HBIC/HB 577
Page 1
AN ACT
RELATING TO INSURANCE; INCLUDING PHARMACISTS AND PHARMACIST
CLINICIANS AS PROVIDERS OF SERVICE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. Section 59A-46-2 NMSA 1978 (being Laws 1993,
Chapter 266, Section 2) is amended to read:
"59A-46-2. DEFINITIONS.--As used in the Health
Maintenance Organization Law:
A. "basic health care services":
(1) means medically necessary services
consisting of preventive care, emergency care, inpatient and
outpatient hospital and physician care, diagnostic laboratory,
diagnostic and therapeutic radiological services and services
of pharmacists and pharmacist clinicians; but
(2) does not include mental health services
or services for alcohol or drug abuse, dental or vision
services or long-term rehabilitation treatment;
B. "capitated basis" means fixed per member per
month payment or percentage of premium payment wherein the
provider assumes the full risk for the cost of contracted
services without regard to the type, value or frequency of
services provided and includes the cost associated with
operating staff model facilities;
C. "carrier" means a health maintenance
pg_0002
HBIC/HB 577
Page 2
organization, an insurer, a nonprofit health care plan or
other entity responsible for the payment of benefits or
provision of services under a group contract;
D. "copayment" means an amount an enrollee must
pay in order to receive a specific service that is not fully
prepaid;
E. "deductible" means the amount an enrollee is
responsible to pay out-of-pocket before the health maintenance
organization begins to pay the costs associated with
treatment;
F. "enrollee" means an individual who is covered
by a health maintenance organization;
G. "evidence of coverage" means a policy, contract
or certificate showing the essential features and services of
the health maintenance organization coverage that is given to
the subscriber by the health maintenance organization or by
the group contract holder;
H. "extension of benefits" means the continuation
of coverage under a particular benefit provided under a
contract or group contract following termination with respect
to an enrollee who is totally disabled on the date of
termination;
I. "grievance" means a written complaint submitted
in accordance with the health maintenance organization's
formal grievance procedure by or on behalf of the enrollee
pg_0003
HBIC/HB 577
Page 3
regarding any aspect of the health maintenance organization
relative to the enrollee;
J. "group contract" means a contract for health
care services that by its terms limits eligibility to members
of a specified group and may include coverage for dependents;
K. "group contract holder" means the person to
whom a group contract has been issued;
L. "health care services" means any services
included in the furnishing to any individual of medical,
mental, dental, pharmaceutical or optometric care or
hospitalization or nursing home care or incident to the
furnishing of such care or hospitalization, as well as the
furnishing to any person of any and all other services for the
purpose of preventing, alleviating, curing or healing human
physical or mental illness or injury;
M. "health maintenance organization" means any
person who undertakes to provide or arrange for the delivery
of basic health care services to enrollees on a prepaid basis,
except for enrollee responsibility for copayments or
deductibles;
N. "health maintenance organization agent" means a
person who solicits, negotiates, effects, procures, delivers,
renews or continues a policy or contract for health
maintenance organization membership or who takes or transmits
a membership fee or premium for such a policy or contract,
pg_0004
HBIC/HB 577
Page 4
other than for himself, or a person who advertises or
otherwise holds himself out to the public as such;
O. "individual contract" means a contract for
health care services issued to and covering an individual and
it may include dependents of the subscriber;
P. "insolvent" or "insolvency" means that the
organization has been declared insolvent and placed under an
order of liquidation by a court of competent jurisdiction;
Q. "managed hospital payment basis" means
agreements in which the financial risk is related primarily to
the degree of utilization rather than to the cost of services;
R. "net worth" means the excess of total admitted
assets over total liabilities, but the liabilities shall not
include fully subordinated debt;
S. "participating provider" means a provider as
defined in Subsection U of this section who, under an express
contract with the health maintenance organization or with its
contractor or subcontractor, has agreed to provide health care
services to enrollees with an expectation of receiving
payment, other than copayment or deductible, directly or
indirectly from the health maintenance organization;
T. "person" means an individual or other legal
entity;
U. "provider" means a physician, pharmacist,
pharmacist clinician, hospital or other person licensed or
pg_0005
HBIC/HB 577
Page 5
otherwise authorized to furnish health care services;
V. "replacement coverage" means the benefits
provided by a succeeding carrier;
W. "subscriber" means an individual whose
employment or other status, except family dependency, is the
basis for eligibility for enrollment in the health maintenance
organization or, in the case of an individual contract, the
person in whose name the contract is issued;
X. "uncovered expenditures" means the costs to the
health maintenance organization for health care services that
are the obligation of the health maintenance organization, for
which an enrollee may also be liable in the event of the
health maintenance organization's insolvency and for which no
alternative arrangements have been made that are acceptable to
the superintendent;
Y. "pharmacist" means a person licensed as a
pharmacist pursuant to the Pharmacy Act; and
Z. "pharmacist clinician" means a pharmacist who
exercises prescriptive authority pursuant to the Pharmacist
Prescriptive Authority Act."
