insurer":
</u>    |
<u></u>0002| <u>              A.  Chapter 59A, Article 1 NMSA 1978;
</u>    |
<u></u>0003| <u>              B.  Chapter 59A, Article 2 NMSA 1978;
</u>    |
<u></u>0004| <u>              C.  Chapter 59A, Article 4 NMSA 1978;
</u>    |
<u></u>0005| <u>              D.  Subsection C of Section 59A-5-22 NMSA 1978;
</u>    |
<u></u>0006| <u>              E.  Sections 59A-6-2 through 59A-6-4 and 
</u>    |
<u></u>0007| <u>    59A-6-6 NMSA 1978;
</u>    |
<u></u>0008| <u>              F.  Section 59A-7-11 NMSA 1978;
</u>    |
<u></u>0009| <u>              G.  Chapter 59A, Article 8 NMSA 1978;
</u>    |
<u></u>0010| <u>              H.  Chapter 59A, Article 10 NMSA 1978;
</u>    |
<u></u>0011| <u>              I.  Section 59A-12-22 NMSA 1978;
</u>    |
<u></u>0012| <u>              J.  Chapter 59A, Article 16 NMSA 1978;
</u>    |
<u></u>0013| <u>              K.  Chapter 59A, Article 18 NMSA 1978;
</u>    |
<u></u>0014| <u>              L.  Chapter 59A, Article 19 NMSA 1978;
</u>    |
<u></u>0015| <u>              M.  Subsections B through E of Section 
</u>    |
<u></u>0016| <u>    59A-22-5 NMSA 1978;
</u>    |
<u></u>0017| <u>              </u>N.  Section 59A-22-14 NMSA 1978<u>;
</u>    |
<u></u>0018| <u>              <s>[N.]</s> </u>O.<u>  Section 59A-22-34.1 NMSA 1978; 
</u>    |
<u></u>0019| <u>              <s>[O.]</s> </u>P.<u>  Section 59A-22-39 NMSA 1978;
</u>    |
<u></u>0020| <u>              <s>[P.]</s> </u>Q.<u>  Section 59A-22-40 NMSA 1978;
</u>    |
<u></u>0021| <u>              <s>[Q.]</s> </u>R.<u>  Sections 59A-34-9 through 59A-34-13 <s>[NMSA
</u></s>    |
<u><s></u></s>0022| <u><s>    1978]</s> and <s>[Section]</s> 59A-34-23 NMSA 1978;
</u>    |
<u></u>0023| <u>              <s>[R.]</s> </u>S.<u>  Chapter 59A, Article 37 NMSA 1978, except
</u>    |
<u></u>0024| <u>    Section 59A-37-7 NMSA 1978; <s>[and
</u></s>    |
<u><s></u></s>0025| <u><s>              S.]</s> </u>T.<u>  Section 59A-46-15 NMSA 1978; </u>and<u>
</u>    |
<u></u>0001| <u>              </u>U.  the Patient Protection Act<u>."
</u>    |
<u></u>0002| <u>         Section 15.  APPROPRIATION.--Two hundred four thousand nine
</u>    |
<u></u>0003| <u>    hundred dollars ($204,900) is appropriated from the general fund
</u>    |
<u></u>0004| <u>    to the department of insurance for expenditure in fiscal year 1998
</u>    |
<u></u>0005| <u>    to pay salaries and benefits and other costs necessary to
</u>    |
<u></u>0006| <u>    establish a managed care ombudsman office and administer the
</u>    |
<u></u>0007| <u>    provisions of the Patient Protection Act.  Any unexpended or
</u>    |
<u></u>0008| <u>    unencumbered balance remaining at the end of fiscal year 1998
</u>    |
<u></u>0009| <u>    shall revert to the general fund.
</u>    |
<u></u>0010| <u>         Section 16.  EFFECTIVE DATE.--The effective date of the
</u>    |
<u></u>0011| <u>    provisions of this act is July 1, 1997.
