0001| HOUSE BILL 351
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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| JOSE R. ABEYTA
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0005|
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0006|
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0007|
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0008| FOR THE HEALTH CARE REFORM COMMITTEE
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0009|
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0010| AN ACT
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0011| RELATING TO HEALTH CARE; ENACTING THE MEDICAID MANAGED CARE
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0012| ACT;
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0013| PROVIDING REQUIREMENTS FOR MEDICAID MANAGED HEALTH CARE PLANS;
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0014| IMPOSING A CIVIL PENALTY.
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0015|
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0016| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0017| Section 1. SHORT TITLE.--This act may be cited as the
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0018| "Medicaid Managed Care Act".
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0019| Section 2. DEFINITIONS.--As used in the Medicaid Managed
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0020| Care Act:
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0021| A. "enrollee", "patient" or "consumer" means an
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0022| individual who is entitled to receive health care benefits from
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0023| a managed health care plan;
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0024| B. "essential community provider" means a person
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0025| that provides a significant portion of its health or
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0001| health-related services to medically needy indigent patients,
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0002| including uninsured, underserved or special needs populations;
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0003| C. "health care facility" means an institution
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0004| providing health care services, including a hospital or other
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0005| licensed inpatient center, an ambulatory surgical or treatment
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0006| center, a skilled nursing center, a residential treatment
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0007| center, a home health agency, a diagnostic, laboratory or
|
0008| imaging center and a rehabilitation or other therapeutic health
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0009| setting;
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0010| D. "health care insurer" means a person that has a
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0011| valid certificate of authority in good standing under the New
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0012| Mexico Insurance Code to act as an insurer, a health
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0013| maintenance organization, a nonprofit health care plan or a
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0014| prepaid dental plan;
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0015| E. "health care professional" means a physician or
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0016| other health care practitioner, including a pharmacist, who is
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0017| licensed, certified or otherwise authorized by the state to
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0018| provide health services consistent with state law;
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0019| F. "health care provider" or "provider" means a
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0020| person that is licensed or otherwise authorized by the state to
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0021| furnish health care services and includes health care
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0022| professionals, health care facilities and essential community
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0023| providers;
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0024| G. "health care services" includes physical health
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0025| services or community-based mental health or developmental
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0001| disability services, including services for developmental
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0002| delay;
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0003| H. "managed health care plan" or "plan" means a
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0004| health benefit plan of a health care insurer or a provider
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0005| service network that either requires an enrollee to use, or
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0006| creates incentives, including financial incentives, for an
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0007| enrollee to use health care providers managed, owned, under
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0008| contract with or employed by the health care insurer. "Managed
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0009| health care plan" or "plan" includes a plan that provides
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0010| comprehensive health care services to enrollees on a prepaid,
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0011| capitated basis and includes the health care services offered
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0012| by a health maintenance organization, a preferred provider
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0013| organization, an individual practice organization, a
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0014| competitive medical plan, an exclusive provider organization,
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0015| an integrated delivery system, an independent physician-
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0016| provider organization, a physician hospital-provider
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0017| organization and a managed care services organization.
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0018| "Managed health care plan" or "plan" does not include a
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0019| traditional fee-for-service indemnity plan or a plan that
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0020| covers only short-term travel, accident-only, limited benefit
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0021| or specified disease policies;
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0022| I. "person" means an individual or other legal
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0023| entity;
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0024| J. "primary health care clinic" means a nonprofit
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0025| community-based entity established to provide the first level
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0001| of basic or general health care needs, including diagnostic and
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0002| treatment services, for residents of a health care underserved
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0003| area as that area is defined in regulation adopted by the
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0004| department of health; and
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0005| K. "provider service network" means two or more
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0006| health care providers affiliated for the purpose of providing
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0007| health care services to enrollees on a capitated or similar
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0008| prepaid, flat-rate basis.
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0009| Section 3. MEDICAID MANAGED HEALTH CARE PLAN OPERATIONS--
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0010| ENROLLMENT RESTRICTIONS--ADMINISTRATIVE ABUSES--PROFITS
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0011| LIMITED.--
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0012| A. Except as otherwise provided in the Medicaid
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0013| Managed Care Act, the human services department shall monitor
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0014| each managed health care plan offered through the medicaid
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0015| program and take all reasonable steps necessary to ensure that
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0016| each plan operates fairly and efficiently, protects patient
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0017| interests and fulfills the plan's primary obligation to deliver
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0018| good quality health care services. The department of health
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0019| shall be responsible for quality assurance and utilization
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0020| review oversight of medicaid managed health care plans.
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0021| B. No managed health care plan offered through the
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0022| medicaid program may directly recruit new members for
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0023| enrollment into the medicaid program. All recruiting and
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0024| enrollment of eligible persons into the medicaid program shall
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0025| be arranged directly by the human services department. The
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0001| department may provide for enrollment directly at hospitals or
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0002| other health care or government facilities.
