0001| SENATE BILL 767
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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| BEN D. ALTAMIRANO
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0005|
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0006|
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0007|
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0008|
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0009|
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0010| AN ACT
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0011| RELATING TO HEALTH INSURANCE; AMENDING AND ENACTING SECTIONS OF
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0012| THE NMSA 1978 TO REQUIRE INSURANCE COVERAGE FOR ADVANCED
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0013| PRACTICE NURSING SERVICES.
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0014|
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0015| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0016| Section 1. A new section of the New Mexico Insurance Code
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0017| is enacted to read:
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0018| "[NEW MATERIAL] INSURANCE COVERAGE--ADVANCED PRACTICE
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0019| NURSING SERVICES.--
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0020| A. All individual and group subscriber contracts
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0021| delivered or issued for delivery in New Mexico that provide for
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0022| treatment of persons for the prevention, cure or correction of
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0023| any illness or physical or mental condition shall include
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0024| coverage for the services of an advanced practice nurse.
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0025| B. As used in this section, "advanced practice
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0001| nursing" means the practice of professional registered nursing
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0002| by a registered nurse who has been prepared through an
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0003| educational program to function beyond the scope of practice of
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0004| professional registered nursing, including certified nurse
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0005| practitioners, certified registered nurse anesthetists and
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0006| clinical nurse specialists."
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0007| Section 2. A new section of the Health Maintenance
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0008| Organization Law is enacted to read:
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0009| "[NEW MATERIAL] ADVANCED PRACTICE NURSES--
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0010| DISCRIMINATION PROHIBITED.--Advanced practice nurses as a class
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0011| of licensed providers willing to meet the terms and conditions
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0012| offered by a health maintenance organization shall not be
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0013| excluded from the health maintenance organization."
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0014| Section 3. Section 59A-15-16 NMSA 1978 (being Laws 1991,
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0015| Chapter 125, Section 22, as amended) is amended to read:
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0016| "59A-15-16. JURISDICTION OVER HEALTH CARE BENEFITS
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0017| PROVIDERS PRESUMED.--Notwithstanding any other provision of law
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0018| and except as provided in the Health Care Benefits Jurisdiction
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0019| Act, [any] a person who provides coverage in this state for
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0020| health benefits, including coverage for medical, surgical,
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0021| hospital, osteopathic, advanced practice nursing, acupuncture
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0022| and oriental medicine, chiropractic, physical therapy, speech
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0023| pathology, audiology, professional mental health, dental or
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0024| optometric expenses, whether such coverage is by direct
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0025| payment, reimbursement or otherwise, shall be presumed to be
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0001| subject to the provisions of the Insurance Code and the
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0002| jurisdiction of the superintendent unless the person provides
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0003| evidence satisfactory to the superintendent that he is subject
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0004| exclusively to the jurisdiction of another agency of this state
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0005| or the federal government."
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0006| Section 4. Section 59A-22-32 NMSA 1978 (being Laws 1984,
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0007| Chapter 127, Section 454, as amended) is amended to read:
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0008| "59A-22-32. FREEDOM OF CHOICE OF HOSPITAL, PRACTITIONER.-
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0009| -
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0010| A. Within the area and limits of coverage offered
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0011| an insured and selected by him in the application for
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0012| insurance, the right of any person to exercise full freedom of
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0013| choice in the selection of any hospital for hospital care or of
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0014| any practitioner of the healing arts or optometrist,
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0015| psychologist, podiatrist, certified nurse-midwife, registered
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0016| lay midwife or registered nurse in [expanded] advanced
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0017| practice, as defined in Subsection B of this section, for
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0018| treatment of any illness or injury within his scope of practice
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0019| shall not be restricted under any new policy of health
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0020| insurance, contract or health care plan issued after June 30,
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0021| 1967 in this state or in the processing of any claim
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0022| thereunder. Any person insured or claiming benefits under any
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0023| such health insurance policy, contract or health care plan
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0024| providing within its coverage for payment of service benefits
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0025| or indemnity for hospital care or treatment of persons for the
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0001| cure or correction of any physical or mental condition shall be
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0002| deemed to have complied with the requirements of the policy,
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0003| contract or health care plan as to submission of proof of loss
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0004| upon submitting written proof supported by the certificate of
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0005| any hospital currently licensed by the department of health
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0006| [and environment department] or any practitioner of the
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0007| healing arts or optometrist, psychologist, podiatrist, cer-
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0008|
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0009| tified nurse-midwife, registered lay midwife or registered
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0010| nurse in [expanded] advanced practice.