</u>    |
<u></u>0012| <u>                                  
</u>    |
<u></u>0013| <u>                            State of New Mexico
</u>    |
<u></u>0014| <u>                      House of Representatives
</u>    |
<u></u>0015| <u>  
</u>    |
<u></u>0016| <u>                      FORTY-THIRD LEGISLATURE
</u>    |
<u></u>0017| <u>                        FIRST SESSION, 1997
</u>    |
<u></u>0018| <u>  
</u>    |
<u></u>0019| <u>  
</u>    |
<u></u>0020| <u>                                                February 28, 1997
</u>    |
<u></u>0021| <u>  
</u>    |
<u></u>0022| <u>  
</u>    |
<u></u>0023| <u>  Mr. Speaker:
</u>    |
<u></u>0024| <u>  
</u>    |
<u></u>0025| <u>       Your JUDICIARY COMMITTEE, to whom has been referred
</u>    |
<u></u>0001| <u>  
</u>    |
<u></u>0002| <u>      LABOR AND HUMAN RESOURCES COMMITTEE SUBSTITUTE FOR
</u>    |
<u></u>0003| <u>                        HOUSE BILL 350
</u>    |
<u></u>0004| <u>                               
</u>    |
<u></u>0005| <u>  has had it under consideration and reports same with
</u>    |
<u></u>0006| <u>  recommendation that it DO PASS, and thence referred to the
</u>    |
<u></u>0007| <u>  APPROPRIATIONS AND FINANCE COMMITTEE.

</u>    |
<u></u>0008| <u>  
</u>    |
<u></u>0009| <u>                                Respectfully submitted,
</u>    |
<u></u>0010| <u>  
</u>    |
<u></u>0011| <u>  
</u>    |
<u></u>0012| <u>  
</u>    |
<u></u>0013| <u>                                </u>                                 
    |
0014|                                 <u>                             Thomas P. Foy, Chairman
</u>    |
<u></u>0015| <u>  
</u>    |
<u></u>0016| <u>  
</u>    |
<u></u>0017| <u>  Adopted </u>                    <u>     Not Adopted </u>                     
    |
0018|   <u>
</u>    |
<u></u>0019| <u>            (Chief Clerk)                       (Chief Clerk)
</u>    |
<u></u>0020| <u>  
</u>    |
<u></u>0021| <u>                        Date </u>            <u>
</u>    |
<u></u>0022| <u>  
</u>    |
<u></u>0023| <u>  The roll call vote was</u> 7 <u> For</u> 0 <u> Against
</u>    |
<u></u>0024| <u>  Yes:      7
</u>    |
<u></u>0025| <u>            Excused:  Alwin, King, Larranaga, Mallory, Rios, Stewart
</u>    |
<u></u>0001| <u>            Absent:   None
</u>    |
<u></u>0002| <u>  
</u>    |
<u></u>0003| <u>  
</u>    |
<u></u>0004| <u>  G:\BILLTEXT\BILLW_97\H0350      
</u>    |
<u></u>0005| <u>                        FORTY-THIRD LEGISLATURE
</u>    |
<u></u>0006| <u>                             FIRST SESSION
</u>    |
<u></u>0007| <u>  
</u>    |
<u></u>0008| <u>  
</u>    |
<u></u>0009| <u>                                                      March 10, 1997
</u>    |
<u></u>0010| <u>  
</u>    |
<u></u>0011| <u>  
</u>    |
<u></u>0012| <u>  HOUSE FLOOR AMENDMENT number ___1___ to HOUSE LABOR AND HUMAN RESOURCES
</u>    |
<u></u>0013| <u>                                   COMMITTEE SUBSTITUTE 
</u>    |
<u></u>0014| <u>                                   FOR HOUSE BILL 350, as amended
</u>    |
<u></u>0015| <u>  
</u>    |
<u></u>0016| <u>  Amendment sponsored by Representative Edward C. Sandoval
</u>    |
<u></u>0017| <u>  
</u>    |
<u></u>0018| <u>  
</u>    |
<u></u>0019| <u>    1.  Strike House Appropriations and Finance Committee 
</u>    |
<u></u>0020| <u>  Amendment 2.