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0003| C. The human services department shall regulate the
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0004| marketing activities of managed health care plans offered
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0005| through the medicaid program and prevent administrative abuses
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0006| in the operation of the plans.
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0007| D. No managed health care plan offered through the
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0008| medicaid program shall be allowed to earn profits in excess of
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0009| eight and one-half percent. The human services department
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0010| shall, in cooperation with the department of insurance, adopt
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0011| regulations to administer the provisions of this subsection.
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0012| The human services department shall enforce the provisions of
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0013| this subsection. Any profits earned in excess of eight and
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0014| one-half percent shall be returned to the human services
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0015| department, deposited by the department into an appropriate
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0016| state fund and expended for the purpose of expanding access to
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0017| health care for the uninsured or underinsured.
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0018| Section 4. SPECIALIZED HEALTH CARE PROGRAMS--ESSENTIAL
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0019| COMMUNITY PROVIDERS.--Until January 1, 2000, no managed health
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0020| care plan offered through the medicaid program shall offer
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0021| specialized behavioral or developmental disability health
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0022| services. The provisions of this section apply to the
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0023| specialized health care services needed for a person treated
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0024| for a developmental disability, a developmental delay, a
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0025| seriously disabling mental illness, a serious emotional
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0001| disturbance, physical or sexual abuse or neglect, substance
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0002| abuse or other behavioral health problem as defined in
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0003| regulation adopted by the department of health. Such
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0004| specialized behavioral or developmental disability health
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0005| services shall instead be provided, until January 1, 2000, only
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0006| by providers, including essential community providers, that
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0007| have been determined pursuant to regulation adopted by the
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0008| department of health or the children, youth and families
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0009| department to be qualified to offer specialized behavioral or
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0010| developmental disability health services.
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0011| Section 5. HEALTH CARE PROVIDER PARTICIPATION.--Any
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0012| health care provider that meets a medicaid managed health care
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0013| plan's reasonable qualification requirements and that is
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0014| willing to participate in the plan under its established
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0015| reasonable terms and conditions shall be allowed to participate
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0016| in the plan.
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0017| Section 6. PRIMARY HEALTH CARE CLINICS PARTICIPATION.--
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0018| A. A managed health care plan offered through the
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0019| medicaid program shall be required to use under reasonable
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0020| terms and conditions any primary health care clinic that elects
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0021| to participate in the plan, if the primary health care clinic
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0022| meets all reasonable quality of care and service payment
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0023| requirements imposed by the plan. The terms shall be no less
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0024| favorable than those offered any other provider, and they shall
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0025| provide payments that are reasonable and adequate to meet costs
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0001| incurred by efficiently and economically operated facilities,
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0002| taking into account the disproportionately greater severity of
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0003| illness and injury experienced by the patient population
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0004| served.
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0005| B. A managed health care plan offered through the
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0006| medicaid program may not limit the number or location of
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0007| primary health care clinics that elect to participate in the
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0008| plan.
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0009| C. In providing payments to a primary health care
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0010| clinic participating in a medicaid managed health care plan,
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0011| the human services department shall administer a program and
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0012| provide direct payments to ensure that a primary health care
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0013| clinic that was a federally qualified health center in 1996
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0014| under applicable federal law receives for at least the same
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0015| amount and type of services rendered in all subsequent years at
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0016| least the same amount of total payments under the medicaid
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0017| program that the primary care clinic received in the calendar
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0018| year ending December 31, 1996.
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0019| D. The human services department and each managed
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0020| health care plan that contracts with a primary health care
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0021| clinic shall provide timely payments at least quarterly to each
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0022| primary care clinic participating in the plan.
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0023| Section 7. INDIAN HEALTH SERVICE.--A Native American
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0024| eligible to receive health care services from the federal
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0025| Indian health service shall be given the option of
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0001| participating in a managed health care plan offered through the
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0002| medicaid program or receiving services directly from the Indian
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0003| health service. If an eligible Native American chooses to
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0004| participate in a managed health care plan, the Native American
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0005| shall at all times retain the option of receiving services
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0006| directly from the Indian health service. In that event, the
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0007| managed health care plan shall ensure that the Indian health
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0008| service receives the same payment it would have received for
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0009| the services rendered if the patient did not participate in the
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0010| plan.
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0011| Section 8. UNIVERSITY OF NEW MEXICO HEALTH SCIENCES
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0012| CENTER.--
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0013| A. A managed health care plan offered through the
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0014| medicaid program shall include participation by the university
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0015| of New Mexico health sciences center. The human services
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0016| department shall administer a program to ensure the
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0017| participation includes delivery of primary care and tertiary
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0018| care services so that the medicaid patient population served by
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0019| the university of New Mexico health sciences center remains at
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0020| least at a level similar to that served by the university of
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0021| New Mexico health sciences center prior to implementation of
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0022| the medicaid managed health care program.
