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(Parenthesis ( ) Indicate Expenditure Decreases)

Duplicates/Conflicts with/Companion to/Relates to

SUMMARY

Synopsis of Bill

Senate Public Affairs Committee substitute for Senate Bill 511 reduces a 45 page bill to one that is now 19 pages. The bill contains the following:

1. Contains a definitions section that now defines "clean claim", "commission' to mean the New Mexico Health Policy Commission, "continuous quality improvement", "enrollee", "emergency care", "Department", "health care facility, provider, professional, services", "insurer","person", "plan", "point of service plan", "provider service network", "superintendent", "utilization review".

2. Amends 59A-57-4 regarding patient rights and changes all references of regulations to now mean "rules" changes language to now describe what the plan's benefits and exclusions mean, the provisions for referrals and authorizations for specialty care, behavior health services, and hospital services, the plan's procedures for changing providers, a summary of the enrollee's rights, information on the plans rules and provisions that are directly related to the enrollee's health care, what responsibilities the enrollee has for payment of portions of the bill. Requires the plan to offer reasonably available health care services that are accessible in a timely manner, and other provisions.

3. Requires the plan to implement a comprehensive utilization review program and describes extensively the components included in the plan.

4. Adds a new section that deals with reports of denial of care and disciplinary action.

5. Changes 59A-57-5 regarding consumer assistance and consumer advisory boards, reports to consumers, and duties of the department and the superintendent and delineates the powers of the department and the superintendent. Changes the phrase "managed care plan" to "plan in every instance, and adds new language to speak to performance measurements, survey of high-use health care consumers, development of measurement tools for measuring performance of managed care plans.

6. Changes 59A-57=6 by adding language regarding contracts not relieving liability, requiring an insurer to provide in a timely manner the necessary response or authorization to any inquiry by a provider required to provide health care services, and the need to exhaust available local remedies if requested by the enrollee or his designee for providing necessary health care services.

7. Adds new material regarding penalty for late payment for services, notice of claims received, and standard forms.

8. Changes language in 59A-57-10 by removing language that allows Medicaid enrollees to file simultaneous appeals to the human services department and the superintendent. Adds new language regarding the promulgation of rules to implement the Patient Protection Act to also apply to Medicaid managed care plans except when they are in conflict with federal rules or regulations.

9. Adds new language regarding confidentiality.

Significant Issues

The committee substitute removes significant portions of the original bill and removes significant portions and detailed sections that spoke to process, liability, continuity of care, duties of the Health Policy Commission, the Department of Health, and the Superintendent of the Insurance Division of the Public Regulation Commission.

FISCAL IMPLICATIONS

Please see the original analysis of Senate Bill 511 to review fiscal implications of this proposed legislation.

ADMINISTRATIVE IMPLICATIONS

Please see the original analysis of Senate Bill 511 to review administrative implications of this proposed legislation.

OTHER SUBSTANTIVE ISSUES

Sufficient time was not available to fully analyze this bill and comments were not received from the Health Policy Commission, the Department of Health or the Public Regulation Commission.

MB/njw