0001| HOUSE BILL 1269
|
0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997
|
0003| INTRODUCED BY
|
0004| JOHN A. HEATON
|
0005|
|
0006|
|
0007|
|
0008|
|
0009|
|
0010| AN ACT
|
0011| RELATING TO HEALTH CARE; ENACTING THE MEDICAID MANAGED CARE
|
0012| ACT;
|
0013| PROVIDING FOR A REASONABLE TRANSITION TO A FAIR AND EFFECTIVE
|
0014| MEDICAID MANAGED HEALTH CARE SYSTEM.
|
0015|
|
0016| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
|
0017| Section 1. SHORT TITLE.--This act may be cited as the
|
0018| "Medicaid Managed Care Act".
|
0019| Section 2. PURPOSE OF ACT.--
|
0020| A. The purpose of the Medicaid Managed Care Act is to
|
0021| provide for a reasonable transition to a fair and effective
|
0022| managed health care system for the medicaid program in New
|
0023| Mexico. The state should convert medicaid to a managed health
|
0024| care system only in a careful, studied and deliberate manner.
|
0025| The system should be implemented initially on a pilot basis in
|
0001| two selected urban sites and one selected rural site and
|
0002| revised as necessary before it is extended to other areas in
|
0003| the state.
|
0004| B. The Medicaid Managed Care Act is designed to
|
0005| protect medicaid recipients, especially those at risk for
|
0006| needed behavioral health services; doctors, hospitals, clinics
|
0007| and others that provide services to the medicaid population in
|
0008| New Mexico, especially those in rural areas that are publicly
|
0009| financed and serve disproportionately large populations of poor
|
0010| persons; and the state, which administers and enforces the
|
0011| medicaid program and seeks to ensure that a fair and equitable
|
0012| health care delivery system is available throughout New Mexico.
|
0013| Section 3. DEFINITIONS.--As used in the Medicaid Managed
|
0014| Care Act:
|
0015| A. "enrollee" or "patient" means an individual who is
|
0016| entitled to receive health care benefits from a managed health
|
0017| care plan;
|
0018| B. "essential community provider" means a person that
|
0019| provides a significant proportion of its health or
|
0020| health-related services to medically needy indigent patients,
|
0021| including uninsured, underserved or special needs populations;
|
0022| C. "health care facility" means an institution
|
0023| providing health care services, including a hospital or other
|
0024| licensed inpatient center, an ambulatory surgical or treatment
|
0025| center, a skilled nursing center, a residential treatment
|
0001| center, a home health agency, a diagnostic, laboratory or
|
0002| imaging center and a rehabilitation or other therapeutic health
|
0003| setting;
|
0004| D. "health care insurer" means a person that has a
|
0005| valid certificate of authority in good standing under the New
|
0006| Mexico Insurance Code to act as an insurer, a health
|
0007| maintenance organization, a nonprofit health care organization
|
0008| or a prepaid dental plan;
|
0009| E. "health care professional" means a physician or
|
0010| other health care practitioner, including a pharmacist, who is
|
0011| licensed, certified or otherwise authorized by the state to
|
0012| provide health services consistent with state law;
|
0013| F. "health care provider" or "provider" means a
|
0014| person that is licensed or otherwise authorized by the state to
|
0015| furnish health care services and includes health care
|
0016| professionals, health care facilities and essential community
|
0017| providers;
|
0018| G. "managed health care plan" or "plan" means a
|
0019| health benefit plan of a health care insurer or a provider
|
0020| service network that either requires an enrollee to use, or
|
0021| creates incentives, including financial incentives, for an
|
0022| enrollee to use health care providers managed, owned, under
|
0023| contract with or employed by the health care insurer. "Managed
|
0024| health care plan" includes a plan that provides comprehensive
|
0025| health care services to enrollees on a prepaid, capitated basis
|
0001| and includes the health care services offered by a health
|
0002| maintenance organization, a preferred provider organization, an
|
0003| individual practice organization, a competitive medical plan,
|
0004| an exclusive provider organization, an integrated delivery
|
0005| system, an independent physician-provider organization, a
|
0006| physician hospital-provider organization and a managed care
|
0007| services organization. "Managed health care plan" or "plan"
|
0008| does not include a traditional fee-for-service indemnity plan
|
0009| or a plan that covers only short-term travel, accident-only,
|
0010| limited benefit or specified disease policies;
|
0011| H. "person" means an individual or other entity;
|
0012| I. "primary health care clinic" means a nonprofit
|
0013| community-based entity established to provide the first level
|
0014| of basic or general health care needs, including diagnostic and
|
0015| treatment services, for residents of a health care underserved
|
0016| area as that area is defined in regulation adopted by the
|
0017| department of health; and
|
0018| J. "provider service network" means two or more
|
0019| health care providers affiliated for the purpose of providing
|
0020| health care services to enrollees on a capitated or similar
|
0021| prepaid flat-rate basis.