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0023| B. A managed health care plan offered through the
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0024| medicaid program shall provide payments to the university of
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0025| New Mexico health sciences center at rates that are reasonable
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0001| and adequate to meet costs incurred by efficiently and
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0002| economically operated facilities, taking into account the
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0003| disproportionately greater severity of illness and injury
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0004| experienced by the patient population served.
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0005| C. The human services department shall administer a
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0006| program and cooperate with the university of New Mexico health
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0007| sciences center to ensure an adequate and diverse patient
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0008| population necessary to preserve the health sciences center's
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0009| educational programs. The human services department shall also
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0010| assure continuity of general support under the state medicaid
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0011| program to the university of New Mexico health sciences center
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0012| for medical education and for serving a disproportionately
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0013| large indigent patient population.
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0014| Section 9. PUBLIC NONPROFIT HOSPITALS.--
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0015| A. A managed health care plan offered through the
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0016| medicaid program shall be required to use under reasonable
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0017| terms and conditions any public nonprofit hospital that elects
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0018| to participate in the plan, if the hospital meets all
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0019| reasonable quality of care and service payment requirements
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0020| imposed by the plan. The terms shall be no less favorable than
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0021| those offered by any other provider, and they shall provide
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0022| payments that are reasonable and adequate to meet costs
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0023| incurred by efficiently and economically operated facilities,
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0024| taking into account the disproportionately greater severity of
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0025| illness and injury experienced by the patient population
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0001| served.
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0002| B. A managed health care plan offered through the
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0003| medicaid program may not limit the number or location of public
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0004| nonprofit hospitals that elect to participate in the plan.
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0005| Section 10. LAS VEGAS MEDICAL CENTER.--A managed health
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0006| care plan offered through the medicaid program shall include
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0007| participation by the Las Vegas medical center for hospitalized
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0008| care of mental health patients and other health services the
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0009| center provides. A plan shall provide payments to the Las
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0010| Vegas medical center under reasonable terms and conditions.
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0011| The terms shall be no less favorable than those offered any
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0012| other provider, and they shall provide payments that are
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0013| reasonable and adequate to meet costs incurred by efficiently
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0014| and economically operated facilities, taking into account the
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0015| disproportionately greater severity of illness and injury
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0016| experienced by the patient population served.
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0017| Section 11. AUTHORIZATION FOR MEDICAID MANAGED CARE
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0018| CONTRACTS DIRECTLY WITH PUBLIC AGENCIES, HOSPITALS, ESSENTIAL
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0019| COMMUNITY PROVIDERS AND PROVIDER SERVICE NETWORKS.--In
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0020| administering the medicaid program or a managed health care
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0021| system for the program, the human services department may
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0022| contract directly with a government agency or public body,
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0023| public nonprofit hospital, the university of New Mexico health
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0024| sciences center, an essential community provider or a provider
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0025| service network. In doing so, the human services department is
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0001| not required to contract with any such entity only through
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0002| arrangements with a health care insurer.
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0003| Section 12. ENFORCEMENT OF THE MEDICAID MANAGED CARE
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0004| ACT.--
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0005| A. The human services department or a person who
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0006| suffers a loss as a result of a violation of a provision in the
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0007| Medicaid Managed Care Act may bring an action to recover actual
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0008| damages or the sum of one hundred dollars ($100), whichever is
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0009| greater. When the trier of fact finds that the party charged
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0010| with the violation acted willfully, the court may award up to
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0011| three times actual damages or three hundred dollars ($300),
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0012| whichever is greater, to the party complaining of the
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0013| violation.
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0014| B. A person likely to be damaged by a denial of a
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0015| right protected in the Medicaid Managed Care Act may be granted
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0016| an injunction under the principles of equity and on terms that
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0017| the court considers reasonable. Proof of monetary damage or
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0018| intent to violate a right is not required.
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0019| C. 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 offered
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0021| through the medicaid program, an enrollee and a health care
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0022| provider participating in or eligible to participate in a
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0023| medicaid managed health care plan shall each be treated as a
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0024| third party beneficiary of the managed health care plan
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0025| contract between the health care insurer and the party with
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0001| which the insurer directly contracts. An enrollee or a health
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0002| care provider may sue to enforce the rights provided in the
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0003| contract that governs the managed health care plan.
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0004| D. The court shall award attorney fees and costs to
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0005| the party complaining of a violation of a right protected in
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0006| the Medicaid Managed Care Act if the party prevails
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0007| substantially in the lawsuit.
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0008| E. The relief provided in this section is in
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0009| addition to other remedies available against the same conduct
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0010| under the common law or other statutes of this state.
