0001| HOUSE BILL 406 | 0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997 | 0003| INTRODUCED BY | 0004| JOSE R. ABEYTA | 0005| | 0006| | 0007| | 0008| | 0009| | 0010| AN ACT | 0011| RELATING TO HEALTH CARE; ENACTING THE ANY WILLING PROVIDER ACT; | 0012| PROVIDING FOR CRIMINAL AND CIVIL PENALTIES AND ENFORCEMENT. | 0013| | 0014| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0015| Section 1. SHORT TITLE.--This act may be cited as the | 0016| "Any Willing Provider Act". | 0017| Section 2. DEFINITIONS.--As used in the Any Willing | 0018| Provider Act: | 0019| A. "durable medical equipment" includes iron lungs, | 0020| oxygen tents, hospital beds and wheelchairs; | 0021| B. "health care facility" means an institution | 0022| providing health care services, including a hospital or other | 0023| licensed inpatient center, an ambulatory surgical or treatment | 0024| center, a skilled nursing center, a residential treatment | 0025| center, a home health agency, a diagnostic, laboratory or | 0001| imaging center and a rehabilitation or other therapeutic health | 0002| setting; | 0003| C. "health care insurer" means a person that has a | 0004| valid certificate of authority in good standing under the New | 0005| Mexico Insurance Code to act as an insurer, health maintenance | 0006| organization, nonprofit health care plan or prepaid dental | 0007| plan; | 0008| D. "health care professional" means a physician or | 0009| other health care practitioner, including a pharmacist, who is | 0010| licensed, certified or otherwise authorized by the state to | 0011| provide health services or durable medical equipment consistent | 0012| with state law; | 0013| E. "health care provider" or "provider" means a | 0014| person that is licensed or otherwise authorized by the state to | 0015| furnish health care services or provide durable medical | 0016| equipment and includes health care professionals and health | 0017| care facilities; | 0018| F. "health care services" includes physical health | 0019| services or community-based mental health or developmental | 0020| disability services; | 0021| G. "managed health care plan" or "plan" means a | 0022| health benefit plan of a health care insurer or a provider | 0023| service network that either requires an enrollee to use, or | 0024| creates incentives, including financial incentives, for an | 0025| enrollee to use health care providers managed, owned, under | 0001| contract with or employed by the health care insurer. "Managed | 0002| health care plan" includes a plan that provides comprehensive | 0003| health care services to enrollees on a prepaid, capitated basis | 0004| and includes the health care services offered by a health | 0005| maintenance organization, a preferred provider organization, an | 0006| individual practice organization, a competitive medical plan, | 0007| an exclusive provider organization, an integrated delivery | 0008| system, an independent physician-provider organization, a | 0009| physician hospital-provider organization and a managed care | 0010| services organization. "Managed health care plan" or "plan" | 0011| does not include a traditional fee-for-service indemnity plan | 0012| or a plan that covers only short-term travel, accidents, | 0013| limited benefits or specified diseases; | 0014| H. "person" means an individual or other legal | 0015| entity; and | 0016| I. "provider service network" means two or more | 0017| health care providers affiliated for the purpose of providing | 0018| health care services to enrollees on a capitated or similar | 0019| prepaid flat-rate basis. | 0020| Section 3. ANY WILLING PROVIDER RULE.-- | 0021| A. Any health care provider that meets a medicaid | 0022| managed health care plan's reasonable qualification | 0023| requirements and that is willing to participate in the plan | 0024| under its established reasonable terms and conditions is | 0025| entitled to participate as a provider in the plan. | 0001| B. Any managed health care plan that is offered, | 0002| delivered, issued for delivery, continued, renewed or operated | 0003| on or after July 1, 1997 that violates the provisions of | 0004| Subsection A of this section shall be null and void. | 0005| Section 4. CRIMINAL PENALTY AND ENFORCEMENT.-- | 0006| A. An insurer that violates the provisions of | 0007| Section 3 of the Any Willing Provider Act is guilty of a | 0008| misdemeanor and shall be punished by a fine of not more than | 0009| five thousand dollars ($5,000) or by imprisonment for a | 0010| definite term not to exceed one year or both. | 0011| B. Each violation of the provisions of Section 3 of | 0012| the Any Willing Provider Act, as to each provider and each | 0013| refusal to comply, constitutes a separate offense. | 0014| C. If the superintendent of insurance has reason to | 0015| believe that a person has violated a provision of the Any | 0016| Willing Provider Act, the superintendent shall refer the matter | 0017| to the attorney general or another appropriate law enforcement | 0018| official for enforcement proceedings pursuant to the provisions | 0019| of Section 59A-2-11 NMSA 1978. | 0020| Section 5. PRIVATE CIVIL ENFORCEMENT.-- | 0021| A. A person who suffers a loss as a result of a | 0022| violation of a provision in the Any Willing Provider Act may | 0023| bring an action to recover actual damages or the sum of one | 0024| hundred dollars ($100), whichever is greater. When the trier | 0025| of fact finds that the party charged with the violation acted | 0001| willfully, the court may award up to three times actual damages | 0002| or three hundred dollars ($300), whichever is greater, to the | 0003| party complaining of the violation. | 0004| B. A person likely to be injured by a violation of | 0005| the Any Willing Provider Act may seek and be granted an | 0006| injunction on terms that the court considers reasonable. Proof | 0007| of monetary damage or intent to violate a right is not | 0008| required. | 0009| C. The court shall award attorney fees and costs to | 0010| the party complaining of a violation of the Any Willing | 0011| Provider Act if the party prevails substantially in the | 0012| lawsuit. | 0013| D. The relief provided in this section is in | 0014| addition to other remedies available against the same conduct | 0015| under the common law or other statutes of this state. | 0016| | 0017| E. In any class action filed under this section, | 0018| the court may award damages to the named plaintiffs as provided | 0019| in this section and may award members of the class the actual | 0020| damages suffered by each member of the class as a result of the | 0021| unlawful practice. | 0022| Section 6. EFFECTIVE DATE.--The effective date of the | 0023| provisions of this act is July 1, 1997. | 0024|  |