0001|                            HOUSE BILL 571
    |
0002|     43rd legislature - STATE OF NEW MEXICO - first session, 1997
    |
0003|                            INTRODUCED BY
    |
0004|                          EDWARD C. SANDOVAL
    |
0005|     
    |
0006|                                   
    |
0007|     
    |
0008|                                   
    |
0009|     
    |
0010|                                AN ACT
    |
0011|     RELATING TO HEALTH INSURANCE; REQUIRING COVERAGE FOR
    |
0012|     INDIVIDUALS WITH DIABETES; AMENDING AND ENACTING SECTIONS OF
    |
0013|     THE NMSA 1978.
    |
0014|     
    |
0015|     BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
    |
0016|          Section 1.  A new section of the New Mexico Insurance
    |
0017|     Code, Section 59A-22-41 NMSA 1978, is enacted to read:
    |
0018|          "59A-22-41.  [<u>NEW MATERIAL</u>]  COVERAGE FOR INDIVIDUALS
    |
0019|     WITH DIABETES.--
    |
0020|               A.  Each individual and group health insurance
    |
0021|     policy, health care plan, certificate of health insurance and
    |
0022|     managed health care plan delivered or issued for delivery in
    |
0023|     this state shall provide coverage for individuals with
    |
0024|     insulin-using diabetes, with non-insulin-using diabetes and
    |
0025|     with elevated blood glucose levels induced by pregnancy.  This
    |
0001|     coverage shall be a basic health care benefit and shall entitle
    |
0002|     each individual to the medically accepted standard of medical
    |
0003|     care for diabetes and benefits for diabetes treatment as well
    |
0004|     as diabetes supplies, and this coverage shall not be reduced or
    |
0005|     eliminated. 
    |
0006|               B.  Coverage for individuals with diabetes may be
    |
0007|     subject to deductibles and coinsurance consistent with those
    |
0008|     imposed on other benefits under the same policy, plan or
    |
0009|     certificate, as long as the annual deductibles or coinsurance
    |
0010|     for benefits are no greater than the annual deductibles or
    |
0011|     coinsurance established for similar benefits within a given
    |
0012|     policy.
    |
0013|               C.  When prescribed or diagnosed by a health care
    |
0014|     practitioner with prescribing authority, all individuals with
    |
0015|     diabetes as described in Subsection A of this section enrolled
    |
0016|     in health policies described in that subsection shall be
    |
0017|     entitled to the following equipment, supplies and appliances to
    |
0018|     treat diabetes:
    |
0019|                    (1)  blood glucose monitors, including those
    |
0020|     for the legally blind;
    |
0021|                    (2)  test strips for blood glucose monitors;
    |
0022|                    (3)  visual reading urine and ketone strips;
    |
0023|                    (4)  lancets and lancet devices;
    |
0024|                    (5)  insulin;
    |
0025|                    (6)  injection aids, including those adaptable
    |
0001|     to meet the needs of the legally blind;
    |
0002|                    (7)  syringes;
    |
0003|                    (8)  prescriptive oral agents for controlling
    |
0004|     blood sugar levels;
    |
0005|                    (9)  podiatric appliances for prevention of
    |
0006|     feet complications associated with diabetes, including
    |
0007|     therapeutic molded or depth-inlay shoes, functional orthotics,
    |
0008|     custom molded inserts, replacement inserts, preventive devices
    |
0009|     and shoe modifications for prevention and treatment; and
    |
0010|                    (10)  glucagon emergency kits.