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0011|
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0012| F. In any class action filed under this section,
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0013| the court may award damages to the named plaintiffs as provided
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0014| in this section and may award members of the class the actual
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0015| damages suffered by each member of the class as a result of the
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0016| unlawful practice.
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0017| G. A person shall not be required to complete
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0018| available grievance procedures or exhaust administrative
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0019| remedies prior to seeking relief in court regarding a complaint
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0020| that may be filed under this section.
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0021| Section 13. PENALTY.--In addition to any other penalties
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0022| provided by law, the secretary of human services may impose a
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0023| civil administrative penalty of up to twenty-five thousand
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0024| dollars ($25,000) for each violation of the Medicaid Managed
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0025| Care Act. An administrative penalty shall be imposed by
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0001| written order of the secretary after holding a hearing as
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0002| provided for in the Administrative Procedures Act.
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0003| Section 14. REGULATIONS.--The human services department
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0004| may adopt regulations it deems necessary or appropriate to
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0005| administer the provisions of the Medicaid Managed Care Act.
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0006| Section 15. EFFECTIVE DATE.--The effective date of the
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0007| provisions of this act is July 1, 1997.
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0008| State of New Mexico
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0009| House of Representatives
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0010|
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0011| FORTY-THIRD LEGISLATURE
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0012| FIRST SESSION, 1997
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0013|
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0014|
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0015| February 18, 1997
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0016|
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0017|
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0018| Mr. Speaker:
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0019|
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0020| Your LABOR AND HUMAN RESOURCES COMMITTEE, to
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0021| whom has been referred
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0022|
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0023| HOUSE BILL 351
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0024|
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0025| has had it under consideration and reports same with
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0001| recommendation that it DO NOT PASS, but that
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0002|
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0003| HOUSE LABOR AND HUMAN RESOURCES COMMITTEE
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0004| SUBSTITUTE FOR HOUSE BILL 351
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0005|
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0006| DO PASS, amended as follows:
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0007|
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0008| 1. On page 12, strike lines 10 through 13 in their entirety
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0009| and reletter the succeeding subsection accordingly.,
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0010|
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0011| and thence referred to the JUDICIARY COMMITTEE.
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0012|
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0013| Respectfully submitted,
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0014|
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0015|
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0016|
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0017|
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0018|
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0019| Rick Miera, Chairman
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0020|
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0021|
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0022| Adopted Not Adopted
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0023|
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0024| (Chief Clerk) (Chief Clerk)
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0025|
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0001| Date
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0002|
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0003| The roll call vote was 5 For 2 Against
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0004| Yes: 5
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0005| No: Macko, Roberts
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0006| Excused: Marquardt
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0007| Absent: None
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0008|
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0009|
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0010|
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0011| G:\BILLTEXT\BILLW_97\H0351
|
0012| State of New Mexico
|
0013| House of Representatives
|
0014|
|
0015| FORTY-THIRD LEGISLATURE
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0016| FIRST SESSION, 1997
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0017|
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0018|
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0019| February 28, 1997
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0020|
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0021|
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0022| Mr. Speaker:
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0023|
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0024| Your JUDICIARY COMMITTEE, to whom has been referred
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0025|
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0001| HOUSE LABOR AND HUMAN RESOURCES COMMITTEE
|
0002| SUBSTITUTE FOR HOUSE BILL 351, as amended
|
0003|
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0004| has had it under consideration and reports same
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0005| with recommendation that it DO PASS, amended as
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0006| follows:
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0007|
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0008| 1. On page 5, line 3, after "E." strike the remainder of
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0009| the line, strike all of lines 4 through 13 and insert in lieu
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0010| thereof:
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0011|
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0012| "A managed health care plan offered through the
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0013| medicaid program shall be required to maintain a medical loss
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0014| ratio of at least ninety percent, so that at a minimum ninety
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0015| percent of all premium dollars collected are paid for the direct
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0016| provision of health care services. The department of insurance
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0017| shall adopt regulations to define the "medical loss ratio"
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0018| consistent with the provisions of this subsection.",
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0019|
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0020| and thence referred to the APPROPRIATIONS AND FINANCE
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0021| COMMITTEE.