</u>    |
<u></u>0021| <u>  
</u>    |
<u></u>0022| <u>    2.  On page 10, line 12, after "(2)" strike the remainder of the
</u>    |
<u></u>0023| <u>  line, strike all of lines 13 and 14 and inset in lieu thereof:
</u>    |
<u></u>0024| <u>  
</u>    |
<u></u>0025| <u>  "include in any of its contracts with health care providers any
</u>    |
<u></u>0001| <u>  provisions that offer an inducement, financial or otherwise, to provide
</u>    |
<u></u>0002| <u>  less than medically necessary services to an enrollee; or".
</u>    |
<u></u>0003| <u>  
</u>    |
<u></u>0004| <u>  
</u>    |
<u></u>0005| <u>  
</u>    |
<u></u>0006| <u>  
</u>    |
<u></u>0007| <u>  
</u>    |
<u></u>0008| <u>  
</u>    |
<u></u>0009| <u>  
</u>    |
<u></u>0010| <u>                                        ___________________________
</u>    |
<u></u>0011| <u>                                        Edward C. Sandoval
</u>    |
<u></u>0012| <u>  
</u>    |
<u></u>0013| <u>  
</u>    |
<u></u>0014| <u>  
</u>    |
<u></u>0015| <u>  Adopted ___________________   Not Adopted ___________________________
</u>    |
<u></u>0016| <u>           (Chief Clerk)                       (Chief Clerk)
</u>    |
<u></u>0017| <u>  
</u>    |
<u></u>0018| <u>  
</u>    |
<u></u>0019| <u>                  Date ________________                        FORTY-THIRD LEGISLATURE
</u>    |
<u></u>0020| <u>                          FIRST SESSION, 1997                       
</u>    |
<u></u>0021| <u>  
</u>    |
<u></u>0022| <u>  
</u>    |
<u></u>0023| <u>                                                      March 17, 1997
</u>    |
<u></u>0024| <u>  Mr. President:
</u>    |
<u></u>0025| <u>  
</u>    |
<u></u>0001| <u>      Your PUBLIC AFFAIRS COMMITTEE, to whom has been referred
</u>    |
<u></u>0002| <u>  
</u>    |
<u></u>0003| <u>         HOUSE LABOR AND HUMAN RESOURCES COMMITTEE SUBSTITUTE 
</u>    |
<u></u>0004| <u>               FOR HOUSE BILL 350, as amended
</u>    |
<u></u>0005| <u>  
</u>    |
<u></u>0006| <u>  has had it under consideration and reports same with recommendation
</u>    |
<u></u>0007| <u>  that it DO PASS, and thence referred to the FINANCE  COMMITTEE.