|
0022| Section 4. MEDICAID MANAGED HEALTH CARE SYSTEM--
|
0023| TRANSITION AND PILOT PROJECT IMPLEMENTATION.--
|
0024| A. The medicaid program in New Mexico shall be
|
0025| converted to a managed health care system only in a careful,
|
0001| studied and deliberate manner. The system shall be implemented
|
0002| initially with managed health care plans only on a pilot
|
0003| project test basis in two selected urban sites and one selected
|
0004| rural site, which shall be chosen by the human services
|
0005| department only after appropriate public notices have been
|
0006| issued, hearings held and written comments received.
|
0007| B. The managed health care system for medicaid shall
|
0008| be revised as necessary, based on the experiences of the pilot
|
0009| projects, before it is extended, to other areas in the state.
|
0010| Before the program is so extended, the human services
|
0011| department shall submit a written, public report to the
|
0012| legislature that assesses the pilot projects' effectiveness and
|
0013| describes the program revisions that will be made based on the
|
0014| experiences of the pilot projects.
|
0015| Section 5. MEDICAID MANAGED HEALTH CARE PLAN OPERATIONS--
|
0016| ENROLLMENT RESTRICTIONS--EDUCATING MEDICAID ENROLLEES ABOUT
|
0017| MANAGED HEALTH CARE PLANS AND OPERATIONS.--
|
0018| A. The human services department shall monitor each
|
0019| managed health care plan offered through the medicaid program
|
0020| and take all reasonable steps necessary to ensure that each
|
0021| plan operates fairly and efficiently, protects patient
|
0022| interests and fulfills the plan's primary obligation to deliver
|
0023| good quality health care services.
|
0024| B. No managed health care plan offered through the
|
0025| medicaid program may directly recruit new members for
|
0001| enrollment into the medicaid program. All recruiting and
|
0002| enrollment of eligible persons into the medicaid program shall
|
0003| be arranged directly by the human services department. The
|
0004| department may provide for enrollment directly at hospitals or
|
0005| other health care or government facilities.
|
0006| C. The human services department shall educate
|
0007| eligible medicaid recipients in clear, conspicuous and
|
0008| understandable ways about:
|
0009| (1) the issues they should consider so they may
|
0010| decide rationally and fairly into which available managed
|
0011| health care plan they should choose to enroll; and
|
0012| (2) how to operate in and use effectively a
|
0013| managed health care plan.
|
0014| Section 6. SPECIALIZED HEALTH CARE PROGRAMS--MANAGED CARE
|
0015| DELAY--PILOT PROJECTS--STUDY AND REPORT.--
|
0016| A. Until at least July 1, 1998, no managed health
|
0017| care plan offered through the medicaid program shall offer
|
0018| specialized behavioral or developmental disability health
|
0019| services except for two pilot project tests, one in an urban
|
0020| and one in a rural setting. The provisions of this section
|
0021| apply to the specialized health care services needed for a
|
0022| person treated for a developmental disability, a developmental
|
0023| delay, a seriously disabling mental illness, a serious
|
0024| emotional disturbance, physical or sexual abuse or neglect,
|
0025| substance abuse or other behavioral health problem as defined
|
0001| in regulations adopted by the department of health.
|
0002| B. The specialized behavioral or developmental
|
0003| disability health services covered under the provisions of this
|
0004| section shall be provided until at least July 1, 1998 only by
|
0005| specialized providers in accordance with regulations adopted by
|
0006| the department of health. The human services department shall,
|
0007| after consulting with the department of health and the
|
0008| children, youth and families department, adopt regulations to
|
0009| designate essential community providers and other providers
|
0010| that may offer specialized behavioral or developmental
|
0011| disability health services during this period.
|
0012| C. The human services department shall study the two
|
0013| pilot project tests required under the provisions of this
|
0014| section and assess the operations and impacts of the test
|
0015| projects before authorizing a managed health care plan to offer
|
0016| specialized behavioral or developmental disability health
|
0017| services in other settings. The department shall submit a
|
0018| written, public report analyzing the effectiveness of the pilot
|
0019| project tests and describing the program revisions based on
|
0020| those tests that will be implemented. The report shall be
|
0021| submitted to the legislature or an appropriate interim
|
0022| legislative committee before specialized behavioral or
|
0023| developmental disability health services are extended to any
|
0024| other settings.