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0022|
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0023|
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0024| Respectfully submitted,
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0025|
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0001|
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0002|
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0003|
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0004|
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0005| Thomas P. Foy, Chairman
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0006|
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0007|
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0008| Adopted Not Adopted
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0009|
|
0010| (Chief Clerk) (Chief Clerk)
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0011|
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0012| Date
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0013|
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0014| The roll call vote was 7 For 0 Against
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0015| Yes: 7
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0016| Excused: Alwin, King, Larranaga, Mallory, Rios, Sanchez
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0017| Absent: None
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0018|
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0019|
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0020| .117858.1
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0021| G:\BILLTEXT\BILLW_97\H0351 HOUSE LABOR AND HUMAN RESOURCES COMMITTEE SUBSTITUTE FOR
|
0022| HOUSE BILL 351
|
0023| 43rd legislature - STATE OF NEW MEXICO - first session, 1997
|
0024|
|
0025|
|
0001|
|
0002|
|
0003|
|
0004|
|
0005|
|
0006| AN ACT
|
0007| RELATING TO HEALTH CARE; ENACTING THE MEDICAID MANAGED CARE
|
0008| ACT;
|
0009| PROVIDING REQUIREMENTS FOR MEDICAID MANAGED HEALTH CARE PLANS;
|
0010| IMPOSING A CIVIL PENALTY.
|
0011|
|
0012| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
|
0013| Section 1. SHORT TITLE.--This act may be cited as the
|
0014| "Medicaid Managed Care Act".
|
0015| Section 2. DEFINITIONS.--As used in the Medicaid Managed
|
0016| Care Act:
|
0017| A. "enrollee", "patient" or "consumer" means an
|
0018| individual who is entitled to receive health care benefits from
|
0019| a managed health care plan;
|
0020| B. "essential community provider" means a person
|
0021| that provides a significant portion of its health or
|
0022| health-related services to medically needy indigent patients,
|
0023| including uninsured, underserved or special needs populations;
|
0024| C. "health care facility" means an institution
|
0025| providing health care services, including a hospital or other
|
0001| licensed inpatient center, an ambulatory surgical or treatment
|
0002| center, a skilled nursing center, a residential treatment
|
0003| center, a home health agency, a diagnostic, laboratory or
|
0004| imaging center and a rehabilitation or other therapeutic health
|
0005| setting;
|
0006| D. "health care insurer" means a person that has a
|
0007| valid certificate of authority in good standing under the New
|
0008| Mexico Insurance Code to act as an insurer, a health
|
0009| maintenance organization, a nonprofit health care plan or a
|
0010| prepaid dental plan;
|
0011| E. "health care professional" means a physician or
|
0012| other health care practitioner, including a pharmacist, who is
|
0013| licensed, certified or otherwise authorized by the state to
|
0014| provide health services consistent with state law;
|
0015| F. "health care provider" or "provider" means a
|
0016| person that is licensed or otherwise authorized by the state to
|
0017| furnish health care services and includes health care
|
0018| professionals, health care facilities and essential community
|
0019| providers;
|
0020| G. "health care services" includes physical health
|
0021| services or community-based mental health or developmental
|
0022| disability services, including services for developmental
|
0023| delay;
|
0024| H. "managed health care plan" or "plan" means a health
|
0025| benefit plan of a health care insurer or a provider service
|
0001| network that either requires an enrollee to use, or creates
|
0002| incentives, including financial incentives, for an enrollee to use
|
0003| health care providers managed, owned, under contract with or
|
0004| employed by the health care insurer. "Managed health care plan"
|
0005| or "plan" does not include a traditional fee-for-service indemnity
|
0006| plan or a plan that covers only short-term travel, accident-only,
|
0007| limited benefit, student health plan or specified disease
|
0008| policies;
|
0009| I. "person" means an individual or other legal entity;
|
0010| J. "primary health care clinic" means a nonprofit
|
0011| community-based entity established to provide the first level of
|
0012| basic or general health care needs, including diagnostic and
|
0013| treatment services, for residents of a health care underserved
|
0014| area as that area is defined in regulation adopted by the
|
0015| department of health; and
|
0016| K. "provider service network" means two or more health
|
0017| care providers affiliated for the purpose of providing health care
|
0018| services to enrollees on a capitated or similar prepaid, flat-rate
|
0019| basis.
|
0020| Section 3. MEDICAID MANAGED HEALTH CARE PLAN OPERATIONS--
|
0021| ENROLLMENT RESTRICTIONS--ADMINISTRATIVE ABUSES--PROFITS LIMITED.--
|
0022| A. Except as otherwise provided in the Medicaid
|
0023| Managed Care Act, the human services department shall monitor each
|
0024| managed health care plan offered through the medicaid program and
|
0025| take all reasonable steps necessary to ensure that each plan
|
0001| operates fairly and efficiently, protects patient interests and
|
0002| fulfills the plan's primary obligation to deliver good quality
|
0003| health care services. The human services department, in
|
0004| cooperation with the department of health, shall be responsible
|
0005| for quality assurance and utilization review oversight of medicaid
|
0006| managed health care plans.
|
0007| B. No managed health care plan offered through the
|
0008| medicaid program may directly recruit new members for enrollment
|
0009| into the medicaid program. All enrollment of eligible persons
|
0010| into the medicaid program shall be arranged directly by the human
|
0011| services department.