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0011| B. As used in this section:
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0012| (1) "hospital care" means hospital service
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0013| provided through a hospital [which] that is maintained by
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0014| the state or any political subdivision of the state or any
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0015| place [which] that is currently licensed as a hospital by
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0016| the department of health [and environment department] and
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0017| has accommodations for resident bed patients, a licensed
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0018| professional registered nurse always on duty or call, a
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0019| laboratory and an operating room where surgical operations are
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0020| performed, but the term does not include a convalescent or
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0021| nursing or rest home;
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0022| (2) "practitioner of the healing arts" means
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0023| any person holding a license or certificate provided for in
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0024| Chapter 61, Article 4, 5, 6, 10 or 14A NMSA 1978 authorizing
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0025| the licensee to offer or undertake to diagnose, treat, operate
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0001| on or prescribe for any human pain, injury, disease, deformity
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0002| or physical or mental condition;
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0003| (3) "optometrist" means any person holding a
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0004| license provided for in Chapter 61, Article 2 NMSA 1978;
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0005| (4) "podiatrist" means any person holding a
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0006| license provided for in Chapter 61, Article 8 NMSA 1978;
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0007| (5) "psychologist" is one who is duly licensed
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0008| or certified in the state where the service is rendered and has
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0009| a doctoral degree in psychology and has had at least two years
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0010| of clinical experience in a recognized health setting or has
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0011| met the standards of the national register of health service
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0012| providers in psychology;
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0013| (6) "certified nurse-midwife" means any person
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0014| licensed by the board of nursing as a registered nurse and who
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0015| is registered with the public health [services] division of
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0016| the department of health [and environment department] as a
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0017| certified nurse-midwife;
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0018| (7) "registered lay midwife" means any person
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0019| who practices lay midwifery and is registered as a registered
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0020| lay midwife by the public health [services] division of the
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0021| department of health [and environment department]; and
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0022| (8) "registered nurse in [expanded]
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0023| advanced practice" means any person licensed by the board of
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0024| nursing as a registered nurse approved for [expanded]
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0025| advanced practice pursuant to the Nursing Practice Act as a
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0001| [certified nurse practitioner] advanced practice nurse,
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0002| certified registered nurse anesthetist, certified clinical
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0003| nurse specialist in psychiatric mental health nursing or
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0004| clinical nurse specialist in private practice and who has a
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0005| master's degree or doctorate in a defined clinical nursing
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0006| [speciality] specialty and is certified by a national
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0007| nursing organization.
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0008| C. This section shall apply to any such policy
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0009| [which] that is delivered or issued for delivery in this
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0010| state on or after July 1, 1979 and to any existing group policy
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0011| or plan on its anniversary or renewal date after June 30, 1979
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0012| or at expiration of the applicable collective bargaining
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0013| contract, if any, whichever is later."
