0001| AN ACT | 0002| RELATING TO INSURANCE; REQUIRING COVERAGE FOR MINIMUM HOSPITAL STAYS | 0003| FOR MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT OF | 0004| BREAST CANCER; AMENDING AND ENACTING SECTIONS OF THE NMSA 1978. | 0005| | 0006| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0007| Section 1. A new Section 59A-22-39.1 NMSA 1978 is enacted to | 0008| read: | 0009| "59A-22-39.1. MASTECTOMIES AND LYMPH NODE DISSECTION--MINIMUM | 0010| HOSPITAL STAY COVERAGE REQUIRED.-- | 0011| A. Each individual and group health insurance policy, | 0012| health care plan and certificate of health insurance delivered or | 0013| issued for delivery in this state shall provide coverage for not less | 0014| than forty-eight hours of inpatient care following a mastectomy and | 0015| not less than twenty-four hours of inpatient care following a lymph | 0016| node dissection for the treatment of breast cancer. | 0017| B. Nothing in this section shall be construed as requiring | 0018| the provision of inpatient coverage where the attending physician and | 0019| patient determine that a shorter period of hospital stay is | 0020| appropriate. | 0021| C. The provisions of this section shall not apply to short- | 0022| term travel, accident-only or limited or specified disease policies. | 0023| D. Coverage for minimum inpatient hospital stays for | 0024| mastectomies and lymph node dissections for the treatment of breast | 0025| cancer may be subject to deductibles and co-insurance consistent with | 0001| those imposed on other benefits under the same policy, plan or | 0002| certificate." | 0003| Section 2. Section 59A-23-4 NMSA 1978 (being Laws 1984, Chapter | 0004| 127, Section 463, as amended) is amended to read: | 0005| "59A-23-4. OTHER PROVISIONS APPLICABLE.-- | 0006| A. No blanket or group health insurance policy or contract | 0007| shall contain any provision relative to notice or proof of loss or the | 0008| time for paying benefits or the time within which suit may be brought | 0009| upon the policy that in the superintendent's opinion is less favorable | 0010| to the insured than would be permitted in the required or optional | 0011| provisions for individual health insurance policies as set forth in | 0012| Chapter 59A, Article 22 NMSA 1978. | 0013| B. The following provisions of Chapter 59A, Article 22 NMSA | 0014| 1978 shall also apply as to Chapter 59A, Article 23 NMSA 1978 and | 0015| blanket and group health insurance contracts: | 0016| (1) Section 59A-22-1 NMSA 1978, except Subsection C | 0017| thereof; and | 0018| (2) Section 59A-22-32 NMSA 1978. | 0019| C. The following provisions of Chapter 59A, Article 22 NMSA | 0020| 1978 shall also apply as to group health insurance contracts: | 0021| (1) Section 59A-22-33 NMSA 1978; | 0022| (2) Section 59A-22-34 NMSA 1978; | 0023| (3) Section 59A-22-34.1 NMSA 1978; | 0024| (4) Section 59A-22-35 NMSA 1978; | 0025| (5) Section 59A-22-36 NMSA 1978; | 0001| (6) Section 59A-22-39 NMSA 1978; | 0002| (7) Section 59A-22-39.1 NMSA 1978; and | 0003| (8) Section 59A-22-40 NMSA 1978." | 0004| Section 3. Section 59A-23B-3 NMSA 1978 (being Laws 1991, Chapter | 0005| 111, Section 3, as amended) is amended to read: | 0006| "59A-23B-3. POLICY OR PLAN--DEFINITION--CRITERIA.-- | 0007| A. For purposes of the Minimum Healthcare Protection Act, | 0008| "policy or plan" means a healthcare benefit policy or healthcare | 0009| benefit plan that the insurer, fraternal benefit society, health | 0010| maintenance organization or nonprofit healthcare plan chooses to offer | 0011| to individuals, families or groups of fewer than twenty members formed | 0012| for purposes other than obtaining insurance coverage and that meets | 0013| the requirements of Subsection B of this section. For purposes of the | 0014| Minimum Healthcare Protection Act, "policy or plan" shall not mean a | 0015| healthcare policy or healthcare benefit plan that an insurer, health | 0016| maintenance organization, fraternal benefit society or nonprofit | 0017| healthcare plan chooses to offer outside the authority of the Minimum | 0018| Healthcare Protection Act. | 0019| B. A policy or plan shall meet the following criteria: | 0020| (1) the individual, family or group obtaining | 0021| coverage under the policy or plan has been without healthcare | 0022| insurance, a health services plan or employer-sponsored healthcare | 0023| coverage for the six-month period immediately preceding the effective | 0024| date of its coverage under a policy or plan, provided that the six- | 0025| month period shall not apply to: | 0001| (a) a group that has been in existence