0001| HOUSE APPROPRIATIONS AND FINANCE COMMITTEE SUBSTITUTE FOR | 0002| HOUSE BILL 1269 | 0003| 43rd legislature - STATE OF NEW MEXICO - first session, 1997 | 0004| | 0005| | 0006| | 0007| | 0008| | 0009| | 0010| | 0011| AN ACT | 0012| RELATING TO HEALTH CARE; ENACTING THE MEDICAID MANAGED CARE | 0013| ACT; PROVIDING REQUIREMENTS FOR THE MEDICAID MANAGED HEALTH | 0014| CARE SYSTEM AND MEDICAID MANAGED HEALTH CARE PLANS; IMPOSING A | 0015| CIVIL PENALTY. | 0016| | 0017| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0018| Section 1. SHORT TITLE.--This act may be cited as the | 0019| "Medicaid Managed Care Act". | 0020| Section 2. PURPOSE OF ACT.-- | 0021| A. The purpose of the Medicaid Managed Care Act is | 0022| to protect medicaid recipients, especially those populations | 0023| with special needs; health care providers serving the medicaid | 0024| population in New Mexico, especially those in rural and | 0025| underserved areas and serving a disproportionately large | 0001| population of poor persons; and the state, which administers | 0002| and helps finance the medicaid program and seeks to ensure that | 0003| an equitable health care delivery system is available | 0004| throughout New Mexico. | 0005| B. The Medicaid Managed Care Act seeks to provide | 0006| for a reasonable transition to a fair and effective managed | 0007| health care system for the medicaid program in New Mexico. | 0008| Section 3. DEFINITIONS.--As used in the Medicaid Managed | 0009| Care Act: | 0010| A. "commission" means the New Mexico health policy | 0011| commission; | 0012| B. "department" means the human services | 0013| department; | 0014| C. "designated legislative interim committee" means | 0015| the New Mexico legislative council or an interim legislative | 0016| committee that is delegated authority by the New Mexico | 0017| legislative council to exercise powers granted to an interim | 0018| legislative committee in the Medicaid Managed Care Act; | 0019| D. "enrollee", "patient" or "consumer" means an | 0020| individual who is enrolled in medicaid and is entitled to | 0021| receive health care benefits from a managed health care plan; | 0022| E. "essential community provider" means a person | 0023| that provides the major portion of its health and health- | 0024| related services to medically needy indigent patients, | 0025| including uninsured, underserved or special needs populations; | 0001| | 0002| F. "excluded metropolitan statistical area" means a | 0003| federally recognized metropolitan statistical area of at least | 0004| three hundred thousand persons; | 0005| G. "health care facility" means an institution | 0006| providing health care services, including a hospital or other | 0007| licensed inpatient center, an ambulatory surgical or treatment | 0008| center, a home health agency, a diagnostic, laboratory or imaging | 0009| center and a rehabilitation or other therapeutic health setting; | 0010| H. "health care insurer" means a person that has a | 0011| valid certificate of authority in good standing under the New | 0012| Mexico Insurance Code to act as an insurer, a health maintenance | 0013| organization, a nonprofit health care plan or a prepaid dental | 0014| plan; | 0015| I. "health care professional" means a physician or | 0016| other health care practitioner, including a pharmacist, who is | 0017| licensed, certified or otherwise authorized by the state to | 0018| provide health services consistent with state law; | 0019| J. "health care provider" or "provider" means a person | 0020| that is licensed or otherwise authorized by the state to furnish | 0021| health care services and includes health care professionals, | 0022| health care facilities and essential community providers; | 0023| K. "health care services" means a service or product | 0024| furnished to an individual for the purpose of preventing, | 0025| diagnosing, alleviating, curing or healing a physical or mental | 0001| illness or injury and includes services incidental to furnishing | 0002| the described services or products, community-based mental health | 0003| services and services for developmental delay; | 0004| L. "managed health care plan" or "plan" means a | 0005| medicaid managed health care plan that is a health benefit plan of | 0006| a health care insurer or a provider service network offered | 0007| through the medicaid program that either requires an enrollee to | 0008| use, or creates incentives, including financial incentives, for an | 0009| enrollee to use health care providers managed, owned, under | 0010| contract with or employed by the health care insurer. "Managed | 0011| health care plan" means a medicaid managed health care plan that | 0012| includes a plan that provides comprehensive health care services | 0013| to enrollees on a prepaid, capitated basis and includes the health | 0014| care services offered by a health maintenance organization, a | 0015| preferred provider organization, an individual practice | 0016| organization, a competitive medical plan, an exclusive provider | 0017| organization, an integrated delivery system, an independent | 0018| physician-provider organization, a physician hospital-provider | 0019| organization and a managed care services organization; | 0020| M. "person" means an individual or other legal entity; | 0021| N. "primary health care clinic" means a nonprofit | 0022| community-based entity established to provide the first level of | 0023| basic or general health care needs, including diagnostic and | 0024| treatment services, for residents of a health care underserved | 0025| area as that area is defined in regulations adopted by the | 0001| department of health; | 0002| O. "provider service network" means two or more health | 0003| care providers affiliated for the purpose of providing health care | 0004| services to enrollees on a capitated or similar prepaid, flat-rate | 0005| basis; and | 0006| P. "secretary" means the secretary of human services. | 0007| Section 4. MEDICAID MANAGED CARE SYSTEM--TRANSITION-- | 0008| REGIONAL IMPLEMENTATION--LEGISLATIVE APPROVAL REQUIRED.