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0014| Section 5. Section 59A-22A-3 NMSA 1978 (being Laws 1993,
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0015| Chapter 320, Section 61) is amended to read:
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0016| "59A-22A-3. DEFINITIONS.--As used in the Preferred
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0017| Provider Arrangements Law:
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0018| A. "advanced practice nursing" means the practice
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0019| of professional registered nursing by registered nurses who
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0020| have been prepared through additional formal education as
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0021| defined in Sections 61-3-23.2 through 61-3-23.4 NMSA 1978 to
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0022| function beyond the scope of practice of professional
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0023| registered nursing, including licensed certified nurse
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0024| practitioners, certified registered nurse anesthetists and
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0025| clinical nurse specialists;
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0001| [A.] B. "covered person" means any person on
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0002| whose behalf the health care insurer is obligated to pay for or
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0003| to provide health benefit services;
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0004| [B.] C. "covered services" means health care
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0005| services [which] that the health care insurer is obligated
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0006| to pay for or to provide under a health benefit plan;
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0007| [C.] D. "emergency care" means covered services
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0008| delivered to a covered person after the sudden onset of a
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0009| medical condition manifesting itself by acute symptoms that are
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0010| severe enough that:
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0011| (1) the lack of immediate medical attention
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0012| could result in:
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0013| (a) placing the person's health in
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0014| jeopardy;
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0015| (b) serious impairment of bodily
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0016| functions; or
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0017| (c) serious dysfunction of any bodily
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0018| organ or part; or
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0019| (2) a reasonable person believes that
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0020| immediate medical attention is required;
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0021| [D.] E. "health benefit plan" means the health
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0022| insurance policy or subscriber agreement between the covered
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0023| person or the policyholder and the health care insurer
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0024| [which] that defines the covered services and benefit
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0025| levels available;
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0001| [E.] F. "health care insurer" means any person
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0002| who provides health insurance in this state. For the purposes
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0003| of the Small Group Rate and Renewability Act, "carrier" or
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0004| "insurer" includes a licensed insurance company, a licensed
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0005| fraternal benefit society, a prepaid hospital or medical
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0006| service plan, a health maintenance organization, a nonprofit
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0007| health care organization, a multiple employer welfare
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0008| arrangement or any other person providing a plan of health
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0009| insurance subject to state insurance regulation;
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0010| [F.] G. "health care provider" means providers
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0011| of health care services licensed as required in this state;
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0012| [G.] H. "health care services" means services
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0013| rendered or products sold by a health care provider within the
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0014| scope of the provider's license. The term includes hospital,
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0015| medical, surgical, dental, advanced practice nursing, vision
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0016| and pharmaceutical services or products;
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0017| [H.] I. "preferred provider" means a health
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0018| care provider or group of providers [who have] that has
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0019| contracted with a health care insurer to provide specified
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0020| covered services to a covered person; and
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0021| [I.] J. "preferred provider arrangement" means
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0022| a contract between or on behalf of the health care insurer and
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0023| a preferred provider [which] that complies with all the
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0024| requirements of the Preferred Provider Arrangements Law."
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0025| Section 6. Section 59A-22A-6 NMSA 1978 (being Laws 1993,
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0001| Chapter 320, Section 64) is amended to read:
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0002| "59A-22A-6. PREFERRED PROVIDER PARTICIPATION
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0003| REQUIREMENTS.--Health care insurers may place reasonable limits
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0004| on the number or classes of preferred providers [which]
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0005| that satisfy the standards set forth by the health care
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0006| insurer; provided that there is no discrimination against
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0007| providers on the basis of religion, race, color, national
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0008| origin, age, sex or marital status; and further provided that
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0009| selection of preferred providers is primarily based on, but not
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0010| limited to, cost and availability of covered services and the
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0011| quality of services performed by the providers. Health
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0012| insurers shall use outcomes measurements recognized by the
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0013| health care providers affected to evaluate the ability of the
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0014| class to provide the care required under the provider
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0015| agreement. As part of the annual report required under Chapter
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0016| 59A, Article 23B NMSA 1978, the health insurer shall provide
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0017| the public with information on the criteria and method of
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0018| analysis used to determine the numbers and classes of
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0019| providers."
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0020| Section 7. Section 59A-23B-3 NMSA 1978 (being Laws 1991,
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0021| Chapter 111, Section 3, as amended) is amended to read:
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0022| "59A-23B-3. POLICY OR PLAN--DEFINITION--CRITERIA.--
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0023| A. For purposes of the Minimum Healthcare
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0024| Protection Act, "policy or plan" means a healthcare benefit
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0025| policy or healthcare benefit plan that the insurer, fraternal
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0001| benefit society, health maintenance organization or nonprofit
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0002| healthcare plan chooses to offer to individuals, families or
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0003| groups of fewer than twenty members formed for purposes other
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0004| than obtaining insurance coverage and that meets the
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0005| requirements of Subsection B of this section. For purposes of
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0006| the Minimum Healthcare Protection Act, "policy or plan" shall
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0007| not mean a healthcare policy or healthcare benefit plan that an
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0008| insurer, health maintenance organization, fraternal benefit
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0009| society or nonprofit healthcare plan chooses to offer outside
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0010| the authority of the Minimum Healthcare Protection Act.