for less | 0002| than six months and has been without healthcare coverage since the | 0003| formation of the group; | 0004| (b) an employee whose healthcare coverage has | 0005| been terminated by an employer; | 0006| (c) a dependent who no longer qualifies as a | 0007| dependent under the terms of the contract; or | 0008| (d) an individual and an individual's dependents | 0009| who no longer have healthcare coverage as a result of termination or | 0010| change in employment of the individual or by reason of death of a | 0011| spouse or dissolution of a marriage, notwithstanding rights the | 0012| individual or individual's dependents may have to continue healthcare | 0013| coverage on a self-pay basis pursuant to the provisions of the federal | 0014| Consolidated Omnibus Budget Reconciliation Act of 1985; | 0015| (2) the policy or plan includes the following managed | 0016| care provisions to control costs: | 0017| (a) an exclusion for services that are not | 0018| medically necessary or are not covered by preventive health services; | 0019| and | 0020| (b) a procedure for preauthorization of elective | 0021| hospital admissions by the insurer, fraternal benefit society, health | 0022| maintenance organization or nonprofit healthcare plan; and | 0023| (3) subject to a maximum limit on the cost of | 0024| healthcare services covered in any calendar year of not less than | 0025| fifty thousand dollars ($50,000), the policy or plan provides the | 0001| following minimum healthcare services to covered individuals: | 0002| (a) inpatient hospitalization coverage or home | 0003| care coverage in lieu of hospitalization or a combination of both, not | 0004| to exceed twenty-five days of coverage inclusive of any deductibles, | 0005| co-payments or co-insurance, provided that a period of inpatient | 0006| hospitalization coverage shall precede any home care coverage; | 0007| (b) prenatal care, including a minimum of one | 0008| prenatal office visit per month during the first two trimesters of | 0009| pregnancy, two office visits per month during the seventh and eighth | 0010| months of pregnancy and one office visit per week during the ninth | 0011| month and until term, provided that coverage for each office visit | 0012| shall also include prenatal counseling and education and necessary and | 0013| appropriate screening, including history, physical examination and the | 0014| laboratory and diagnostic procedures deemed appropriate by the | 0015| physician based upon recognized medical criteria for the risk group of | 0016| which the patient is a member; | 0017| (c) obstetrical care, including physicians' and | 0018| certified nurse midwives' services, delivery room and other medically | 0019| necessary services directly associated with delivery; | 0020| (d) well-baby and well-child care, including | 0021| periodic evaluation of a child's physical and emotional status, a | 0022| history, a complete physical examination, a developmental assessment, | 0023| anticipatory guidance, appropriate immunizations and laboratory tests | 0024| in keeping with prevailing medical standards, provided that such | 0025| evaluation and care shall be covered when performed at approximately | 0001| the age intervals of birth, two weeks, two months, four months, six | 0002| months, nine months, twelve months, fifteen months, eighteen months, | 0003| two years, three years, four years, five years and six years; | 0004| (e) coverage for low-dose screening mammograms | 0005| for determining the presence of breast cancer, provided that the | 0006| mammogram coverage shall include one baseline mammogram for persons | 0007| age thirty-five through thirty-nine years, one biennial mammogram for | 0008| persons age forty through forty-nine years and one annual mammogram | 0009| for persons age fifty years and over, and further provided that the | 0010| mammogram coverage shall only be subject to deductibles and | 0011| co-insurance requirements consistent with those imposed on other | 0012| benefits under the same policy or plan; | 0013| (f) coverage for cytologic screening, to include | 0014| a Papanicolaou test and pelvic exam for asymptomatic as well as | 0015| symptomatic women; | 0016| (g) a basic level of primary and preventive | 0017| care, including, but not limited to, no less than seven physician, | 0018| nurse practitioner, nurse midwife or physician assistant office visits | 0019| per calendar year, including any ancillary diagnostic or laboratory | 0020| tests related to the office visit; and | 0021| (h) coverage for not less than forty-eight hours | 0022| of inpatient