SENATE BILL 656
49th legislature - STATE OF NEW MEXICO - first session, 2009
INTRODUCED BY
Carroll H. Leavell
AN ACT
RELATING TO HEALTH INSURANCE; AMENDING THE PREFERRED PROVIDER ARRANGEMENTS LAW TO INCLUDE EXCLUSIVE PROVIDER ARRANGEMENTS.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
Section 1. Section 59A-22A-1 NMSA 1978 (being Laws 1993, Chapter 320, Section 59) is amended to read:
"59A-22A-1. SHORT TITLE.--Chapter 59A, Article 22A NMSA 1978 shall be known and may be cited as the "Preferred Provider and Exclusive Provider Arrangements Law"."
Section 2. Section 59A-22A-2 NMSA 1978 (being Laws 1993, Chapter 320, Section 60) is amended to read:
"59A-22A-2. PURPOSE.--The purpose of the Preferred Provider and Exclusive Provider Arrangements Law is to encourage health care cost containment while preserving quality of care by allowing health care insurers to enter into preferred provider arrangements and exclusive provider arrangements in accordance with minimum standards for preferred provider arrangements and exclusive provider arrangements and for the health benefit plans associated with those arrangements."
Section 3. Section 59A-22A-3 NMSA 1978 (being Laws 1993, Chapter 320, Section 61) is amended to read:
"59A-22A-3. DEFINITIONS.--As used in the Preferred Provider and Exclusive Provider Arrangements Law:
A. "covered person" means any person on whose behalf the health care insurer is obligated to pay for or to provide health benefit services;
B. "covered services" means health care services [which] that the health care insurer is obligated to pay for or to provide under a health benefit plan;
C. "emergency care" means covered services delivered to a covered person after the sudden onset of a medical condition manifesting itself by acute symptoms that are severe enough that:
(1) the lack of immediate medical attention could result in:
(a) placing the person's health in jeopardy;
(b) serious impairment of bodily functions; or
(c) serious dysfunction of any bodily organ or part; or
(2) a reasonable person believes that immediate medical attention is required;
D. "exclusive provider arrangement" means a contract between or on behalf of a health care insurer and a preferred provider that requires persons covered under a health care insurer's plan to use the services of preferred providers and that complies with all the requirements of the Preferred Provider and Exclusive Provider Arrangements Law;
[D.] E. "health benefit plan" means the health insurance policy or subscriber agreement between the covered person or the policyholder and the health care insurer [which] that defines the covered services and benefit levels available;
[E.] F. "health care insurer" means any person who provides health insurance in this state. For the purposes of the Small Group Rate and Renewability Act, "carrier" or "insurer" includes a licensed insurance company, a licensed fraternal benefit society, a prepaid hospital or medical service plan, a health maintenance organization, a nonprofit health care organization, a multiple employer welfare arrangement or any other person providing a plan of health insurance subject to state insurance regulation;
[F.] G. "health care provider" means providers of health care services licensed as required in this state;
[G.] H. "health care services" means services rendered or products sold by a health care provider within the scope of the provider's license. The term includes hospital, medical, surgical, dental, vision and pharmaceutical services or products;
[H.] I. "preferred provider" means a health care provider or group of providers who have contracted with a health care insurer to provide specified covered services to a covered person; and
[I.] J. "preferred provider arrangement" means a contract between or on behalf of the health care insurer and a preferred provider [which] that complies with all the requirements of the Preferred Provider and Exclusive Provider Arrangements Law."
Section 4. Section 59A-22A-4 NMSA 1978 (being Laws 1993, Chapter 320, Section 62) is amended to read:
"59A-22A-4. PREFERRED PROVIDER ARRANGEMENTS AND EXCLUSIVE PROVIDER ARRANGEMENTS.--
A. Notwithstanding any provisions of law to contrary, any health care insurer may enter into preferred provider arrangements and exclusive provider arrangements.
[A.] B. Such arrangements shall:
(1) establish the amount and manner of payment to the preferred provider. Such amount and manner of payment may include capitation payments for preferred providers;
(2) include mechanisms [which] that are designed to minimize the cost of the health benefit plan; for example:
(a) the review or control of utilization of health care services; or
(b) procedures for determining whether health care services rendered are medically necessary; and
(3) assure reasonable access to covered services available under the preferred provider arrangement and an adequate number of preferred providers to render those services.
[B.] C. Such arrangements shall not unfairly deny health benefits for medically necessary covered services.
[C.] D. If an entity enters into a contract providing covered services with a health care provider, but is not engaged in activities [which] that would require it to be licensed as a health care insurer, such entity shall file with the superintendent information describing its activities, a description of the contract or agreement it has entered into with the health care providers and such other information as is required by the provisions of the Health Care Benefits Jurisdiction Act and any regulations promulgated under its authority. Employers who enter into contracts with health care providers for the exclusive benefit of their employees and dependents are subject to the Health Care Benefits Jurisdiction Act and are exempt from this requirement only to the extent required by federal law."
Section 5. Section 59A-22A-5 NMSA 1978 (being Laws 1993, Chapter 320, Section 63) is amended to read:
"59A-22A-5. HEALTH BENEFIT PLANS.--
A. Health care insurers may issue preferred provider arrangement health benefit plans [which] that provide for incentives for covered persons to use the health care services of preferred providers. Such policies or subscriber agreement shall contain at least the following provisions:
(1) a provision that if a covered person receives emergency care for services specified in the preferred provider arrangement and cannot reasonably reach a preferred provider that emergency care rendered during the course of the emergency will be reimbursed as though the covered person had been treated by a preferred provider; and
(2) a provision [which] that clearly identifies the differentials in benefit levels for health care services of preferred providers and benefit levels for health care services of non-preferred providers.
B. If a preferred provider arrangement health benefit plan provides differences in benefit levels payable to preferred providers compared to other providers, such differences shall not unfairly deny payment for covered services and shall be no greater than necessary to provide a reasonable incentive for covered persons to use the preferred provider.
C. Health care insurers may issue exclusive provider arrangement health benefit plans that require covered persons to use the health care services of preferred providers. These policies or subscriber agreements shall contain a provision stating that in the event a covered person receives emergency care for services specified in the exclusive provider arrangement and cannot reasonably reach a preferred provider, emergency care rendered during the course of the emergency will be reimbursed as though the covered person had been treated by a preferred provider."
Section 6. Section 59A-22A-7 NMSA 1978 (being Laws 1993, Chapter 320, Section 65) is amended to read:
"59A-22A-7. GENERAL REQUIREMENTS.--Health care insurers complying with the Preferred Provider and Exclusive Provider Arrangements Law shall be subject to and are required to comply with all other applicable laws, rules and regulations of this state."
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