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0011| B. A policy or plan shall meet the following
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0012| criteria:
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0013| (1) the individual, family or group obtaining
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0014| coverage under the policy or plan has been without healthcare
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0015| insurance, a health services plan or employer-sponsored
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0016| healthcare coverage for the six-month period immediately
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0017| preceding the effective date of its coverage under a policy or
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0018| plan, provided that the six-month period shall not apply to:
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0019| (a) a group that has been in existence
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0020| for less than six months and has been without healthcare
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0021| coverage since the formation of the group;
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0022| (b) an employee whose healthcare
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0023| coverage has been terminated by an employer;
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0024| (c) a dependent who no longer qualifies
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0025| as a dependent under the terms of the contract; or
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0001| (d) an individual and an individual's
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0002| dependents who no longer have healthcare coverage as a result
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0003| of termination or change in employment of the individual or by
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0004| reason of death of a spouse or dissolution of a marriage,
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0005| notwithstanding rights the individual or individual's
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0006| dependents may have to continue healthcare coverage on a self-
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0007| pay basis pursuant to the provisions of the federal
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0008| Consolidated Omnibus Budget Reconciliation Act of 1985;
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0009| (2) the policy or plan includes the following
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0010| managed care provisions to control costs:
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0011| (a) an exclusion for services that are
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0012| not medically necessary or are not covered by preventive health
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0013| services; and
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0014| (b) a procedure for preauthorization of
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0015| elective hospital admissions by the insurer, fraternal benefit
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0016| society, health maintenance organization or nonprofit
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0017| healthcare plan; and
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0018| (3) subject to a maximum limit on the cost of
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0019| healthcare services covered in any calendar year of not less
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0020| than fifty thousand dollars ($50,000), the policy or plan
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0021| provides the following minimum healthcare services to covered
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0022| individuals:
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0023| (a) inpatient hospitalization coverage
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0024| or home care coverage in lieu of hospitalization or a
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0025| combination of both, not to exceed twenty-five days of coverage
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0001| inclusive of any deductibles, co-payments or co-insurance,
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0002| provided that a period of inpatient hospitalization coverage
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0003| shall precede any home care coverage;
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0004| (b) prenatal care, including a minimum
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0005| of one prenatal office visit per month during the first two
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0006| trimesters of pregnancy, two office visits per month during the
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0007| seventh and eighth months of pregnancy and one office visit per
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0008| week during the ninth month and until term, provided that
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0009| coverage for each office visit shall also include prenatal
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0010| counseling and education and necessary and appropriate
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0011| screening, including history, physical examination and the
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0012| laboratory and diagnostic procedures deemed appropriate by the
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0013| [physician] licensed provider based upon recognized
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0014| [medical criteria] and prevailing standards of care for the
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0015| risk group of which the patient is a member;
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0016| (c) obstetrical care, including
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0017| physicians' and certified nurse midwives' services, advanced
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0018| practice nurses certified in obstetrics and gynecology,
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0019| delivery room and other medically necessary services directly
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0020| associated with delivery;
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0021| (d) well-baby and well-child care,
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0022| including periodic evaluation of a child's physical and
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0023| emotional status, a history, a complete physical examination, a
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0024| developmental assessment, anticipatory guidance, appropriate
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0025| immunizations and laboratory tests in keeping with recognized
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0001| and prevailing [medical] standards of care; provided that
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0002| such evaluation and care shall be covered when performed at
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0003| approximately the age intervals of birth, two weeks, two
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0004| months, four months, six months, nine months, twelve months,
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0005| fifteen months, eighteen months, two years, three years, four
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0006| years, five years and six years;
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0007| (e) coverage for low-dose screening
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0008| mammograms for determining the presence of breast cancer;
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0009| provided that the mammogram coverage shall include one baseline
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0010| mammogram for persons age thirty-five through thirty-nine
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0011| years, one biennial mammogram for persons age forty through
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0012| forty-nine years and one annual mammogram for persons age fifty
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0013| years and over; and further provided that the mammogram
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0014| coverage shall only be subject to deductibles and co-insurance
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0015| requirements consistent with those imposed on other benefits
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0016| under the same policy or plan;
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0017| (f) coverage for cytologic screening, to
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0018| include a Papanicolaou test and pelvic exam for asymptomatic as
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0019| well as symptomatic women; and
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0020| (g) a basic level of primary and
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0021| preventive care, including, but not limited to, no less than
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0022| seven physician, [nurse practitioner, nurse midwife]
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0023| advanced practice nurse, clinical specialist or physician
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0024| assistant office visits per calendar year, including any
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0025| ancillary diagnostic or laboratory tests related to the office
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0001| visit.