care following a mastectomy and not less than twenty-four | 0023| hours of inpatient care following a lymph node dissection for the | 0024| treatment of breast cancer, provided that nothing in this subparagraph | 0025| shall be construed as requiring the provision of inpatient coverage | 0001| where the attending physician and patient determine that a shorter | 0002| period of hospital stay is appropriate and further provided that | 0003| coverage for minimum inpatient hospital stays for mastectomies and | 0004| lymph node dissections for the treatment of breast cancer may be | 0005| subject to deductibles and co-insurance consistent with those imposed | 0006| on other benefits under the same policy or plan. | 0007| C. A policy or plan may include the following managed care | 0008| and cost control features to control costs: | 0009| (1) a panel of providers who have entered into | 0010| written agreements with the insurer, fraternal benefit society, health | 0011| maintenance organization or nonprofit healthcare plan to provide | 0012| covered healthcare services at specified levels of reimbursement, | 0013| provided that any such written agreement shall contain a provision | 0014| relieving the individual, family or group covered by the policy or | 0015| plan from any obligation to pay for any healthcare service performed | 0016| by the provider that is determined by the insurer, fraternal benefit | 0017| society, health maintenance organization or nonprofit healthcare plan | 0018| not to be medically necessary; | 0019| (2) a requirement for obtaining a second opinion | 0020| before elective surgery is performed; | 0021| (3) a procedure for utilization review by the | 0022| insurer, fraternal benefit society, health maintenance organization or | 0023| nonprofit healthcare plan; and | 0024| (4) a maximum limit on the cost of healthcare | 0025| services covered in any calendar year of not less than fifty thousand | 0001| dollars ($50,000). | 0002| D. Nothing contained in Subsection C of this section shall | 0003| prohibit an insurer, fraternal benefit society, health maintenance | 0004| organization or nonprofit healthcare plan from including in the policy | 0005| or plan additional managed care and cost control provisions that the | 0006| superintendent of insurance determines to have the potential for | 0007| controlling costs in a manner that does not cause discriminatory | 0008| treatment of individuals, families or groups covered by the policy or | 0009| plan. | 0010| E. Notwithstanding any other provisions of law, a policy or | 0011| plan shall not exclude coverage for losses incurred for a preexisting | 0012| condition more than six months from the effective date of coverage. | 0013| The policy or plan shall not define a preexisting condition more | 0014| restrictively than a condition for which medical advice was given or | 0015| treatment recommended by or received from a physician within six | 0016| months before the effective date of coverage. | 0017| F. No medical group, independent practice association or | 0018| health professional employed by or contracting with an insurer, | 0019| fraternal benefit society, health maintenance organization or | 0020| nonprofit healthcare plan shall maintain any action against any | 0021| insured person, family or group member for sums owed by an insurer, | 0022| fraternal benefit society, health maintenance organization or | 0023| nonprofit healthcare plan, for sums higher than those agreed to | 0024| pursuant to a policy or plan." | 0025| Section 4. A new Section 59A-46-41.1 NMSA 1978 is enacted to | 0001| read: | 0002| "59A-46-41.1. MASTECTOMIES AND LYMPH NODE DISSECTION--MINIMUM | 0003| HOSPITAL STAY COVERAGE REQUIRED.-- | 0004| A. Each individual and group health maintenance contract | 0005| delivered or issued for delivery in this state shall provide coverage | 0006| for not less than forty-eight hours of inpatient care following a | 0007| mastectomy and not less than twenty-four hours of inpatient care | 0008| following a lymph node dissection for the treatment of breast cancer. | 0009| B. Nothing in this section shall be construed as requiring | 0010| the provision of inpatient coverage where the attending physician and | 0011| patient determine that a shorter period of hospital stay is | 0012| appropriate. | 0013| C. Coverage for minimum inpatient hospital stays for | 0014| mastectomies and lymph node dissections for the treatment of | 0015| breast cancer may be subject to deductibles and co-insurance | 0016| consistent with those imposed on other benefits under the same | 0017| contract." |