    |
0011|               D.  When prescribed or diagnosed by a health care
    |
0012|     practitioner with prescribing authority, all individuals with
    |
0013|     diabetes as described in Subsection A of this section enrolled
    |
0014|     in health policies described in that subsection shall be
    |
0015|     entitled to the following basic health care benefits:
    |
0016|                    (1)  diabetes self-management training that
    |
0017|     shall be provided by a certified, registered or licensed health
    |
0018|     care professional with recent education in diabetes management,
    |
0019|     which shall be limited to:
    |
0020|                         (a)  medically necessary visits upon the
    |
0021|     diagnosis of diabetes;
    |
0022|                         (b)  visits following a physician
    |
0023|     diagnosis that represents a significant change in the patient's
    |
0024|     symptoms or condition that warrants changes in the patient's
    |
0025|     self-management; and
    |
0001|                         (c)  visits when re-education or
    |
0002|     refresher training is prescribed by a health care practitioner
    |
0003|     with prescribing authority; and
    |
0004|                    (2)  medical nutrition therapy related to
    |
0005|     diabetes management.
    |
0006|               E.  When new or improved equipment, appliances,
    |
0007|     prescription drugs for the treatment of diabetes, insulin or
    |
0008|     supplies for the treatment of diabetes are approved by the food
    |
0009|     and drug administration, all individual or group health
    |
0010|     insurance policies as described in Subsection A of this section
    |
0011|     shall:
    |
0012|                    (1)  maintain an adequate formulary to provide
    |
0013|     these resources to individuals with diabetes; and
    |
0014|                    (2)  guarantee reimbursement or coverage for
    |
0015|     the equipment, appliances, prescription drug, insulin or
    |
0016|     supplies described in this subsection within the limits of the
    |
0017|     health care plan, policy or certificate.
    |
0018|               F.  The provisions of Subsections A through E of
    |
0019|     this section shall be enforced by the superintendent.
    |
0020|               G.  The provisions of this section shall not apply
    |
0021|     to short-term travel, accident-only or limited or specified
    |
0022|     disease policies.
    |
0023|               H.  For purposes of this section:
    |
0024|                    (1)  "basic health care benefits":
    |
0025|                         (a)  means benefits for medically
    |
0001|     necessary services consisting of preventive care, emergency
    |
0002|     care, inpatient and outpatient hospital and physician care,
    |
0003|     diagnostic laboratory and diagnostic and therapeutic
    |
0004|     radiological services; and
    |
0005|                         (b)  does not include mental health
    |
0006|     services or services for alcohol or drug abuse, dental or
    |
0007|     vision services or long-term rehabilitation treatment; and
    |
0008|                    (2)  "managed health care plan" means a health
    |
0009|     benefit plan offered by a health care insurer that provides for
    |
0010|     the delivery of comprehensive basic health care services and
    |
0011|     medically necessary services to individuals enrolled in the
    |
0012|     plan through its own employed health care providers or by
    |
0013|     contracting with selected or participating health care
    |
0014|     providers.  A managed health care plan includes only those
    |
0015|     plans that provide comprehensive basic health care services to
    |
0016|     enrollees on a prepaid, capitated basis, including the
    |
0017|     following:
    |
0018|                         (a)  health maintenance organizations;
    |
0019|                         (b)  preferred provider organizations;
    |
0020|                         (c)  individual practice associations;
    |
0021|                         (d)  competitive medical plans;
    |
0022|                         (e)  exclusive provider organizations;
    |
0023|                         (f)  integrated delivery systems;
    |
0024|                         (g)  independent physician-provider
    |
0025|     organizations; 
    |
0001|                         (h)  physician hospital-provider
    |
0002|     organizations; and
    |
0003|                         (i)  managed care services
    |
0004|     organizations."     Section 2.  Section 59A-23-4 NMSA 1978
    |
0005|     (being Laws 1984, Chapter 127, Section 463, as amended) is
    |
0006|     amended to read:
    |
0007|          "59A-23-4.  OTHER PROVISIONS APPLICABLE.--
    |
0008|               A.  No blanket or group health insurance policy or
    |
0009|     contract shall contain any provision relative to notice or
    |
0010|     proof of loss or the time for paying benefits or the time
    |
0011|     within which suit may be brought upon the policy that in the
    |
0012|     superintendent's opinion is less favorable to the insured than
    |
0013|     would be permitted in the required or optional provisions for
    |
0014|     individual health insurance policies as set forth in Chapter
    |
0015|     59A, Article 22 NMSA 1978.