|
0025| Section 7. PUBLIC NONPROFIT HOSPITALS.--
|
0001| A. A managed health care plan offered through the
|
0002| medicaid program shall be required to use under reasonable
|
0003| terms and conditions any public nonprofit hospital that elects
|
0004| to participate in the plan, if the hospital meets all
|
0005| reasonable quality of care and service payment requirements
|
0006| imposed by the plan. The terms shall be no less favorable than
|
0007| those offered any other provider, and they shall provide
|
0008| payments that are reasonable and adequate to meet costs
|
0009| incurred by efficiently and economically operated facilities,
|
0010| taking into account the disproportionately greater severity of
|
0011| illness and injury experienced by the patient population
|
0012| served.
|
0013| B. The human services department shall assure
|
0014| continuity of general support from a managed health care plan
|
0015| offered through the medicaid program to a public nonprofit
|
0016| hospital that provides for medical education and that serves a
|
0017| disproportionately large indigent population.
|
0018| C. A managed health care plan offered through the
|
0019| medicaid program may not limit the number or location of public
|
0020| nonprofit hospitals that elect to participate in the plan.
|
0021| Section 8. PRIMARY HEALTH CARE CLINICS PARTICIPATION.--
|
0022| A. A managed health care plan offered through the
|
0023| medicaid program shall be required to use under reasonable
|
0024| terms and conditions any primary health care clinic that elects
|
0025| to participate in the plan, if the primary health care clinic
|
0001| meets all reasonable quality of care and service payment
|
0002| requirements imposed by the plan. The terms shall be no less
|
0003| favorable than those offered by any other provider, and they
|
0004| shall provide payments that are reasonable and adequate to meet
|
0005| costs incurred by efficiently and economically operated
|
0006| facilities, taking into account the disproportionately greater
|
0007| severity of illness and injury experienced by the patient
|
0008| population served.
|
0009| B. A managed health care plan offered through the
|
0010| medicaid program may not limit the number or location of
|
0011| primary health care clinics that elect to participate in the
|
0012| plan.
|
0013| Section 9. PLAN ARRANGEMENTS WITH HEALTH CARE PROVIDERS.-
|
0014| -A managed health care plan offered through the medicaid
|
0015| program may not adopt a gag rule or practice that prohibits a
|
0016| health care provider from discussing a more expensive or
|
0017| different treatment option with an enrollee, even if the plan
|
0018| does not approve of the option. A plan shall be required to
|
0019| fully inform all enrollees of any arrangements with providers
|
0020| that create a financial incentive for a provider to limit or
|
0021| deny health care services.
|
0022| Section 10. ENROLLEE GRIEVANCES AND APPEALS.--A managed
|
0023| health care plan offered through the medicaid program shall
|
0024| adopt and implement a prompt and fair grievance procedure for
|
0025| resolving enrollee complaints and addressing enrollee questions
|
0001| and concerns regarding any aspect of the plan, including the
|
0002| quality of and access to health care, the choice of health care
|
0003| provider or treatment and the adequacy of the plan's provider
|
0004| network. The grievance procedure shall notify enrollees of
|
0005| their statutory appeal rights. The provisions of the Public
|
0006| Assistance Appeals Act apply to appeals by enrollees under the
|
0007| Medicaid Managed Care Act.
|
0008| Section 11. REGULATIONS.--The human services department
|
0009| may adopt regulations it deems necessary or appropriate to
|
0010| administer the provisions of the Medicaid Managed Care Act.
|
0011| Section 12. EFFECTIVE DATE.--The effective date of the
|
0012| provisions of this act is July 1, 1997.
|
0013|
|
0014|
|
0015|
|
0016|
|
0017| State of New Mexico
|
0018| House of Representatives
|
0019|
|
0020| FORTY-THIRD LEGISLATURE
|
0021| FIRST SESSION, 1997
|
0022|
|
0023|
|
0024| March 6, 1997
|
0025|
|
0001|
|
0002| Mr. Speaker:
|
0003|
|
0004| Your CONSUMER AND PUBLIC AFFAIRS COMMITTEE, to
|
0005| whom has been referred
|
0006|
|
0007| HOUSE BILL 1269
|
0008|
|
0009| has had it under consideration and reports same with
|
0010| recommendation that it DO PASS, amended as follows:
|
0011|
|
0012| 1. On page 3, line 20, after the period strike the
|
0013| remainder of the line and strike lines 21 through 25.
|
0014|
|
0015| 2. On page 4, strike lines 1 through 3 and on line 4,
|
0016| strike "organization.".
|
0017|
|
0018| 3. On page 4, between lines 7 and 8 insert the following
|
0019| new subsection:
|
0020|
|
0021| "H. "managed health care system" means a delivery
|
0022| system of comprehensive coverage providing basic health care and
|
0023| health- related services that utilize principles of management,
|
0024| coordination and medical review to achieve financial and quality-
|
0025| of-care efficiencies in the medicaid program; and that may
|
0001| include the development of a primary care network, utilization
|
0002| review activities, continuous quality improvement efforts,
|
0003| methods of prospective reimbursement, regional purchasing
|
0004| contracts, use of provider service networks and incentives to
|
0005| encourage health promotion, prevention and financial
|
0006| accountability and prudence;".
