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