    |
0016|               B.  The following provisions of Chapter 59A, Article
    |
0017|     22 NMSA 1978 shall also apply as to Chapter 59A, Article 23
    |
0018|     NMSA 1978 and blanket and group health insurance contracts:
    |
0019|                    (1)  Section 59A-22-1 NMSA 1978, except
    |
0020|     Subsection C <s>[thereof]</s> <u>of that section</u>; and
    |
0021|                    (2)  Section 59A-22-32 NMSA 1978.
    |
0022|               C.  The following provisions of Chapter 59A, Article
    |
0023|     22 NMSA 1978 shall also apply as to group health insurance
    |
0024|     contracts:
    |
0025|                    (1)  Section 59A-22-33 NMSA 1978;
    |
0001|                    (2)  Section 59A-22-34 NMSA 1978;
    |
0002|                    (3)  Section 59A-22-34.1 NMSA 1978;
    |
0003|                    (4)  Section 59A-22-35 NMSA 1978; 
    |
0004|                    (5)  Section 59A-22-36 NMSA 1978; 
    |
0005|                    (6)  Section 59A-22-39 NMSA 1978; <s>[and]</s>
    |
0006|                    (7)  Section 59A-22-40 NMSA 1978; <u>and</u>
    |
0007|                    <u>(8)  Section 59A-22-41 NMSA 1978</u>."    
    |
0008|          Section 3.  A new section of the Health Maintenance
    |
0009|     Organization Law, Section 59A-46-43 NMSA 1978, is enacted to
    |
0010|     read:
    |
0011|          "59A-46-43.  [<u>NEW MATERIAL</u>]  COVERAGE FOR INDIVIDUALS
    |
0012|     WITH DIABETES.--
    |
0013|               A.  Each individual and group health maintenance
    |
0014|     organization contract delivered or issued for delivery in this
    |
0015|     state shall provide coverage for individuals with insulin-using
    |
0016|     diabetes, with non-insulin-using diabetes and with elevated
    |
0017|     blood glucose levels induced by pregnancy.  This coverage shall
    |
0018|     be a basic health care service and shall entitle each
    |
0019|     individual to the medically accepted standard of medical care
    |
0020|     for diabetes and benefits for diabetes treatment as well as
    |
0021|     diabetes supplies, and this coverage shall not be reduced or
    |
0022|     eliminated.
    |
0023|               B.  Coverage for individuals with diabetes may be
    |
0024|     subject to deductibles and coinsurance consistent with those
    |
0025|     imposed on other benefits under the same contract, as long as
    |
0001|     the annual deductibles or coinsurance for benefits are no
    |
0002|     greater than the annual deductibles or coinsurance established
    |
0003|     for similar benefits within a given contract.
    |
0004|               C.  When prescribed or diagnosed by a health care
    |
0005|     practitioner with prescribing authority, all individuals with
    |
0006|     diabetes as described in Subsection A of this section enrolled
    |
0007|     under an individual or group health maintenance organization
    |
0008|     contract shall be entitled to the following equipment, supplies
    |
0009|     and appliances to treat diabetes:
    |
0010|                    (1)  blood glucose monitors, including those
    |
0011|     for the legally blind;
    |
0012|                    (2)  test strips for blood glucose monitors;
    |
0013|                    (3)  visual reading urine and ketone strips;
    |
0014|                    (4)  lancets and lancet devices;
    |
0015|                    (5)  insulin;
    |
0016|                    (6)  injection aids, including those adaptable
    |
0017|     to meet the needs of the legally blind;
    |
0018|                    (7)  syringes;
    |
0019|                    (8)  prescriptive oral agents for controlling
    |
0020|     blood sugar levels;
    |
0021|                    (9)  podiatric appliances for prevention of
    |
0022|     feet complications associated with diabetes, including
    |
0023|     therapeutic molded or depth-inlay shoes, functional orthotics,
    |
0024|     custom molded inserts, replacement inserts, preventive devices
    |
0025|     and shoe modifications for prevention and treatment; and
    |
0001|                    (10)  glucagon emergency kits.