-- | 0009| A. The medicaid program in New Mexico shall be | 0010| converted to a managed health care system only in a careful, | 0011| studied and deliberate manner. The department shall implement the | 0012| system in phases by regions, as appropriate, over a period not to | 0013| exceed two years. There shall be no fewer than four regions, | 0014| starting first with the greater Albuquerque area. Areas of the | 0015| state that are chosen as regions for implementation of the | 0016| medicaid managed health care system shall be selected based on the | 0017| health care delivery system capacity to meet the needs of the | 0018| enrollees, with those areas that have the greatest such capacity | 0019| being chosen as regions first. | 0020| B. The department shall study each regional phase-in | 0021| of the medicaid managed care system and assess the operations and | 0022| impact of each phase-in on the region and the state as a whole | 0023| prior to extending the system to another region. At the same | 0024| time, the commission shall establish a technical workgroup to | 0025| gather information, review and conduct a separate, independent | 0001| assessment of each regional phase-in of the medicaid managed care | 0002| system. The department shall make available to the commission and | 0003| its technical workgroup all requested data, information, analysis | 0004| and reviews. | 0005| C. Before each time that the medicaid managed care | 0006| system is extended to another region, the department and the | 0007| commission technical workgroup shall submit their reports to the | 0008| designated legislative interim committee on the system's | 0009| effectiveness and its impact on health care services | 0010| infrastructure and access to care for indigent individuals. | 0011| D. If the department implements a medicaid managed | 0012| care system pursuant to a waiver from the federal government under | 0013| Section 1915(b) of the federal Social Security Act, legislative | 0014| approval shall be obtained each time before the medicaid managed | 0015| care system is extended to another region in the state beyond the | 0016| greater Albuquerque area. Legislative approval shall also be | 0017| obtained before the system is revised pursuant to any waiver that | 0018| may be sought from the federal government under Section 1115 of | 0019| the federal Social Security Act. | 0020| E. A contract with a managed health care plan shall | 0021| not exceed a two-year term without legislative approval. | 0022| F. The legislative approvals required in this section | 0023| may be obtained either by the full legislature, by a resolution | 0024| adopted by both houses, or preliminarily by the designated | 0025| legislative interim committee, subject to final approval by the | 0001| full legislature. If the legislature does not act on the approval | 0002| in the next regular session following the action taken by the | 0003| designated legislative interim committee, the action taken by the | 0004| committee shall be deemed to be approved by the full legislature. | 0005| Section 5. PATIENT PROTECTION--DISCLOSURES--RIGHTS TO | 0006| HEALTH CARE SERVICES--GRIEVANCE PROCEDURE--UTILIZATION REVIEW | 0007| PROGRAM--CONTINUOUS QUALITY PROGRAM--DEPARTMENT OF INSURANCE | 0008| REGULATIONS.-- | 0009| A. Each covered person enrolled in a managed health | 0010| care plan offered through the medicaid program has the right to be | 0011| treated fairly. A managed health care plan offered through the | 0012| medicaid program shall deliver high quality and appropriate health | 0013| care services to enrollees. The department shall ensure that each | 0014| covered person enrolled in a managed health care plan is treated | 0015| fairly and is accorded the rights necessary to protect patient | 0016| interests. | 0017| B. The department shall ensure at a minimum that: | 0018| (1) a managed health care plan shall provide | 0019| oral and written summaries, policies and procedures that explain, | 0020| prior to or at the time of enrollment and at subsequent periodic | 0021| times as appropriate, in a clear, conspicuous and readily | 0022| understandable form, full and fair disclosure of the plan's | 0023| benefits, terms, conditions, prior authorization requirements, | 0024| enrollee financial responsibility for copayments, grievance | 0025| procedures, appeal rights and the patient rights generally | 0001| available to all covered persons; | 0002| (2) a managed health care plan shall provide | 0003| each covered person with appropriate basic and comprehensive | 0004| health care services, in accordance with the medicaid program | 0005| regulations, that are reasonably accessible and available in a | 0006| timely manner to each covered person; | 0007| (3) in providing the right to reasonably | 0008| accessible health care services that are available in a timely | 0009| manner, a managed health care plan shall ensure that: | 0010| (a) the plan offers sufficient numbers and | 0011| types of credentialed and adequately staffed health care providers | 0012| at reasonable hours of service to meet the health needs of the | 0013| enrolled population, and takes into account cultural aspects and | 0014| limited English capacity of enrollees; | 0015| (b) health care providers that are | 0016| specialists may act as primary care providers for patients with | 0017| chronic medical conditions, provided the specialists offer all | 0018| reasonable primary care services required by a managed health care | 0019| plan and are credentialed by the managed health care plan to | 0020| provide primary care services; | 0021| (c) as medically indicated, reasonable | 0022| access is provided to out-of-network specialty health care | 0023| providers; and | 0024| (d) emergency care is immediately available | 0025| without prior authorization requirements, and appropriate out-of- | 0001| network emergency care is not subject to additional costs; | 0002| (4) a managed health care plan offered through | 0003| the medicaid program shall adopt and implement a prompt and fair | 0004| grievance procedure for resolving patient complaints and | 0005| addressing patient questions and concerns regarding any aspect of | 0006| the plan, including the quality of and access to health care, the | 0007| choice of health care provider or treatment and the adequacy of | 0008| the plan's provider network. The grievance procedures shall | 0009| notify patients of their statutory appeal rights, including the | 0010| option of seeking immediate relief in court, and shall provide for | 0011| a prompt and fair appeal of a plan's decision to the secretary, | 0012| including special provisions to govern emergency appeals to the | 0013| secretary in the case of health emergencies; | 0014| (5) a managed health care plan offered through | 0015| the medicaid program shall adopt and implement a comprehensive | 0016| utilization review program. The basis of a decision to approve or | 0017| deny care shall be disclosed to an affected enrollee. The | 0018| decision to approve or deny care to a patient shall be made in a | 0019| timely manner, including decisions regarding emergency care, and | 0020| the final decision shall be made by a qualified health care | 0021| professional. A plan's utilization review program shall ensure | 0022| that enrollees have proper access to health care services, | 0023| including referrals to necessary specialists. A decision made in | 0024| a plan's utilization review program shall be subject to the plan's | 0025| grievance procedure and appeal to the secretary; | 0001| (6) a managed health care plan offered through | 0002| the medicaid program shall adopt and implement a continuous | 0003| quality improvement program that monitors the quality and | 0004| appropriateness of the health care services provided by the plan; | 0005| and | 0006| (7) a managed health care plan offered through | 0007| the medicaid program shall at a minimum comply with the department | 0008| of insurance regulations applicable to managed care. | 0009| C. The department shall maintain and adequately staff | 0010| at all times a toll-free telephone line to respond to enrollee | 0011| questions and concerns and to assist enrollees in exercising their | 0012| rights and protecting their interests as health care consumers and | 0013| as provided for in the Medicaid Managed Care Act. | 0014| Section 6. MEDICAID MANAGED HEALTH CARE PLAN OPERATIONS.-- | 0015| A. The department shall monitor each managed health | 0016| care plan offered through the medicaid program and take all | 0017| reasonable steps necessary to ensure that each plan operates | 0018| fairly and efficiently, protects patient interests and fulfills | 0019| the plan's primary obligation to deliver high quality health care | 0020| services. | 0021| B. No managed health care plan offered through the | 0022| medicaid program may directly solicit new members for enrollment | 0023| into the medicaid program. All enrollment of eligible persons | 0024| into the medicaid program shall be arranged directly by the | 0025| department. The department may provide for enrollment directly at | 0001| government facilities or other health care facilities. | 0002| C. The department, through its own offices and | 0003| employees, joint powers agreements with other state agencies or by | 0004| contracting with one or more brokering agencies independent of any | 0005| managed health care plan offered through the medicaid program, | 0006| shall fully inform medicaid-eligible persons of their choices for | 0007| enrollment into a managed health care plan and shall conduct the | 0008| enrollment process and default assignments of enrollees who do not | 0009| choose a plan. The department shall ensure that the enrollment | 0010| process includes adequate time and information provided in a | 0011| clear, conspicuous and understandable manner that is appropriate | 0012| for the medicaid enrollee, or legal guardian in the case of a | 0013| child, including those with limited English language and reading | 0014| ability. At a minimum, the information shall include: | 0015| (1) the issues to be considered in making an | 0016| informed decision about which available managed health care plan | 0017| to choose; | 0018| (2) for each managed health care plan offered | 0019| through the medicaid