|
0007|
|
0008| 4. Reletter the succeeding subsections accordingly.
|
0009|
|
0010| 5. On page 4, line 23, after the period insert:
|
0011|
|
0012| "The managed health care system for the medicaid program shall be
|
0013| operated by the human services department or through managed
|
0014| health care plans contracting with the human services
|
0015| department.".
|
0016|
|
0017| 6. On page 4, line 23, strike "shall" and insert in lieu
|
0018| thereof "may".
|
0019|
|
0020| 7. On page 5, line 4, after "B." strike lines 4 through 6.
|
0021|
|
0022| 8. On page 5, line 7, strike "program is so extended" and
|
0023| insert in lieu thereof "managed health care plan pilot projects
|
0024| are extended to other areas of the state".
|
0025|
|
0001| 9. On page 5, between lines 11 and 12, insert the following
|
0002| new subsection:
|
0003|
|
0004| "C. The human services department may implement the
|
0005| managed health care system by instituting any of the principles
|
0006| of a managed health care system on a pilot project test basis.
|
0007| The managed health care system for the medicaid program shall be
|
0008| revised as necessary, based on the experiences of the pilot
|
0009| projects.".,
|
0010|
|
0011| and thence referred to the BUSINESS AND INDUSTRY
|
0012| COMMITTEE.
|
0013|
|
0014|
|
0015| Respectfully submitted,
|
0016|
|
0017|
|
0018|
|
0019|
|
0020|
|
0021|
|
0022| Gary King, Chairman
|
0023|
|
0024|
|
0025| Adopted Not Adopted
|
0001| (Chief Clerk)
|
0002| (Chief Clerk)
|
0003|
|
0004| Date
|
0005|
|
0006| The roll call vote was 5 For 3 Against
|
0007| Yes: 5
|
0008| No: Dana, Johnson, Vaughn
|
0009| Excused: Crook, Rios
|
0010| Absent: None
|
0011|
|
0012|
|
0013| .118128.1
|
0014| G:\BILLTEXT\BILLW_97\H1269 State of New Mexico
|
0015| House of Representatives
|
0016|
|
0017| FORTY-THIRD LEGISLATURE
|
0018| FIRST SESSION, 1997
|
0019|
|
0020|
|
0021| March 13, 1997
|
0022|
|
0023|
|
0024| Mr. Speaker:
|
0025|
|
0001| Your APPROPRIATIONS AND FINANCE COMMITTEE, to
|
0002| whom has been referred
|
0003|
|
0004| HOUSE BILL 1269, as amended
|
0005|
|
0006| has had it under consideration and reports same with
|
0007| recommendation that it DO NOT PASS, but that
|
0008|
|
0009| HOUSE APPROPRIATIONS AND FINANCE COMMITTEE
|
0010| SUBSTITUTE FOR HOUSE BILL 1269
|
0011|
|
0012| DO PASS.
|
0013|
|
0014|
|
0015| Respectfully submitted,
|
0016|
|
0017|
|
0018|
|
0019|
|
0020|
|
0021|
|
0022| Max Coll, Chairman
|
0023|
|
0024|
|
0025| Adopted Not Adopted
|
0001| (Chief Clerk)
|
0002| (Chief Clerk)
|
0003|
|
0004| Date
|
0005|
|
0006| The roll call vote was 13 For 4 Against
|
0007| Yes: 13
|
0008| No: Bird, Buffett, Knowles, Marquardt
|
0009| Excused: None
|
0010| Absent: None
|
0011|
|
0012| G:\BILLTEXT\BILLW_97\H1269 HOUSE APPROPRIATIONS AND FINANCE COMMITTEE SUBSTITUTE FOR
|
0013| HOUSE BILL 1269
|
0014| 43rd legislature - STATE OF NEW MEXICO - first session, 1997
|
0015|
|
0016|
|
0017|
|
0018|
|
0019|
|
0020|
|
0021|
|
0022| AN ACT
|
0023| RELATING TO HEALTH CARE; ENACTING THE MEDICAID MANAGED CARE
|
0024| ACT; PROVIDING REQUIREMENTS FOR THE MEDICAID MANAGED HEALTH
|
0025| CARE SYSTEM AND MEDICAID MANAGED HEALTH CARE PLANS; IMPOSING A
|
0001| CIVIL PENALTY.
|
0002|
|
0003| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
|
0004| Section 1. SHORT TITLE.--This act may be cited as the
|
0005| "Medicaid Managed Care Act".