    |
0002|               D.  When prescribed or diagnosed by a health care
    |
0003|     practitioner with prescribing authority, all individuals with
    |
0004|     diabetes as described in Subsection A of this section enrolled
    |
0005|     under an individual or group health maintenance contract shall
    |
0006|     be entitled to the following basic health care services:
    |
0007|                    (1)  diabetes self-management training that
    |
0008|     shall be provided by a certified, registered or licensed health
    |
0009|     care professional with recent education in diabetes management,
    |
0010|     which shall be limited to:
    |
0011|                         (a)  medically necessary visits upon the
    |
0012|     diagnosis of diabetes;
    |
0013|                         (b)  visits following a physician
    |
0014|     diagnosis that represents a significant change in the patient's
    |
0015|     symptoms or condition that warrants changes in the patient's
    |
0016|     self-management; and
    |
0017|                         (c)  visits when re-education or
    |
0018|     refresher training is prescribed by a health care practitioner
    |
0019|     with prescribing authority; and
    |
0020|                    (2)  medical nutrition therapy related to
    |
0021|     diabetes management.
    |
0022|               E.  When new or improved equipment, appliances,
    |
0023|     prescription drugs for the treatment of diabetes, insulin or
    |
0024|     supplies for the treatment of diabetes are approved by the food
    |
0025|     and drug administration, each individual or group health
    |
0001|     maintenance organization contract shall:
    |
0002|                    (1)  maintain an adequate formulary to provide
    |
0003|     these resources to individuals with diabetes; and
    |
0004|                    (2)  guarantee reimbursement or coverage for
    |
0005|     the equipment, appliances, prescription drug, insulin or
    |
0006|     supplies described in this subsection within the limits of the
    |
0007|     health care plan, policy or certificate.
    |
0008|               F.  The provisions of Subsections A through E of
    |
0009|     this section shall be enforced by the superintendent.
    |
0010|               G.  The provisions of this section shall not apply
    |
0011|     to short-term travel, accident-only or limited or specified
    |
0012|     disease policies."
    |
0013|          Section 4.  Section 59A-47-33 NMSA 1978 (being Laws 1984,
    |
0014|     Chapter 127, Section 879.32, as amended by Laws 1994, Chapter
    |
0015|     64, Section 10 and also by Laws 1994, Chapter 75, Section 34)
    |
0016|     is amended to read:
    |
0017|          "59A-47-33.  OTHER PROVISIONS APPLICABLE.--The provisions
    |
0018|     of the Insurance Code other than Chapter 59A, Article 47 NMSA
    |
0019|     1978 shall not apply to health care plans except as expressly
    |
0020|     provided in the Insurance Code and that article.  To the extent
    |
0021|     reasonable and not inconsistent with the provisions of that
    |
0022|     article, the following articles and provisions of the Insurance
    |
0023|     Code shall also apply to health care plans, their promoters,
    |
0024|     sponsors, directors, officers, employees, agents, solicitors
    |
0025|     and other representatives; and, for the purposes of such
    |
0001|     applicability, a health care plan may therein be referred to as
    |
0002|     an "insurer":
    |
0003|               A.  Chapter 59A, Article 1 NMSA 1978;
    |
0004|               B.  Chapter 59A, Article 2 NMSA 1978;