program, details regarding participating | 0020| providers, geographic availability of services, benefits, | 0021| emergency care and out-of-state or out-of-area medical services, | 0022| terms, conditions, including any copayments or other restrictions, | 0023| and available valid information pertaining to quality, outcomes, | 0024| patient satisfaction and grievances; | 0025| (3) after the initial year of implementation, | 0001| comparative information on the quality of care, including medicaid | 0002| enrollee satisfaction and grievances, on each managed care health | 0003| plan; | 0004| (4) how to operate in and use effectively a | 0005| managed health care plan; and | 0006| (5) enrollee rights to change providers and | 0007| managed health care plans and challenge and appeal plan decisions. | 0008| D. No managed health care plan offered through the | 0009| medicaid program shall directly market to medicaid recipients or | 0010| directly enroll medicaid recipients into its plan. | 0011| E. No managed health care plan shall require or | 0012| establish exclusive contracts with any health care provider, | 0013| except for salaried employment contracts. | 0014| F. Unless the department requires, by regulation, a | 0015| higher percentage, a managed health care plan offered through the | 0016| medicaid program shall be required to maintain a medical loss | 0017| ratio of at least eighty percent, so that at a minimum eighty | 0018| percent of all capitated medicaid payments paid to a managed | 0019| health care plan is expended for the direct provision of health | 0020| care services. The department may establish maximum | 0021| administrative expenses and profit margins that will be allowed. | 0022| The department, after consultation with the department of | 0023| insurance, shall adopt regulations to define the allowable medical | 0024| loss ratio, administrative expenses and profit margin consistent | 0025| with the provisions of this subsection. | 0001| G. To ensure freedom of choice capacity for enrollees, | 0002| the department shall seek a waiver from applicable federal | 0003| requirements to provide for an appropriate mixture of medicaid and | 0004| commercial, paying patients in any given managed health care plan. | 0005| Section 7. SPECIALIZED HEALTH CARE PROGRAMS--PHASE-IN | 0006| IMPLEMENTATION--LEGISLATIVE APPROVAL REQUIRED.-- | 0007| A. Except as otherwise provided in Subsection B of | 0008| this section, until July 1, 1999, no managed health care plan | 0009| offered through the medicaid program shall offer specialized | 0010| behavioral or developmental disability health care services. The | 0011| provisions of this section apply to the specialized health care | 0012| services needed for a person treated for a developmental | 0013| disability, a developmental delay, a seriously disabling mental | 0014| illness, a serious emotional disturbance, physical or sexual abuse | 0015| or neglect, substance abuse or other chronic, serious behavioral | 0016| health problem. | 0017| B. As a pilot project, and pursuant to a waiver from | 0018| the federal government under Section 1915(b) of the federal Social | 0019| Security Act, specialized behavioral or developmental disability | 0020| health care services may be immediately provided by the managed | 0021| health care plans that are offered through the medicaid program in | 0022| the greater Albuquerque area. | 0023| C. The department shall study the pilot project | 0024| authorized in Subsection B of this section and assess the | 0025| operations and impact of the pilot project on the region and the | 0001| state as a whole prior to extending the system to another region | 0002| after July 1, 1999. At the same time, the commission shall | 0003| establish a technical workgroup, which shall include among its | 0004| members representatives of appropriate behavioral health and | 0005| developmental disability stakeholders, to gather information, | 0006| review and conduct an independent assessment of the specialized | 0007| health care services pilot project of the medicaid managed care | 0008| system. The department shall make available to the commission all | 0009| requested data, information, analysis and reviews. | 0010| D. Before each time that specialized behavioral or | 0011| developmental disability health care services covered in this | 0012| section are extended beyond the greater Albuquerque area to | 0013| another region in the state, the department and the commission | 0014| technical workgroup shall submit their reports to the designated | 0015| legislative interim committee on the program's effectiveness and | 0016| its impact on health care services infrastructure and access to | 0017| care for indigent individuals; outside evaluations, including | 0018| those of the federal health care financing authority; and the | 0019| program revisions that will be made based on the experiences. The | 0020| department's report shall include copies of any relevant reports | 0021| prepared by outside evaluators, including the federal health care | 0022| financing administration and the state's medicaid advisory | 0023| committee, and a description of the program revisions that will be | 0024| made based on the input received and experience. | 0025| E. If the department includes specialized behavioral | 0001| or developmental disability health care services in its medicaid | 0002| managed care system pursuant to a waiver from the federal | 0003| government