0001| SENATE BILL 1137 | 0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997 | 0003| INTRODUCED BY | 0004| MARY JANE M. GARCIA | 0005| | 0006| | 0007| | 0008| | 0009| | 0010| AN ACT | 0011| RELATING TO HEALTH CARE; ADDRESSING MEDICAID MANAGED CARE, THE | 0012| UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER AND OTHER | 0013| PROVIDERS. | 0014| | 0015| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0016| Section 1. A new section of the Public Assistance Act is | 0017| enacted to read: | 0018| "[NEW MATERIAL] MEDICAID MANAGED CARE--UNIVERSITY OF | 0019| NEW MEXICO HEALTH SCIENCES CENTER--AUTHORIZATION FOR CONTRACTS | 0020| DIRECTLY WITH PUBLIC AGENCIES, HOSPITALS, ESSENTIAL COMMUNITY | 0021| PROVIDERS AND PROVIDER SERVICE NETWORKS.-- | 0022| A. A managed health care plan offered through the | 0023| medicaid program shall include participation by the university | 0024| of New Mexico health sciences center. The human services | 0025| department shall administer a program to ensure the | 0001| participation includes delivery of primary care and tertiary | 0002| care services and to attempt to ensure, to the extent permitted | 0003| by federal law, that the medicaid patient population served by | 0004| the university of New Mexico health sciences center remains at | 0005| least at a level similar to that served by the university of | 0006| New Mexico health sciences center prior to implementation of | 0007| the medicaid managed health care program. | 0008| B. A managed health care plan offered through the | 0009| medicaid program shall provide payments to the university of | 0010| New Mexico health sciences center at rates that are reasonable | 0011| and adequate to meet costs incurred by efficiently and | 0012| economically operated facilities, taking into account the | 0013| disproportionately greater severity of illness and injury | 0014| experienced by the patient population served. | 0015| C. The human services department shall administer a | 0016| program and cooperate with the university of New Mexico health | 0017| sciences center to ensure an adequate and diverse patient | 0018| population necessary to preserve the health sciences center's | 0019| educational programs. The human services department shall also | 0020| assure continuity of general support under the state medicaid | 0021| program to the university of New Mexico health sciences center | 0022| for medical education and for serving a disproportionately | 0023| large indigent patient population. | 0024| D. In administering the medicaid program or a | 0025| managed health care system for the program, the human services | 0001| department may contract directly with a government agency or | 0002| public body, public nonprofit hospital, the university of New | 0003| Mexico health sciences center, an essential community provider | 0004| or a provider service network. In doing so, the human services | 0005| department is not required to contract with any such entity | 0006| only through arrangements with a health care insurer. | 0007| E. For the purposes of this section: | 0008| (1) "enrollee", "patient" or "consumer" means | 0009| an individual who is entitled to receive health care benefits | 0010| from a managed health care plan; | 0011| (2) "essential community provider" means a | 0012| person that provides a significant portion of its health or | 0013| health-related services to medically needy indigent patients, | 0014| including uninsured, underserved or special needs populations; | 0015| (3) "health care facility" means an | 0016| institution providing health care services, including a | 0017| hospital or other licensed inpatient center, an ambulatory | 0018| surgical or treatment center, a skilled nursing center, a | 0019| residential treatment center, a home health agency, a | 0020| diagnostic, laboratory or imaging center and a rehabilitation | 0021| or other therapeutic health setting; | 0022| (4) "health care insurer" means a person that | 0023| has a valid certificate of authority in good standing under the | 0024| New Mexico Insurance Code to act as an insurer, a health | 0025| maintenance organization, a nonprofit health care plan or a | 0001| prepaid dental plan; | 0002| (5) "health care professional" means a | 0003| physician or other health care practitioner, including a | 0004| pharmacist, who is licensed, certified or otherwise authorized | 0005| by the state to provide health services consistent with state | 0006| law; | 0007| (6) "health care provider" or "provider" means | 0008| a person that is licensed or otherwise authorized by the state | 0009| to furnish health care services and includes health care | 0010| professionals, health care facilities and essential community | 0011| providers; | 0012| (7) "health care services" includes physical | 0013| health services or community-based mental health or | 0014| developmental disability services, including services for | 0015| developmental delay; | 0016| (8) "managed health care plan" or "plan" means | 0017| a health benefit plan of a health care insurer or a provider | 0018| service network that either requires an enrollee to use, or | 0019| creates incentives, including financial incentives, for an | 0020| enrollee to use health care providers managed, owned, under | 0021| contract with or employed by the health care insurer. "Managed | 0022| health care plan" or "plan" does not include a traditional fee- | 0023| for-service indemnity plan or a plan that covers only short- | 0024| term travel, accident-only, limited benefit, student health | 0025| plan or specified disease policies; | 0001| (9) "person" means an individual or other | 0002| legal entity; | 0003| (10) "primary health care clinic" means a | 0004| nonprofit community-based entity established to provide the | 0005| first level of basic or general health care needs, including | 0006| diagnostic and treatment services, for residents of a health | 0007| care underserved area as that area is defined in regulation | 0008| adopted by the department of health; and | 0009| (11) "provider service network" means two or | 0010| more health care providers affiliated for the purpose of | 0011| providing health care services to enrollees on a capitated or | 0012| similar prepaid, flat-rate basis." | 0013|  |