|
0006| Section 2. PURPOSE OF ACT.--
|
0007| A. The purpose of the Medicaid Managed Care Act is to
|
0008| protect medicaid recipients, especially those populations with
|
0009| special needs; health care providers serving the medicaid
|
0010| population in New Mexico, especially those in rural and
|
0011| underserved areas and serving a disproportionately large
|
0012| population of poor persons; and the state, which administers
|
0013| and helps finance the medicaid program and seeks to ensure that
|
0014| an equitable health care delivery system is available
|
0015| throughout New Mexico.
|
0016| B. The Medicaid Managed Care Act seeks to provide for
|
0017| a reasonable transition to a fair and effective managed health
|
0018| care system for the medicaid program in New Mexico.
|
0019| Section 3. DEFINITIONS.--As used in the Medicaid Managed
|
0020| Care Act:
|
0021| A. "commission" means the New Mexico health policy
|
0022| commission;
|
0023| B. "department" means the human services department;
|
0024| C. "designated legislative interim committee" means
|
0025| the New Mexico legislative council or an interim legislative
|
0001| committee that is delegated authority by the New Mexico
|
0002| legislative council to exercise powers granted to an interim
|
0003| legislative committee in the Medicaid Managed Care Act;
|
0004|
|
0005| D. "enrollee", "patient" or "consumer" means an
|
0006| individual who is enrolled in medicaid and is entitled to
|
0007| receive health care benefits from a managed health care plan;
|
0008| E. "essential community provider" means a person that
|
0009| provides the major portion of its health and health-related
|
0010| services to medically needy indigent patients, including
|
0011| uninsured, underserved or special needs populations;
|
0012| F. "excluded metropolitan statistical area" means a
|
0013| federally recognized metropolitan statistical area of at least
|
0014| three hundred thousand persons;
|
0015| G. "health care facility" means an institution providing
|
0016| health care services, including a hospital or other licensed
|
0017| inpatient center, an ambulatory surgical or treatment center, a
|
0018| home health agency, a diagnostic, laboratory or imaging center and
|
0019| a rehabilitation or other therapeutic health setting;
|
0020| H. "health care insurer" means a person that has a valid
|
0021| certificate of authority in good standing under the New Mexico
|
0022| Insurance Code to act as an insurer, a health maintenance
|
0023| organization, a nonprofit health care plan or a prepaid dental
|
0024| plan;
|
0025| I. "health care professional" means a physician or other
|
0001| health care practitioner, including a pharmacist, who is licensed,
|
0002| certified or otherwise authorized by the state to provide health
|
0003| services consistent with state law;
|
0004| J. "health care provider" or "provider" means a person
|
0005| that is licensed or otherwise authorized by the state to furnish
|
0006| health care services and includes health care professionals,
|
0007| health care facilities and essential community providers;
|
0008| K. "health care services" means a service or product
|
0009| furnished to an individual for the purpose of preventing,
|
0010| diagnosing, alleviating, curing or healing a physical or mental
|
0011| illness or injury and includes services incidental to furnishing
|
0012| the described services or products, community-based mental health
|
0013| services and services for developmental delay;
|
0014| L. "managed health care plan" or "plan" means a medicaid
|
0015| managed health care plan that is a health benefit plan of a health
|
0016| care insurer or a provider service network offered through the
|
0017| medicaid program that either requires an enrollee to use, or
|
0018| creates incentives, including financial incentives, for an
|
0019| enrollee to use health care providers managed, owned, under
|
0020| contract with or employed by the health care insurer. "Managed
|
0021| health care plan" means a medicaid managed health care plan that
|
0022| includes a plan that provides comprehensive health care services
|
0023| to enrollees on a prepaid, capitated basis and includes the health
|
0024| care services offered by a health maintenance organization, a
|
0025| preferred provider organization, an individual practice
|
0001| organization, a competitive medical plan, an exclusive provider
|
0002| organization, an integrated delivery system, an independent
|
0003| physician-provider organization, a physician hospital-provider
|
0004| organization and a managed care services organization;
|
0005| M. "person" means an individual or other legal entity;
|
0006| N. "primary health care clinic" means a nonprofit
|
0007| community-based entity established to provide the first level of
|
0008| basic or general health care needs, including diagnostic and
|
0009| treatment services, for residents of a health care underserved
|
0010| area as that area is defined in regulations adopted by the
|
0011| department of health;
|
0012| O. "provider service network" means two or more health
|
0013| care providers affiliated for the purpose of providing health care
|
0014| services to enrollees on a capitated or similar prepaid, flat-rate
|
0015| basis; and
|
0016| P. "secretary" means the secretary of human services.