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0002| C. A policy or plan may include the following
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0003| managed care and cost-control features to control costs:
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0004| (1) a panel of providers who have entered into
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0005| written agreements with the insurer, fraternal benefit society,
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0006| health maintenance organization or nonprofit healthcare plan to
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0007| provide covered healthcare services at specified levels of
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0008| reimbursement; provided that any such written agreement shall
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0009| contain a provision relieving the individual, family or group
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0010| covered by the policy or plan from any obligation to pay for
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0011| any healthcare service performed by the provider that is
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0012| determined by the insurer, fraternal benefit society, health
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0013| maintenance organization or nonprofit healthcare plan not to be
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0014| medically necessary;
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0015| (2) a requirement for obtaining a second
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0016| opinion before elective surgery is performed;
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0017| (3) a procedure for utilization review by the
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0018| insurer, fraternal benefit society, health maintenance
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0019| organization or nonprofit healthcare plan; and
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0020| (4) a maximum limit on the cost of healthcare
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0021| services covered in any calendar year of not less than fifty
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0022| thousand dollars ($50,000).
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0023| D. Nothing contained in Subsection C of this
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0024| section shall prohibit an insurer, fraternal benefit society,
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0025| health maintenance organization or nonprofit healthcare plan
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0001| from including in the policy or plan additional managed care
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0002| and cost-control provisions that the superintendent of
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0003| insurance determines to have the potential for controlling
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0004| costs in a manner that does not cause discriminatory treatment
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0005| of individuals, families or groups covered by the policy or
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0006| plan.
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0007| E. Notwithstanding any other provisions of law, a
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0008| policy or plan shall not exclude coverage for losses incurred
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0009| for a pre-existing condition more than six months from the
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0010| effective date of coverage. The policy or plan shall not
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0011| define a pre-existing condition more restrictively than a
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0012| condition for which medical advice was given or treatment
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0013| recommended by or received from a [physician] licensed
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0014| provider within six months before the effective date of
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0015| coverage.
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0016| F. No medical group, independent practice
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0017| association or health professional employed by or contracting
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0018| with an insurer, fraternal benefit society, health maintenance
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0019| organization or nonprofit healthcare plan shall maintain any
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0020| action against any insured person, family or group member for
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0021| sums owed by an insurer, fraternal benefit society, health
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0022| maintenance organization or nonprofit healthcare plan, for sums
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0023| higher than those agreed to pursuant to a policy or plan."