|
0012| C. The human services department, through its own
|
0013| offices and employees, joint powers agreements with other state
|
0014| agencies or by contract with one or more brokering agencies
|
0015| independent of any managed health care provider, shall fully
|
0016| inform medicaid eligible persons of their choices for enrollment
|
0017| into a managed health care plan. The department shall ensure that
|
0018| the enrollment process includes adequate time and information for
|
0019| enrollees to make informed choices about a plan. No managed
|
0020| health care plan offered through the medicaid program shall enroll
|
0021| medicaid recipients into its managed health care plan unless the
|
0022| enrollment is in accordance with arrangements approved by the
|
0023| department.
|
0024| D. The human services department shall regulate the
|
0025| marketing activities of managed health care plans offered through
|
0001| the medicaid program and prevent administrative abuses in the
|
0002| operation of the plans.
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0003| E. No managed health care plan offered through the
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0004| medicaid program shall be allowed to earn profits in excess of
|
0005| eight and one-half percent. The human services department shall,
|
0006| in cooperation with the department of insurance, adopt regulations
|
0007| to administer the provisions of this subsection. The human
|
0008| services department shall enforce the provisions of this
|
0009| subsection. Any profits earned in excess of eight and one-half
|
0010| percent shall be returned to the human services department,
|
0011| deposited by the department into an appropriate state fund and
|
0012| expended for the purpose of expanding access to health care for
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0013| the uninsured or underinsured.
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0014| Section 4. SPECIALIZED HEALTH CARE PROGRAMS--ESSENTIAL
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0015| COMMUNITY PROVIDERS.--Except as otherwise provided in the Medicaid
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0016| Managed Care Act, until January 1, 2000, no managed health care
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0017| plan offered through the medicaid program shall offer specialized
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0018| behavioral or developmental disability health services. The
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0019| provisions of this section apply to the specialized health care
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0020| services needed for a person treated for a developmental
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0021| disability, a developmental delay, a seriously disabling mental
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0022| illness, a serious emotional disturbance, physical or sexual abuse
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0023| or neglect, substance abuse or other behavioral health problem as
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0024| defined in regulation adopted by the department of health. Such
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0025| specialized behavioral or developmental disability health services
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0001| shall instead be provided, until January 1, 2000, only by
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0002| providers, including essential community providers, that have been
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0003| determined pursuant to regulation adopted by the department of
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0004| health or the children, youth and families department to be
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0005| qualified to offer specialized behavioral or developmental
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0006| disability health services.
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0007| Section 5. HEALTH CARE PROVIDER PARTICIPATION.--Any health
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0008| care provider that meets a medicaid managed health care plan's
|
0009| reasonable qualification requirements and that is willing to
|
0010| participate in the plan under its established reasonable terms and
|
0011| conditions shall be allowed to participate in the plan.
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0012| Section 6. PRIMARY HEALTH CARE CLINICS PARTICIPATION.--
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0013| A. A managed health care plan offered through the
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0014| medicaid program shall be required to use under reasonable terms
|
0015| and conditions any primary health care clinic that elects to
|
0016| participate in the plan, if the primary health care clinic meets
|
0017| all reasonable quality of care and service payment requirements
|
0018| imposed by the plan. The terms shall be no less favorable than
|
0019| those offered any other provider, and they shall provide payments
|
0020| that are reasonable and adequate to meet costs incurred by
|
0021| efficiently and economically operated facilities, taking into
|
0022| account the disproportionately greater severity of illness and
|
0023| injury experienced by the patient population served.
|
0024| B. A managed health care plan offered through the
|
0025| medicaid program may not limit the number or location of primary
|
0001| health care clinics that elect to participate in the plan.
|
0002| C. In providing payments under the medicaid program,
|
0003| the human services department shall ensure that a primary health
|
0004| care clinic that was or would have qualified as a federally
|
0005| qualified health center in 1996 under the federal act, as defined
|
0006| in 42 U.S.C. Section 1396d(l)(2), shall receive one hundred
|
0007| percent reasonable cost-based reimbursement for services, as was
|
0008| provided in the federal act during 1996 for the centers pursuant
|
0009| to the provisions of 42 U.S.C. Section 1396a(a)(13)(E).
|
0010| D. In administering the medicaid program, the human
|
0011| services department shall ensure that any managed care program for
|
0012| medicaid, whether implemented through a federal waiver, block
|
0013| grant or otherwise, shall require each health plan participating
|
0014| in the medicaid managed care program to contract with each primary
|
0015| health care clinic in its service area that was or would have
|
0016| qualified as a federally qualified health center in 1996 under the
|
0017| federal act, as defined in 42 U.S.C. Section 1396d(l)(2), for
|
0018| delivery of covered services at terms no less favorable than those
|
0019| offered to other providers in the plan for equivalent services.