    |
0005|               C.  Chapter 59A, Article 4 NMSA 1978;
    |
0006|               D.  Subsection C of Section 59A-5-22 NMSA 1978;
    |
0007|               E.  Sections 59A-6-2 through 59A-6-4 and 
    |
0008|     59A-6-6 NMSA 1978;
    |
0009|               F.  Section 59A-7-11 NMSA 1978;
    |
0010|               G.  Chapter 59A, Article 8 NMSA 1978;
    |
0011|               H.  Chapter 59A, Article 10 NMSA 1978;
    |
0012|               I.  Section 59A-12-22 NMSA 1978;
    |
0013|               J.  Chapter 59A, Article 16 NMSA 1978;
    |
0014|               K.  Chapter 59A, Article 18 NMSA 1978;
    |
0015|               L.  Chapter 59A, Article 19 NMSA 1978;
    |
0016|               M.  Subsections B through E of Section 
    |
0017|     59A-22-5 NMSA 1978;
    |
0018|               N.  Section 59A-22-34.1 NMSA 1978; 
    |
0019|               O.  Section 59A-22-39 NMSA 1978;
    |
0020|               P.  Section 59A-22-40 NMSA 1978;
    |
0021|               <u>Q.  Section 59A-22-41 NMSA 1978</u>;
    |
0022|               <s>[Q.]</s> <u>R.</u>  Sections 59A-34-9 through 59A-34-13
    |
0023|     <s>[NMSA 1978]</s> and <s>[Section]</s> 59A-34-23 NMSA 1978;
    |
0024|               <s>[R.]</s> <u>S.</u>  Chapter 59A, Article 37 NMSA 1978,
    |
0025|     except Section 59A-37-7 NMSA 1978; and
    |
0001|               <s>[S.]</s> <u>T.</u>  Section 59A-46-15 NMSA 1978."
    |
0002|          Section 5.  EFFECTIVE DATE.--The effective date of the
    |
0003|     provisions of this act is January 1, 1998.
    |
0004|                                - 11 -                       State of New Mexico
    |
0005|                      House of Representatives
    |
0006|   
    |
0007|                      FORTY-THIRD LEGISLATURE
    |
0008|                        FIRST SESSION, 1997
    |
0009|   
    |
0010|   
    |
0011|                                               February 20, 1997
    |
0012|   
    |
0013|   
    |
0014|   Mr. Speaker:
    |
0015|   
    |
0016|        Your CONSUMER AND PUBLIC AFFAIRS COMMITTEE, to
    |
0017|   whom has been referred
    |
0018|   
    |
0019|                        HOUSE BILL 571
    |
0020|   
    |
0021|   has had it under consideration and reports same with
    |
0022|   recommendation that it DO PASS, amended as follows:
    |
0023|   
    |
0024|        
    |
0025|        1.  On page 3, line 4, after "(9)" insert "medically
    |
0001|   necessary".
    |
0002|   
    |
0003|        2.  On page 8, line 17, after "(9)" insert "medically
    |
0004|   necessary".,
    |
0005|   
    |
0006|   
    |
0007|   
    |
0008|   and thence referred to the APPROPRIATIONS AND FINANCE
    |
0009|   COMMITTEE.
    |
0010|   
    |
0011|                                 Respectfully submitted,
    |
0012|   
    |
0013|   
    |
0014|   
    |
0015|                                 <u>                                
</u>    |
<u></u>0016| <u>  
</u>    |
<u></u>0017| <u>                                </u>                             Gary King, Chairman
    |
0018|   
    |
0019|   
    |
0020|   Adopted <u>                    </u>     Not Adopted <u>                    
</u>    |
<u></u>0021| <u>   </u>
    |
0022|             (Chief Clerk)                       (Chief Clerk)
    |
0023|   
    |
0024|                        Date <u>            </u>
    |
0025|   
    |
0001|   The roll call vote was<u> 8 </u> For<u> 0 </u> Against
    |
0002|                  Yes:      8    
    |
0003|             Excused:  Rios, Vigil
    |
0004|             Absent:   None
    |
0005|   
    |
0006|   
    |
0007|   117545.1
    |
0008|   G:\BILLTEXT\BILLW_97\H0571
    |