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0024| Section 8. Section 59A-46-2 NMSA 1978 (being Laws 1993,
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0025| Chapter 266, Section 2) is amended to read:
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0001| "59A-46-2. DEFINITIONS.--As used in the Health
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0002| Maintenance Organization Law:
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0003| A. "basic health care services":
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0004| (1) means medically necessary services
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0005| consisting of preventive care, emergency care, inpatient and
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0006| outpatient hospital [and physician care], physician and
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0007| advanced practice nursing care, diagnostic laboratory and
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0008| diagnostic and therapeutic radiological services; but
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0009| (2) does not include mental health services or
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0010| services for alcohol or drug abuse, dental or vision services
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0011| or long-term rehabilitation treatment;
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0012| B. "capitated basis" means fixed per member per
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0013| month payment or percentage of premium payment wherein the
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0014| provider assumes the full risk for the cost of contracted
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0015| services without regard to the type, value or frequency of
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0016| services provided and includes the cost associated with
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0017| operating staff model facilities;
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0018| C. "carrier" means a health maintenance
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0019| organization, an insurer, a nonprofit health care plan or other
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0020| entity responsible for the payment of benefits or provision of
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0021| services under a group contract;
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0022| D. "copayment" means an amount an enrollee must pay
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0023| in order to receive a specific service that is not fully
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0024| prepaid;
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0025| E. "deductible" means the amount an enrollee is
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0001| responsible to pay out of pocket before the health maintenance
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0002| organization begins to pay the costs associated with treatment;
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0003| F. "enrollee" means an individual who is covered by
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0004| a health maintenance organization;
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0005| G. "evidence of coverage" means a policy, contract
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0006| or certificate showing the essential features and services of
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0007| the health maintenance organization coverage that is given to
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0008| the subscriber by the health maintenance organization or by the
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0009| group contract holder;
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0010| H. "extension of benefits" means the continuation
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0011| of coverage under a particular benefit provided under a
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0012| contract or group contract following termination with respect
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0013| to an enrollee who is totally disabled on the date of
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0014| termination;
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0015| I. "grievance" means a written complaint submitted
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0016| in accordance with the health maintenance organization's formal
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0017| grievance procedure by or on behalf of the enrollee regarding
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0018| any aspect of the health maintenance organization relative to
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0019| the enrollee;
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0020| J. "group contract" means a contract for health
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0021| care services that by its terms limits eligibility to members
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0022| of a specified group and may include coverage for dependents;
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0023| K. "group contract holder" means the person to
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0024| [which] whom a group contract has been issued;
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0025| L. "health care services" means any services
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0001| included in the furnishing to any individual of medical,
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0002| mental, dental, advanced practice nursing or optometric care
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0003| or hospitalization or nursing home care or incident to the
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0004| furnishing of such care or hospitalization, as well as the
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0005| furnishing to any person of any and all other services for the
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0006| purpose of preventing, alleviating, curing or healing human
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0007| physical or mental illness or injury;
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0008| M. "health maintenance organization" means any
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0009| person who undertakes to provide or arrange for the delivery of
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0010| basic health care services to enrollees on a prepaid basis,
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0011| except for enrollee responsibility for copayments or
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0012| deductibles;
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0013| N. "health maintenance organization agent" means a
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0014| person who solicits, negotiates, effects, procures, delivers,
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0015| renews or continues a policy or contract for health maintenance
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0016| organization membership or who takes or transmits a membership
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0017| fee or premium for such a policy or contract, other than for
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0018| himself, or a person who advertises or otherwise holds himself
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0019| out to the public as such;
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0020| O. "individual contract" means a contract for
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0021| health care services issued to and covering an individual and
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0022| it may include dependents of the subscriber;
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0023| P. "insolvent" or "insolvency" means that the
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0024| organization has been declared insolvent and placed under an
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0025| order of liquidation by a court of competent jurisdiction;
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0001| Q. "managed hospital payment basis" means
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0002| agreements in which the financial risk is related primarily to
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0003| the degree of utilization rather than to the cost of services;
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0004| R. "net worth" means the excess of total admitted
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0005| assets over total liabilities, but the liabilities shall not
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0006| include fully subordinated debt;
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0007| S. "participating provider" means a provider as
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0008| defined in Subsection U of this section who, under an express
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0009| contract with the health maintenance organization or with its
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0010| contractor or subcontractor, has agreed to provide health care
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0011| services to enrollees with an expectation of receiving payment,
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0012| other than copayment or deductible, directly or indirectly from
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0013| the health maintenance organization;
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0014| T. "person" means an individual or any other legal
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0015| entity;
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0016| U. "provider" means any physician, hospital or
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0017| other person licensed or otherwise authorized to furnish health
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0018| care services;
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0019| V. "replacement coverage" means the benefits
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0020| provided by a succeeding carrier;
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0021| W. "subscriber" means an individual whose
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0022| employment or other status, except family dependency, is the
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0023| basis for eligibility for enrollment in the health maintenance
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0024| organization or, in the case of an individual contract, the
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0025| person in whose name the contract is issued; and
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0001| X. "uncovered expenditures" means the costs to the
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0002| health maintenance organization for health care services that
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0003| are the obligation of the health maintenance organization, for
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0004| which an enrollee may also be liable in the event of the health
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0005| maintenance organization's insolvency and for which no
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0006| alternative arrangements have been made that are acceptable to
|
0007| the superintendent."