|
0017| Section 4. MEDICAID MANAGED CARE SYSTEM--TRANSITION--
|
0018| REGIONAL IMPLEMENTATION--LEGISLATIVE APPROVAL REQUIRED.--
|
0019|
|
0020| A. The medicaid program in New Mexico shall be converted
|
0021| to a managed health care system only in a careful, studied and
|
0022| deliberate manner. The department shall implement the system in
|
0023| phases by regions, as appropriate, over a period not to exceed two
|
0024| years. There shall be no fewer than four regions, starting first
|
0025| with the greater Albuquerque area. Areas of the state that are
|
0001| chosen as regions for implementation of the medicaid managed
|
0002| health care system shall be selected based on the health care
|
0003| delivery system capacity to meet the needs of the enrollees, with
|
0004| those areas that have the greatest such capacity being chosen as
|
0005| regions first.
|
0006| B. The department shall study each regional phase-in of
|
0007| the medicaid managed care system and assess the operations and
|
0008| impact of each phase-in on the region and the state as a whole
|
0009| prior to extending the system to another region. At the same
|
0010| time, the commission shall establish a technical workgroup to
|
0011| gather information, review and conduct a separate, independent
|
0012| assessment of each regional phase-in of the medicaid managed care
|
0013| system. The department shall make available to the commission and
|
0014| its technical workgroup all requested data, information, analysis
|
0015| and reviews.
|
0016| C. Before each time that the medicaid managed care
|
0017| system is extended to another region, the department and the
|
0018| commission technical workgroup shall submit their reports to the
|
0019| designated legislative interim committee on the system's
|
0020| effectiveness and its impact on health care services
|
0021| infrastructure and access to care for indigent individuals.
|
0022| D. If the department implements a medicaid managed care
|
0023| system pursuant to a waiver from the federal government under
|
0024| Section 1915(b) of the federal Social Security Act, legislative
|
0025| approval shall be obtained each time before the medicaid managed
|
0001| care system is extended to another region in the state beyond the
|
0002| greater Albuquerque area. Legislative approval shall also be
|
0003| obtained before the system is revised pursuant to any waiver that
|
0004| may be sought from the federal government under Section 1115 of
|
0005| the federal Social Security Act.
|
0006| E. A contract with a managed health care plan shall not
|
0007| exceed a two-year term without legislative approval.
|
0008| F. The legislative approvals required in this section
|
0009| may be obtained either by the full legislature, by a resolution
|
0010| adopted by both houses, or preliminarily by the designated
|
0011| legislative interim committee, subject to final approval by the
|
0012| full legislature. If the legislature does not act on the approval
|
0013| in the next regular session following the action taken by the
|
0014| designated legislative interim committee, the action taken by the
|
0015| committee shall be deemed to be approved by the full legislature.
|
0016| Section 5. PATIENT PROTECTION--DISCLOSURES--RIGHTS TO HEALTH
|
0017| CARE SERVICES--GRIEVANCE PROCEDURE--UTILIZATION REVIEW PROGRAM--
|
0018| CONTINUOUS QUALITY PROGRAM--DEPARTMENT OF INSURANCE REGULATIONS.--
|
0019| A. Each covered person enrolled in a managed health care
|
0020| plan offered through the medicaid program has the right to be
|
0021| treated fairly. A managed health care plan offered through the
|
0022| medicaid program shall deliver high quality and appropriate health
|
0023| care services to enrollees. The department shall ensure that each
|
0024| covered person enrolled in a managed health care plan is treated
|
0025| fairly and is accorded the rights necessary to protect patient
|
0001| interests.