|
0020| The department shall provide timely payments at least quarterly to
|
0021| federally qualified health centers to cover the difference between
|
0022| their one hundred percent reasonable costs, as was provided in the
|
0023| federal act during 1996 for the centers pursuant to the provisions
|
0024| of 42 U.S.C. Section 1396a(a)(13)(E), and the payments under
|
0025| medicaid managed care that are received by the federally qualified
|
0001| health centers.
|
0002| Section 7. INDIAN HEALTH SERVICE.--A Native American
|
0003| enrolled in a managed health care plan offered through the
|
0004| medicaid program shall be given the option of leaving that plan
|
0005| and receiving services directly from the Indian health service or
|
0006| health services provided by tribes under the federal Indian Self-
|
0007| Determination and Education Assistance Act, the federal urban
|
0008| Indian health program or the federal Indian children's program.
|
0009| If an eligible Native American chooses to participate in a managed
|
0010| health care plan, the Native American shall at all times retain
|
0011| the option of receiving services directly from the Indian health
|
0012| service or health services provided by tribes under the federal
|
0013| Indian Self-Determination and Education Assistance Act, the
|
0014| federal urban Indian health program or the federal Indian
|
0015| children's program. In that event, the managed health care plan
|
0016| shall ensure that the Indian health service receives the same
|
0017| payment it would have received for the services rendered if the
|
0018| patient did not participate in the plan.
|
0019| Section 8. UNIVERSITY OF NEW MEXICO HEALTH SCIENCES
|
0020| CENTER.--
|
0021| A. A managed health care plan offered through the
|
0022| medicaid program shall include participation by the university of
|
0023| New Mexico health sciences center. The human services department
|
0024| shall administer a program to ensure the participation includes
|
0025| delivery of primary care and tertiary care services and to attempt
|
0001| to ensure, to the extent permitted by federal law, that the
|
0002| medicaid patient population served by the university of New Mexico
|
0003| health sciences center remains at least at a level similar to that
|
0004| served by the university of New Mexico health sciences center
|
0005| prior to implementation of the medicaid managed health care
|
0006| program.
|
0007| B. A managed health care plan offered through the
|
0008| medicaid program shall provide payments to the university of New
|
0009| Mexico health sciences center at rates that are reasonable and
|
0010| adequate to meet costs incurred by efficiently and economically
|
0011| operated facilities, taking into account the disproportionately
|
0012| greater severity of illness and injury experienced by the patient
|
0013| population served.
|
0014| C. The human services department shall administer a
|
0015| program and cooperate with the university of New Mexico health
|
0016| sciences center to ensure an adequate and diverse patient
|
0017| population necessary to preserve the health sciences center's
|
0018| educational programs. The human services department shall also
|
0019| assure continuity of general support under the state medicaid
|
0020| program to the university of New Mexico health sciences center for
|
0021| medical education and for serving a disproportionately large
|
0022| indigent patient population.
|
0023| Section 9. PUBLIC NONPROFIT HOSPITALS.--
|
0024| A. A managed health care plan offered through the
|
0025| medicaid program shall be required to use under reasonable terms
|
0001| and conditions any public nonprofit hospital that elects to
|
0002| participate in the plan, if the hospital meets all reasonable
|
0003| quality of care and service payment requirements imposed by the
|
0004| plan. The terms shall be no less favorable than those offered by
|
0005| any other provider, and they shall provide payments that are
|
0006| reasonable and adequate to meet costs incurred by efficiently and
|
0007| economically operated facilities, taking into account the
|
0008| disproportionately greater severity of illness and injury
|
0009| experienced by the patient population served.
|
0010| B. A managed health care plan offered through the
|
0011| medicaid program may not limit the number or location of public
|
0012| nonprofit hospitals that elect to participate in the plan.
|
0013| Section 10. LAS VEGAS MEDICAL CENTER.--A managed health
|
0014| care plan offered through the medicaid program that offers mental
|
0015| health services shall include participation by the Las Vegas
|
0016| medical center for hospitalized care of mental health patients and
|
0017| other health services the center provides. A plan shall provide
|
0018| payments to the Las Vegas medical center under reasonable terms
|
0019| and conditions. For medicaid eligible populations, the terms
|
0020| shall be no less favorable than those offered any other provider,
|
0021| and they shall provide payments that are reasonable and adequate
|
0022| to meet costs incurred by efficiently and economically operated
|
0023| facilities, taking into account the disproportionately greater
|
0024| severity of illness and injury experienced by the patient
|
0025| population served.