under Section 1915(b) of the federal Social Security | 0004| Act, legislative approval shall be obtained each time before the | 0005| specialized behavioral or developmental disability health care | 0006| services are extended beyond the greater Albuquerque area to | 0007| another region in the state. Legislative approval shall also be | 0008| obtained before the coverage of specialized behavioral or | 0009| developmental disability health care services in the medicaid | 0010| managed care system is revised pursuant to any waiver that may be | 0011| sought under Section 1115 of the federal Social Security Act. | 0012| F. The legislative approvals required in this section | 0013| may be obtained either by the full legislature, by a resolution | 0014| adopted by both houses, or preliminarily by the designated | 0015| legislative interim committee, subject to final approval by the | 0016| full legislature. If the legislature does not act on the approval | 0017| in the next regular session following the action taken by the | 0018| designated legislative interim committee, the action taken by the | 0019| committee shall be deemed to be approved by the full legislature. | 0020| Section 8. NATIVE AMERICAN HEALTH SERVICES.-- | 0021| A. Native Americans enrolled in a managed health care | 0022| plan offered through the medicaid program shall at all times | 0023| retain the option of receiving health services directly from the | 0024| Indian health service or health services provided by tribes under | 0025| the federal Indian Self-Determination and Education Assistance | 0001| Act, the federal urban Indian health program or the federal Indian | 0002| children's program. The department shall ensure that the Indian | 0003| health service receives the same payment it would have received | 0004| for the services rendered if the patient did not participate in | 0005| the managed health care plan. | 0006| B. The department shall pursue alternative mechanisms | 0007| for Native Americans in the medicaid managed care program to | 0008| recognize their sovereignty, their right to self-determination and | 0009| the dual responsibility of the federal and state governments. | 0010| Section 9. HOSPITALS OTHER THAN THE UNIVERSITY OF NEW | 0011| MEXICO HEALTH SCIENCES CENTER.-- | 0012| A. Any managed health care plan offered through the | 0013| medicaid program shall be required to use under reasonable terms | 0014| and conditions any hospital, except a hospital in an excluded | 0015| metropolitan statistical area, that elects to participate in the | 0016| plan, if the hospital meets all reasonable quality of care and | 0017| service payment requirements imposed by the plan. The terms shall | 0018| be no less favorable than those offered any other equivalent, | 0019| similarly situated provider for the same services. | 0020| B. The department shall assure continuity of general | 0021| support for any hospital that provides for medical education or | 0022| serves a disproportionately large indigent population. Within | 0023| allowable federal law and regulations, the department shall ensure | 0024| an adequate and diverse patient population necessary to preserve | 0025| the health professional education programs in New Mexico. | 0001| C. A managed health care plan offered through the | 0002| medicaid program that offers specialized behavioral or | 0003| developmental disability health services as provided in Section 7 | 0004| of the Medicaid Managed Care Act shall include participation by | 0005| state-operated inpatient facilities. Payment rates for services | 0006| provided by the state hospitals providing such specialized | 0007| services shall be established by the department. The rates shall | 0008| provide by regulation for payments that are reasonable for an | 0009| efficiently operated facility providing similar services taking | 0010| into account the severity of illness and shall include, as | 0011| determined by the department, retrospective adjustment to account | 0012| for adverse patient selection. | 0013| D. A managed health care plan offered through the | 0014| medicaid program may not limit the number or location of state | 0015| facilities or hospitals, except hospitals in an excluded | 0016| metropolitan statistical area, that elect to participate in the | 0017| plan. A managed health care plan shall not offer providers or | 0018| impose on patients financial or other incentives, penalties or | 0019| barriers to affect the use of any hospital participating in its | 0020| plan as provided for in Subsection A or C of this section. | 0021| Section 10. UNIVERSITY OF NEW MEXICO HEALTH SCIENCES | 0022| CENTER.