|
0002| B. The department shall ensure at a minimum that:
|
0003| (1) a managed health care plan shall provide oral
|
0004| and written summaries, policies and procedures that explain, prior
|
0005| to or at the time of enrollment and at subsequent periodic times
|
0006| as appropriate, in a clear, conspicuous and readily understandable
|
0007| form, full and fair disclosure of the plan's benefits, terms,
|
0008| conditions, prior authorization requirements, enrollee financial
|
0009| responsibility for copayments, grievance procedures, appeal rights
|
0010| and the patient rights generally available to all covered persons;
|
0011| (2) a managed health care plan shall provide each
|
0012| covered person with appropriate basic and comprehensive health
|
0013| care services, in accordance with the medicaid program
|
0014| regulations, that are reasonably accessible and available in a
|
0015| timely manner to each covered person;
|
0016| (3) in providing the right to reasonably accessible
|
0017| health care services that are available in a timely manner, a
|
0018| managed health care plan shall ensure that:
|
0019| (a) the plan offers sufficient numbers and
|
0020| types of credentialed and adequately staffed health care providers
|
0021| at reasonable hours of service to meet the health needs of the
|
0022| enrolled population, and takes into account cultural aspects and
|
0023| limited English capacity of enrollees;
|
0024| (b) health care providers that are specialists
|
0025| may act as primary care providers for patients with chronic
|
0001| medical conditions, provided the specialists offer all reasonable
|
0002| primary care services required by a managed health care plan and
|
0003| are credentialed by the managed health care plan to provide
|
0004| primary care services;
|
0005| (c) as medically indicated, reasonable access
|
0006| is provided to out-of-network specialty health care providers; and
|
0007| (d) emergency care is immediately available
|
0008| without prior authorization requirements, and appropriate out-of-
|
0009| network emergency care is not subject to additional costs;
|
0010| (4) a managed health care plan offered through the
|
0011| medicaid program shall adopt and implement a prompt and fair
|
0012| grievance procedure for resolving patient complaints and
|
0013| addressing patient questions and concerns regarding any aspect of
|
0014| the plan, including the quality of and access to health care, the
|
0015| choice of health care provider or treatment and the adequacy of
|
0016| the plan's provider network. The grievance procedures shall
|
0017| notify patients of their statutory appeal rights, including the
|
0018| option of seeking immediate relief in court, and shall provide for
|
0019| a prompt and fair appeal of a plan's decision to the secretary,
|
0020| including special provisions to govern emergency appeals to the
|
0021| secretary in the case of health emergencies;
|
0022| (5) a managed health care plan offered through the
|
0023| medicaid program shall adopt and implement a comprehensive
|
0024| utilization review program. The basis of a decision to approve or
|
0025| deny care shall be disclosed to an affected enrollee. The
|
0001| decision to approve or deny care to a patient shall be made in a
|
0002| timely manner, including decisions regarding emergency care, and
|
0003| the final decision shall be made by a qualified health care
|
0004| professional. A plan's utilization review program shall ensure
|
0005| that enrollees have proper access to health care services,
|
0006| including referrals to necessary specialists. A decision made in
|
0007| a plan's utilization review program shall be subject to the plan's
|
0008| grievance procedure and appeal to the secretary;
|
0009| (6) a managed health care plan offered through the
|
0010| medicaid program shall adopt and implement a continuous quality
|
0011| improvement program that monitors the quality and appropriateness
|
0012| of the health care services provided by the plan; and
|
0013| (7) a managed health care plan offered through the
|
0014| medicaid program shall at a minimum comply with the department of
|
0015| insurance regulations applicable to managed care.
|
0016| C. The department shall maintain and adequately staff at
|
0017| all times a toll-free telephone line to respond to enrollee
|
0018| questions and concerns and to assist enrollees in exercising their
|
0019| rights and protecting their interests as health care consumers and
|
0020| as provided for in the Medicaid Managed Care Act.
|
0021| Section 6. MEDICAID MANAGED HEALTH CARE PLAN OPERATIONS.--
|
0022| A. The department shall monitor each managed health care
|
0023| plan offered through the medicaid program and take all reasonable
|
0024| steps necessary to ensure that each plan operates fairly and
|
0025| efficiently, protects patient interests and fulfills the plan's
|
0001| primary obligation to deliver high quality health care services.
|
0002| B. No managed health care plan offered through the
|
0003| medicaid program may directly solicit new members for enrollment
|
0004| into the medicaid program. All enrollment of eligible persons
|
0005| into the medicaid program shall be arranged directly by the
|
0006| department. The department may provide for enrollment directly at
|
0007| government facilities or other health care facilities.
|
0008| C. The department, through its own offices and
|
0009| employees, joint powers agreements with other state agencies or by
|
0010| contracting with one or more brokering agencies independent of any
|
0011| managed health care plan offered through the medicaid program,
|
0012| shall fully inform medicaid-eligible persons of their choices for
|
0013| enrollment into a managed health care plan and shall conduct the
|
0014| enrollment process and default assignments of enrollees who do not
|
0015| choose a plan. The department shall ensure that the enrollment
|
0016| process includes adequate time and information provided in a
|
0017| clear, conspicuous and understandable manner that is appropriate
|
0018| for the medicaid enrollee, or legal guardian in the case of a
|
0019| child, including those with limited English language and reading
|
0020| ability. At a minimum, the information shall include:
|
0021| (1) the issues to be considered in making an
|
0022| informed decision about which available managed health care plan
|
0023| to choose;
|
0024| (2) for each managed health care plan offered
|
0025| through the medicaid program, details regarding participating
|
0001| providers, geographic availability of services, benefits,
|
0002| emergency care and out-of-state or out-of-area medical services,
|
0003| terms, conditions, including any copayments or other restrictions,
|
0004| and available valid information pertaining to quality, outcomes,
|
0005| patient satisfaction and grievances;
|
0006| (3) after the initial year of implementation,
|
0007| comparative information on the quality of care, including medicaid
|
0008| enrollee satisfaction and grievances, on each managed care health
|
0009| plan;
|
0010| (4) how to operate in and use effectively a managed
|
0011| health care plan; and
|
0012| (5) enrollee rights to change providers and managed
|
0013| health care plans and challenge and appeal plan decisions.