|
0001| Section 11. AUTHORIZATION FOR MEDICAID MANAGED CARE
|
0002| CONTRACTS DIRECTLY WITH PUBLIC AGENCIES, HOSPITALS, ESSENTIAL
|
0003| COMMUNITY PROVIDERS AND PROVIDER SERVICE NETWORKS.--In
|
0004| administering the medicaid program or a managed health care system
|
0005| for the program, the human services department may contract
|
0006| directly with a government agency or public body, public nonprofit
|
0007| hospital, the university of New Mexico health sciences center, an
|
0008| essential community provider or a provider service network. In
|
0009| doing so, the human services department is not required to
|
0010| contract with any such entity only through arrangements with a
|
0011| health care insurer.
|
0012| Section 12. ENFORCEMENT OF THE MEDICAID MANAGED CARE
|
0013| ACT.--
|
0014| A. The human services department or a person who
|
0015| suffers a loss as a result of a violation of a provision in the
|
0016| Medicaid Managed Care Act may bring an action to recover actual
|
0017| damages or the sum of one hundred dollars ($100), whichever is
|
0018| greater. When the trier of fact finds that the party charged with
|
0019| the violation acted willfully, the court may award up to three
|
0020| times actual damages or three hundred dollars ($300), whichever is
|
0021| greater, to the party complaining of the violation.
|
0022| B. A person likely to be damaged by a denial of a
|
0023| right protected in the Medicaid Managed Care Act may be granted an
|
0024| injunction under the principles of equity and on terms that the
|
0025| court considers reasonable. Proof of monetary damage or intent to
|
0001| violate a right is not required.
|
0002| C. To protect and enforce an enrollee's or a health
|
0003| care provider's rights in a managed health care plan offered
|
0004| through the medicaid program, an enrollee and a health care
|
0005| provider participating in or eligible to participate in a medicaid
|
0006| managed health care plan shall each be treated as a third party
|
0007| beneficiary of the managed health care plan contract between the
|
0008| health care insurer and the party with which the insurer directly
|
0009| contracts. An enrollee or a health care provider may sue to
|
0010| enforce the rights provided in the contract that governs the
|
0011| managed health care plan.
|
0012| D. The court shall award attorney fees and costs to
|
0013| the party complaining of a violation of a right protected in the
|
0014| Medicaid Managed Care Act if the party prevails substantially in
|
0015| the lawsuit.
|
0016| E. The relief provided in this section is in addition
|
0017| to other remedies available against the same conduct under the
|
0018| common law or other statutes of this state.
|
0019| F. In any class action filed under this section, the
|
0020| court may award damages to the named plaintiffs as provided in
|
0021| this section and may award members of the class the actual damages
|
0022| suffered by each member of the class as a result of the unlawful
|
0023| practice.
|
0024| G. A person shall not be required to complete
|
0025| available grievance procedures or exhaust administrative remedies
|
0001| prior to seeking relief in court regarding a complaint that may be
|
0002| filed under this section.
|
0003| Section 13. PENALTY.--In addition to any other penalties
|
0004| provided by law, the secretary of human services may impose a
|
0005| civil administrative penalty of up to twenty-five thousand dollars
|
0006| ($25,000) for each violation of the Medicaid Managed Care Act. An
|
0007| administrative penalty shall be imposed by written order of the
|
0008| secretary after holding a hearing as provided for in the Public
|
0009| Assistance Appeals Act.
|
0010| Section 14. REGULATIONS.--The human services department may
|
0011| adopt regulations it deems necessary or appropriate to administer
|
0012| the provisions of the Medicaid Managed Care Act.
|
0013| Section 15. EFFECTIVE DATE.--The effective date of the
|
0014| provisions of this act is July 1, 1997.
|
0015|
|
0016|
|
0017| FORTY-THIRD LEGISLATURE
|
0018| FIRST SESSION, 1997
|
0019|
|
0020|
|
0021| March 16, 1997
|
0022|
|
0023| Mr. President:
|
0024|
|
0025| Your PUBLIC AFFAIRS COMMITTEE, to whom has been referred
|
0001|
|
0002| HOUSE LABOR AND HUMAN RESOURCES
|
0003| COMMITTEE SUBSTITUTE FOR
|
0004| HOUSE BILL 351, as amended
|
0005|
|
0006| has had it under consideration and reports same with recommendation
|
0007| that it DO PASS.
|
0008|
|
0009| Respectfully submitted,
|
0010|
|
0011|
|
0012|
|
0013| __________________________________
|
0014| Shannon Robinson, Chairman
|
0015|
|
0016|
|
0017|
|
0018| Adopted_______________________ Not Adopted_______________________
|
0019| (Chief Clerk) (Chief Clerk)
|
0020|
|
0021|
|
0022|
|
0023| Date ________________________
|
0024|
|
0025|
|
0001| The roll call vote was 5 For 0 Against
|
0002| Yes: 5
|
0003| No: 0
|
0004| Excused: Boitano, Garcia, Ingle, Rodarte
|
0005| Absent: None
|
0006|
|
0007|
|
0008| H0351PA1
|