-- | 0023| A. Any managed care health plan offered through the | 0024| medicaid program shall be required to use the university of New | 0025| Mexico health sciences center's hospitals and specialty services, | 0001| as appropriate, including inpatient and outpatient services. | 0002| Payment rates for services provided by the university of New | 0003| Mexico health sciences center's hospitals and specialty services | 0004| shall be established by the department. Such payment rates, which | 0005| shall be adopted by regulation, shall provide for payments that | 0006| are reasonable for an efficiently operated hospital or outpatient | 0007| specialty facility providing similar services taking into account | 0008| the severity of illness and shall provide, as determined by the | 0009| department, for retrospective adjustment to account for adverse | 0010| patient selection; provided, however, that nothing in this section | 0011| shall prohibit the university of New Mexico health sciences center | 0012| from negotiating alternative rates and payment methodologies with | 0013| a managed health care plan offered through the medicaid program. | 0014| B. The department shall assure continuity of general | 0015| support for the university of New Mexico health sciences center | 0016| for medical education and a disproportionately large indigent | 0017| population. Within allowable federal law and regulations, the | 0018| department shall ensure an adequate and diverse patient population | 0019| necessary to preserve the health professional education programs | 0020| in New Mexico. | 0021| C. A managed health care plan shall not offer | 0022| providers or impose on patients financial or other incentives, | 0023| penalties or barriers to affect the use of the university of New | 0024| Mexico health sciences center's hospitals or specialty services, | 0025| including inpatient and outpatient specialty services. | 0001| Section 11. PRIMARY HEALTH CARE CLINICS' PARTICIPATION.-- | 0002| A. A managed health care plan offered through the | 0003| medicaid program shall be required to use under reasonable terms | 0004| and conditions any primary health care clinic that elects to | 0005| participate in the plan, if the primary health care clinic meets | 0006| all reasonable quality of care and service payment requirements | 0007| imposed by the plan. The terms shall be no less favorable than | 0008| those offered to any other equivalent, similarly situated provider | 0009| for the same services. | 0010| B. A managed health care plan offered through the | 0011| medicaid program may not limit the number or location of primary | 0012| health care clinics that elect to participate in the plan. A | 0013| managed health care plan shall not offer providers or impose on | 0014| patients financial or other incentives, penalties or barriers to | 0015| affect the use of any primary health care clinic participating in | 0016| its plan. | 0017| C. The department shall provide timely payments at | 0018| least quarterly to each federal qualified health center under the | 0019| federal Social Security Act, as defined in 42 U.S.C. Section | 0020| 1396d(1)(2), to cover the difference between the payment that | 0021| should have been received pursuant to the provisions of 42 U.S.C. | 0022| Section 1396a(a)(13)(E) and the payments from the managed health | 0023| care plan offered through the medicaid program that were received | 0024| by the federally qualified health center. The full amount of that | 0025| difference shall be paid by the department in fiscal year 1998. | 0001| To the extent allowable by federal law and regulations, the | 0002| department's payment for that difference shall be reduced by one- | 0003| third annually from the full level of the difference provided in | 0004| fiscal year 1998 such that by July 1, 2000, no differential | 0005| payment based on federally qualified health center status shall be | 0006| required. | 0007| D. Nothing in Subsection C of this section shall | 0008| prohibit a federally qualified health center from negotiating | 0009| alternative rates and payment methodologies with a managed health | 0010| care plan offered through the medicaid program. | 0011| Section 12. AUTHORIZATION FOR MEDICAID MANAGED CARE | 0012| CONTRACTS DIRECTLY WITH PUBLIC AGENCIES, HOSPITALS, HEALTH CARE | 0013| PROVIDERS AND PROVIDER SERVICE NETWORKS.--In administering the | 0014| medicaid program or a managed health care system for the program, | 0015| the department may contract directly with a government agency or | 0016| public body, health care provider or provider service network | 0017| belonging to and participating in the provider service network | 0018| guaranty association. In doing so, the department is not required | 0019| to contract with any such entity only through arrangements with a | 0020| health care insurer. | 0021| Section 13. PLAN ARRANGEMENTS WITH HEALTH CARE PROVIDERS-- | 0022| FAIR DISCLOSURE TO ENROLLEES--PROTECTIONS FOR PROVIDERS.-- | 0023| A. A managed health care plan offered through the | 0024| medicaid program may not contract with a health care provider to | 0025| limit the provider's disclosure to an enrollee, or any person | 0001| acting on behalf of the enrollee, of any information that relates | 0002| to the enrollee's medical condition or treatment options. | 0003| B. A health care provider shall not be penalized, or | 0004| have a contract with a managed health care plan terminated, | 0005| because the provider offers a referral to, or discusses medically | 0006| necessary or appropriate care with, an enrollee or any person | 0007| acting on behalf of the enrollee. A health care provider may not | 0008| be prohibited by a plan from discussing all treatment options with | 0009| an enrollee. | 0010| C. A health care provider shall not be adversely | 0011| affected by a managed health care plan for discussing with an | 0012| enrollee financial incentives or financial arrangements between | 0013| the provider and the plan. | 0014| D. A managed health care plan offered through the | 0015| medicaid program shall not include in any of its contracts with | 0016| health care providers any provisions that offer an inducement, | 0017| financial or otherwise, to provide less than medically necessary | 0018| health care services. A managed health care plan shall inform its | 0019| enrollees in writing of the financial arrangements between the | 0020| plan and participating providers if those arrangements include an | 0021| incentive or bonus for restricting the amount of health care | 0022| services provided to the enrollee. | 0023| Section 14. GENERAL POLICY DEVELOPMENT OF THE MEDICAID | 0024| MANAGED CARE SYSTEM.