</u>    |
<u></u>0008| <u>               
</u>    |
<u></u>0009| <u>                               Respectfully submitted,
</u>    |
<u></u>0010| <u>  
</u>    |
<u></u>0011| <u>  
</u>    |
<u></u>0012| <u>  
</u>    |
<u></u>0013| <u>  
</u>    |
<u></u>0014| <u>                               __________________________________
</u>    |
<u></u>0015| <u>                               Shannon Robinson, Chairman 
</u>    |
<u></u>0016| <u>  
</u>    |
<u></u>0017| <u>  
</u>    |
<u></u>0018| <u>  Adopted_______________________   Not Adopted_______________________
</u>    |
<u></u>0019| <u>            (Chief Clerk)                          (Chief Clerk)
</u>    |
<u></u>0020| <u>  
</u>    |
<u></u>0021| <u>  
</u>    |
<u></u>0022| <u>                    Date ________________________
</u>    |
<u></u>0023| <u>  
</u>    |
<u></u>0024| <u>  
</u>    |
<u></u>0025| <u>  
</u>    |
<u></u>0001| <u>  The roll call vote was </u> 3 <u> For </u> 2 <u> Against
</u>    |
<u></u>0002| <u>          Yes:    3
</u>    |
<u></u>0003| <u>          No:     Adair, Boitano
</u>    |
<u></u>0004| <u>  Excused: Vernon, Rodarte, Garcia, Ingle
</u>    |
<u></u>0005| <u>          Absent: None
</u>    |
<u></u>0006| <u>  
</u>    |
<u></u>0007| <u>  
</u>    |
<u></u>0008| <u>  
</u>    |
<u></u>0009| <u>  
</u>    |
<u></u>0010| <u>  
</u>    |
<u></u>0011| <u>  H0350PA1                                                          
</u>    |
<u></u>0012| <u>  
</u>    |
<u></u>0013| <u>  
</u>    |
<u></u>0014| <u>  
</u>    |
<u></u>0015| <u>    
</u>    |
<u></u>0016| <u>  
</u>    |
<u></u>0017| <u>                        FORTY-THIRD LEGISLATURE
</u>    |
<u></u>0018| <u>                          FIRST SESSION, 1997
</u>    |
<u></u>0019| <u>  
</u>    |
<u></u>0020| <u>  
</u>    |
<u></u>0021| <u>                                                      March 19, 1997
</u>    |
<u></u>0022| <u>  
</u>    |
<u></u>0023| <u>  Mr. President:
</u>    |
<u></u>0024| <u>  
</u>    |
<u></u>0025| <u>      Your FINANCE COMMITTEE, to whom has been referred
</u>    |
<u></u>0001| <u>  
</u>    |
<u></u>0002| <u>            HOUSE LABOR AND HUMAN RESOURCES SUBSTITUTE FOR
</u>    |
<u></u>0003| <u>                      HOUSE BILL 350, as amended
</u>    |
<u></u>0004| <u>  
</u>    |
<u></u>0005| <u>  has had it under consideration and reports same with recommendation
</u>    |
<u></u>0006| <u>  that it DO PASS.
</u>    |
<u></u>0007| <u>  
</u>    |
<u></u>0008| <u>                               Respectfully submitted,
</u>    |
<u></u>0009| <u>  
</u>    |
<u></u>0010| <u>  
</u>    |
<u></u>0011| <u>  
</u>    |
<u></u>0012| <u>                               __________________________________
</u>    |
<u></u>0013| <u>                               Ben D. Altamirano, Chairman 
</u>    |
<u></u>0014| <u>  
</u>    |
<u></u>0015| <u>  
</u>    |
<u></u>0016| <u>  
</u>    |
<u></u>0017| <u>  Adopted_______________________   Not Adopted_______________________
</u>    |
<u></u>0018| <u>            (Chief Clerk)                          (Chief Clerk)
</u>    |
<u></u>0019| <u>  
</u>    |
<u></u>0020| <u>  
</u>    |
<u></u>0021| <u>  
</u>    |
<u></u>0022| <u>                    Date ________________________
</u>    |
<u></u>0023| <u>  
</u>    |
<u></u>0024| <u>  
</u>    |
<u></u>0025| <u>  The roll call vote was </u> 6 <u> For </u> 0 <u> Against
</u>    |
<u></u>0001| <u>          Yes:    6
</u>    |
<u></u>0002| <u>          No:     None
</u>    |
<u></u>0003| <u>               Excused:     Aragon, Eisenstadt, Ingle, McKibben, Smith
</u>    |
<u></u>0004| <u>          Absent: None
</u>    |
<u></u>0005| <u>  
</u>    |
<u></u>0006| <u>  
</u>    |
<u></u>0007| <u>  H0350FC1
</u>    |
<u>