Section 2. Section 59A-47-3 NMSA 1978 (being Laws 1984,
Chapter 127, Section 879.1, as amended) is amended to read:
"59A-47-3. DEFINITIONS.--As used in Chapter 59A,
Article 47 NMSA 1978:
A. "health care" means the treatment of persons
pg_0006
HBIC/HB 577
Page 6
for the prevention, cure or correction of any illness or
physical or mental condition, including optometric services;
B. "item of health care" includes any services or
materials used in health care;
C. "health care expense payment" means a payment
for health care to a purveyor on behalf of a subscriber, or
such a payment to the subscriber;
D. "purveyor" means a person who furnishes any
item of health care and charges for that item;
E. "service benefit" means a payment that the
purveyor has agreed to accept as payment in full for health
care furnished the subscriber;
F. "indemnity benefit" means a payment that the
purveyor has not agreed to accept as payment in full for
health care furnished the subscriber;
G. "subscriber" means any individual who, because
of a contract with a health care plan entered into by or for
the individual, is entitled to have health care expense
payments made on the individual's behalf or to the individual
by the health care plan;
H. "underwriting manual" means the health care
plan's written criteria, approved by the superintendent, that
defines the terms and conditions under which subscribers may
be selected. The underwriting manual may be amended from time
to time, but amendment will not be effective until approved by
pg_0007
HBIC/HB 577
Page 7
the superintendent. The superintendent shall notify the
health care plan filing the underwriting manual or the
amendment thereto of the superintendent's approval or
disapproval thereof in writing within thirty days after filing
or within sixty days after filing if the superintendent shall
so extend the time. If the superintendent fails to act within
such period, the filing shall be deemed to be approved;
I. "acquisition expenses" includes all expenses
incurred in connection with the solicitation and enrollment of
subscribers;
J. "administration expenses" means all expenses of
the health care plan other than the cost of health care
expense payments and acquisition expenses;
K. "health care plan" means a nonprofit
corporation authorized by the superintendent to enter into
contracts with subscribers and to make health care expense
payments;
L. "agent" means a person appointed by a health
care plan authorized to transact business in this state to act
as its representative in any given locality for soliciting
health care policies and other related duties as may be
authorized;
M. "solicitor" means a person employed by the
licensed agent of a health care plan for the purpose of
soliciting health care policies and other related duties in
pg_0008
connection with the handling of the business of the agent as
may be authorized and paid for the person's services either on
a commission basis or salary basis or part by commission and
part by salary;
N. "chiropractor" means any person holding a
license provided for in the Chiropractic Physician Practice
Act;
O. "doctor of oriental medicine" means any person
licensed as a doctor of oriental medicine under the
Acupuncture and Oriental Medicine Practice Act;
P. "pharmacist" means a person licensed as a
pharmacist pursuant to the Pharmacy Act; and
Q. "pharmacist clinician" means a pharmacist who
exercises prescriptive authority pursuant to the Pharmacist
Prescriptive Authority Act."
HBIC/HB 577
Page 8