-- | 0025| A. The department, in conjunction with the commission, | 0001| shall continue to study and propose how to refine the medicaid | 0002| managed care program to improve the value derived from public | 0003| resources and to further the health policy of New Mexico as | 0004| provided in Section 9-7-11.1 NMSA 1978. This shall include | 0005| consideration of: | 0006| (1) the benefit structure as provided for in | 0007| Senate Joint Memorial 50 of the second session of the forty-second | 0008| legislature in 1996; | 0009| (2) cost containment and purchasing methods; | 0010| (3) the desirability of a directly state- | 0011| operated managed care system for medicaid in certain regions of | 0012| the state; and | 0013| (4) a waiver from the federal government | 0014| pursuant to Section 1115 of the federal Social Security Act. | 0015| B. The department and the commission shall report | 0016| annually to the designated legislative interim committee on the | 0017| progress and recommendations relevant to the considerations | 0018| specified in this section. | 0019| Section 15. MONITORING AND REPORTING.-- | 0020| A. The department shall ensure that any managed health | 0021| care plan offered through the medicaid program provides quality | 0022| health care consistent with nationally recognized and New Mexico | 0023| specific standards. | 0024| B. The department shall establish appropriate | 0025| standards to be met by any managed health care plan participating | 0001| in the medicaid program to ensure and monitor the quality of care | 0002| provided. By the use of nationally recognized standards and | 0003| electronic reporting, all reasonable efforts shall be made to | 0004| contain the administrative costs of both the participating managed | 0005| health care plans and the department for its oversight | 0006| responsibilities. The department shall ensure that: | 0007| (1) plans report on the basis of the latest | 0008| adopted national health plan employer data and information set | 0009| measures, or other nationally recognized equivalent measures, and | 0010| the mental health statistics improvement project in the case of | 0011| behavioral health services, for the enrolled medicaid population | 0012| in the managed health care plan; | 0013| (2) at least annually a standardized patient | 0014| satisfaction survey is publicly reported; | 0015| (3) at least annually an assessment of | 0016| enrollees' access to services, including waiting time to receive | 0017| services and geographic availability consistent with contract | 0018| terms, is publicly reported; | 0019| (4) a quality improvement plan is adopted by the | 0020| board of each managed health care plan and that there is evidence | 0021| of an effective quality improvement program, including the | 0022| participation by and monitoring of contract providers; | 0023| (5) there is credentialing of all providers and | 0024| evidence of malpractice coverage, including contract providers, | 0025| participating in the managed health care plan; and | 0001| (6) there is broad participation of the provider | 0002| network in quality improvement and utilization management | 0003| processes. | 0004| C. Except as provided elsewhere in the Medicaid | 0005| Managed Care Act, the department shall prepare and submit to the | 0006| designated legislative interim committee by October 1 of each year | 0007| a public report that shall include for each managed health care | 0008| plan offered through the medicaid program a summary of the | 0009| following: | 0010| (1) the quality of care provided, including | 0011| enrollee satisfaction, grievances, disenrollments and changes in | 0012| plan enrollment; | 0013| (2) the numbers and demographics of medicaid | 0014| enrollees; | 0015| (3) the medical loss ratio and a breakdown of | 0016| the expenditures by specific service type, including the percent | 0017| of capitated payments for administrative expenses, and the profits | 0018| earned; | 0019| (4) changes in the provider service network and | 0020| the turnover of primary care and specialty providers; | 0021| (5) additional benefits offered; | 0022| (6) utilization management activities, including | 0023| the number of out-of-network approvals, denials for services and | 0024| appeals; | 0025| (7) any additional information determined by the | 0001| department to be relevant to quality, outcomes, financing and | 0002| utilization required to be reported by each managed health care | 0003| plan to the department; and | 0004| (8) compliance with the provisions of the | 0005| Medicaid Managed Care Act. | 0006| D. Except as provided elsewhere in the Medicaid | 0007| Managed Care Act, the department shall prepare and submit to the | 0008| designated legislative interim committee by October 1 of each year | 0009| a public report that shall address: | 0010| (1) the efficiency and effectiveness of the | 0011| medicaid managed care program in general, including overall | 0012| compliance with the Medicaid Managed Care Act; | 0013| (2) trends in expenditures in the medicaid | 0014| program; | 0015| (3) impact of the medicaid managed care program | 0016| on health services infrastructure, health services availability | 0017| throughout the state and health professionals' supply and | 0018| distribution; | 0019| (4) impact of the medicaid managed care program | 0020| on health services access for indigent persons; | 0021| (5) program revisions to be made based on the | 0022| review of the program and input of the state medicaid advisory | 0023| committee, providers and public; and | 0024| (6) legislative recommendations for the medicaid | 0025| managed care program to further the health policy of New Mexico. | 0001| E. The department shall provide for a yearly | 0002| independent analysis of medicaid managed care that includes an | 0003| assessment of the quality and outcomes of care received by | 0004| medicaid enrollees in each managed care plan and a comparison with | 0005| commercial enrollees. | 0006| F. The department shall implement an information | 0007| system to provide for the collection of patient-level encounter | 0008| data to monitor the analysis provided in Subsections C, D and E of | 0009| this section; provide for actuarially sound cost projections; | 0010| assist in the development of standards of care and appropriate | 0011| service provisions for enrollees; and provide sufficient | 0012| information for the department to effectively and efficiently | 0013| manage, operate and administer the medicaid program. In | 0014| cooperation with the commission and the health information | 0015| alliance established under the Health Information System Act, the | 0016| department shall pursue an integrated statewide health data | 0017| network with streamlined administrative transactions, provider | 0018| reporting and access to information and consumer education. The | 0019| department shall require that every managed care plan offered | 0020| through the medicaid program develop information system capacity | 0021| to meet these requirements and the minimum requirements | 0022| established pursuant to the Health Information System Act. | 0023| Section 16. ENFORCEMENT.-- | 0024| A. The department or a person who suffers a loss as a | 0025| result of a violation of a provision in the Medicaid Managed Care | 0001| Act may bring an action to recover actual damages or the sum of | 0002| one hundred dollars ($100), whichever is greater. When the trier | 0003| of fact finds that the party charged with the violation acted | 0004| willfully, the court may award up to three times actual damages or | 0005| three hundred dollars ($300), whichever is greater, to the party | 0006| complaining of the violation. | 0007| B. A person likely to be damaged by a denial of a | 0008| right protected in the Medicaid Managed Care Act may be granted an | 0009| injunction under the principles of equity and on terms that the | 0010| court considers reasonable. Proof of monetary damages or intent | 0011| to violate a right is not required. | 0012| C. To protect and enforce an enrollee's or a health | 0013| care provider's rights in a managed health care plan offered | 0014| through the medicaid program, an enrollee and a health care | 0015| provider participating in or eligible to participate in a medicaid | 0016| managed health care plan shall each be treated as a third-party | 0017| beneficiary of the managed health care plan contract between the | 0018| health care insurer and the party with which the insurer directly | 0019| contracts. An enrollee or a health care provider may sue to | 0020| enforce the rights provided in the contract that governs the | 0021| managed health care plan. | 0022| D. The relief provided in this section is in addition | 0023| to other remedies available against the same conduct under the | 0024| common law or other statutes of this state. | 0025| E. In any class action filed under this section, the | 0001| court may award damages to the named plaintiffs as provided in | 0002| this section and may award members of the class the actual damages | 0003| suffered by each member of the class as a result of the unlawful | 0004| practice. | 0005| F. A person shall not be required to complete | 0006| available grievance procedures or exhaust administrative remedies | 0007| prior to seeking relief in court regarding a complaint that may be | 0008| filed under this section. | 0009| Section 17. PENALTY.--In addition to any other penalties | 0010| provided by law, the secretary may impose a civil administrative | 0011| penalty of up to twenty-five thousand dollars ($25,000) for each | 0012| violation of the Medicaid Managed Care Act. An administrative | 0013| penalty shall be imposed by written order of the secretary after | 0014| holding a hearing as provided for in the Public Assistance Appeals | 0015| Act. | 0016| Section 18. REGULATIONS.--The department may adopt | 0017| regulations it deems necessary or appropriate to administer the | 0018| provisions of the Medicaid Managed Care Act. | 0019| Section 19. APPLICABILITY.--The provisions of the Medicaid | 0020| Managed Care Act apply to all contracts for medicaid managed care | 0021| entered into by the department after July 1, 1997, but do not | 0022| apply to or invalidate terms in contracts that were entered into | 0023| prior to July 1, 1997, provided those contracts are completed by | 0024| July 1, 1999. | 0025| Section 20. EFFECTIVE DATE.--The effective date of the | 0001| provisions of this act is July 1, 1997. | 0002|  |