|
0008| Section 9. Section 59A-46-7 NMSA 1978 (being Laws 1993,
|
0009| Chapter 266, Section 7) is amended to read:
|
0010| "59A-46-7. QUALITY ASSURANCE PROGRAM.--
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0011| A. A health maintenance organization shall
|
0012| establish procedures to assure that the health care services
|
0013| provided to enrollees shall be rendered under reasonable
|
0014| standards of quality of care consistent with prevailing
|
0015| professionally recognized standards of medical practice. Such
|
0016| procedures shall include mechanisms to assure availability,
|
0017| accessibility and continuity of care.
|
0018| B. A health maintenance organization shall have an
|
0019| ongoing internal quality assurance program to monitor and
|
0020| evaluate its health care services, including primary and
|
0021| specialist physician services, and ancillary and preventive
|
0022| health care services, across all institutional and non-
|
0023| institutional settings. The program shall include, at a
|
0024| minimum, the following:
|
0025| (1) a written statement of goals and
|
0001| objectives that emphasizes improved health status in evaluating
|
0002| the quality of care rendered to enrollees;
|
0003| (2) a written quality assurance plan that
|
0004| describes the following:
|
0005| (a) the health maintenance
|
0006| organization's scope and purpose in quality assurance;
|
0007| (b) the organizational structure
|
0008| responsible for quality assurance activities;
|
0009| (c) contractual arrangements, where
|
0010| appropriate, for delegation of quality assurance activities;
|
0011| (d) confidentiality policies and
|
0012| procedures;
|
0013| (e) a system of ongoing evaluation
|
0014| activities;
|
0015| (f) a system of focused evaluation
|
0016| activities;
|
0017| (g) a system for credentialing providers
|
0018| and performing peer review activities; and
|
0019| (h) duties and responsibilities of the
|
0020| designated physician or advanced practice nurse responsible
|
0021| for the quality assurance activities;
|
0022| (3) a written statement describing the system
|
0023| of ongoing quality assurance activities, including:
|
0024| (a) problem assessment, identification,
|
0025| selection and study;
|
0001| (b) corrective action, monitoring,
|
0002| evaluation and reassessment; and
|
0003| (c) interpretation and analysis of
|
0004| patterns of care rendered to individual patients by individual
|
0005| providers;
|
0006| (4) a written statement describing the system
|
0007| of focused quality assurance activities based on representative
|
0008| samples of the enrolled population that identifies [method]
|
0009| methods of topic selection, study, data collection, analysis,
|
0010| interpretation and report format; and
|
0011| (5) written plans for taking appropriate
|
0012| corrective action whenever, as determined by the quality
|
0013| assurance program, inappropriate or substandard services have
|
0014| been provided or services that should have been furnished have
|
0015| not been provided.
|
0016| C. A health maintenance organization shall record
|
0017| proceedings of formal quality assurance program activities and
|
0018| maintain documentation in a confidential manner. Quality
|
0019| assurance program minutes shall be available for examination by
|
0020| the superintendent and by the secretary of health if requested
|
0021| by the superintendent but shall not be disclosed to third
|
0022| parties except as permitted by the provisions of Chapter 59A,
|
0023| Article 46 NMSA 1978.
|
0024| D. A health maintenance organization shall ensure
|
0025| the use and maintenance of an adequate patient record system
|
0001| that will facilitate documentation and retrieval of clinical
|
0002| information for the purpose of the health maintenance
|
0003| organization evaluating continuity and coordination of patient
|
0004| care and assessing the quality of health and medical care
|
0005| provided to enrollees.
|
0006| E. Except as otherwise restricted or prohibited by
|
0007| state or federal law, enrollee clinical records shall be
|
0008| available to the superintendent or an authorized designee for
|
0009| examination and review to ascertain compliance with this
|
0010| section or as deemed necessary by the superintendent.
|
0011| F. A health maintenance organization shall
|
0012| establish a mechanism for periodic reporting of quality
|
0013| assurance program activities to the governing body, providers
|
0014| and appropriate organization staff."
|
0015| Section 10. Section 59A-46-35 NMSA 1978 (being Laws 1987,
|
0016| Chapter 335, Section 1, as amended) is amended to read:
|
0017| "59A-46-35. PROVIDER DISCRIMINATION PROHIBITED.--No class
|
0018| of licensed individual providers willing to meet the terms and
|
0019| conditions offered by a health maintenance organization shall
|
0020| be excluded from a health maintenance organization. For
|
0021| purposes of this section, "providers" means those persons
|
0022| licensed under [Articles] Chapter 61, Article 2, 3, 4, 5,
|
0023| 6, 8, 9, 10 or 11 [of Chapter 61] NMSA 1978."
|
0024|
|
0025|
|
0001| FORTY-THIRD LEGISLATURE
|
0002| FIRST SESSION, 1997
|
0003|
|
0004|
|
0005| March 17, 1997
|
0006|
|
0007| Mr. President:
|
0008|
|
0009| Your PUBLIC AFFAIRS COMMITTEE, to whom has been referred
|
0010|
|
0011| SENATE BILL 767
|
0012|
|
0013| has had it under consideration and reports same WITHOUT
|
0014| RECOMMENDATION, and thence referred to the CORPORATIONS &
|
0015| TRANSPORTATION COMMITTEE.
|
0016|
|
0017| Respectfully submitted,
|
0018|
|
0019|
|
0020|
|
0021| __________________________________
|
0022| Shannon Robinson, Chairman
|
0023|
|
0024|
|
0025| Adopted_______________________ Not Adopted_______________________
|
0001| (Chief Clerk) (Chief Clerk)
|
0002|
|
0003|
|
0004| Date ________________________
|
0005|
|
0006|
|
0007| The roll call vote was 6 For 0 Against
|
0008| Yes: 6
|
0009| No: 0
|
0010| Excused: Ingle, Vernon, Rodarte
|
0011| Absent: None
|
0012|
|
0013|
|
0014|
|
0015|
|
0016|
|
0017| S0767PA1
|
0018|
|
0019| FORTY-THIRD LEGISLATURE
|
0020| FIRST SESSION, 1997
|
0021|
|
0022|
|
0023| March 19, 1997
|
0024|
|
0025| Mr. President:
|
0001|
|
0002| Your CORPORATIONS & TRANSPORTATION COMMITTEE, to whom
|
0003| has been referred
|
0004|
|
0005| SENATE BILL 767
|
0006|
|
0007| has had it under consideration and reports same with recommendation
|
0008| that it DO PASS.
|
0009|
|
0010| Respectfully submitted,
|
0011|
|
0012|
|
0013|
|
0014| __________________________________
|
0015| Roman M. Maes, III, Chairman
|
0016|
|
0017|
|
0018|
|
0019| Adopted_______________________ Not Adopted_______________________
|
0020| (Chief Clerk) (Chief Clerk)
|
0021|
|
0022|
|
0023|
|
0024| Date ________________________
|
0025|
|
0001|
|
0002| The roll call vote was 10 For 0 Against
|
0003| Yes: 10
|
0004| No: 0
|
0005| Excused: None
|
0006| Absent: None
|
0007|
|
0008|
|
0009| S0767CT1
|