|
0014| D. No managed health care plan offered through the
|
0015| medicaid program shall directly market to medicaid recipients or
|
0016| directly enroll medicaid recipients into its plan.
|
0017| E. No managed health care plan shall require or
|
0018| establish exclusive contracts with any health care provider,
|
0019| except for salaried employment contracts.
|
0020| F. Unless the department requires, by regulation, a
|
0021| higher percentage, a managed health care plan offered through the
|
0022| medicaid program shall be required to maintain a medical loss
|
0023| ratio of at least eighty percent, so that at a minimum eighty
|
0024| percent of all capitated medicaid payments paid to a managed
|
0025| health care plan is expended for the direct provision of health
|
0001| care services. The department may establish maximum
|
0002| administrative expenses and profit margins that will be allowed.
|
0003| The department, after consultation with the department of
|
0004| insurance, shall adopt regulations to define the allowable medical
|
0005| loss ratio, administrative expenses and profit margin consistent
|
0006| with the provisions of this subsection.
|
0007| G. To ensure freedom of choice capacity for enrollees,
|
0008| the department shall seek a waiver from applicable federal
|
0009| requirements to provide for an appropriate mixture of medicaid and
|
0010| commercial, paying patients in any given managed health care plan.
|
0011| Section 7. SPECIALIZED HEALTH CARE PROGRAMS--PHASE-IN
|
0012| IMPLEMENTATION--LEGISLATIVE APPROVAL REQUIRED.--
|
0013| A. Except as otherwise provided in Subsection B of this
|
0014| section, until July 1, 1999, no managed health care plan offered
|
0015| through the medicaid program shall offer specialized behavioral or
|
0016| developmental disability health care services. The provisions of
|
0017| this section apply to the specialized health care services needed
|
0018| for a person treated for a developmental disability, a
|
0019| developmental delay, a seriously disabling mental illness, a
|
0020| serious emotional disturbance, physical or sexual abuse or
|
0021| neglect, substance abuse or other chronic, serious behavioral
|
0022| health problem.
|
0023| B. As a pilot project, and pursuant to a waiver from the
|
0024| federal government under Section 1915(b) of the federal Social
|
0025| Security Act, specialized behavioral or developmental disability
|
0001| health care services may be immediately provided by the managed
|
0002| health care plans that are offered through the medicaid program in
|
0003| the greater Albuquerque area.
|
0004| C. The department shall study the pilot project
|
0005| authorized in Subsection B of this section and assess the
|
0006| operations and impact of the pilot project on the region and the
|
0007| state as a whole prior to extending the system to another region
|
0008| after July 1, 1999. At the same time, the commission shall
|
0009| establish a technical workgroup, which shall include among its
|
0010| members representatives of appropriate behavioral health and
|
0011| developmental disability stakeholders, to gather information,
|
0012| review and conduct an independent assessment of the specialized
|
0013| health care services pilot project of the medicaid managed care
|
0014| system. The department shall make available to the commission all
|
0015| requested data, information, analysis and reviews.
|
0016| D. Before each time that specialized behavioral or
|
0017| developmental disability health care services covered in this
|
0018| section are extended beyond the greater Albuquerque area to
|
0019| another region in the state, the department and the commission
|
0020| technical workgroup shall submit their reports to the designated
|
0021| legislative interim committee on the program's effectiveness and
|
0022| its impact on health care services infrastructure and access to
|
0023| care for indigent individuals; outside evaluations, including
|
0024| those of the federal health care financing authority; and the
|
0025| program revisions that will be made based on the experiences. The
|
0001| department's report shall include copies of any relevant reports
|
0002| prepared by outside evaluators, including the federal health care
|
0003| financing administration and the state's medicaid advisory
|
0004| committee, and a description of the program revisions that will be
|
0005| made based on the input received and experience.
|
0006| E. If the department includes specialized behavioral or
|
0007| developmental disability health care services in its medicaid
|
0008| managed care system pursuant to a waiver from the federal
|
0009| government under Section 1915(b) of the federal Social Security
|
0010| Act, legislative approval shall be obtained each time before the
|
0011| specialized behavioral or developmental disability health care
|
0012| services are extended beyond the greater Albuquerque area to
|
0013| another region in the state. Legislative approval shall also be
|
0014| obtained before the coverage of specialized behavioral or
|
0015| developmental disability health care services in the medicaid
|
0016| managed care system is revised pursuant to any waiver that may be
|
0017| sought under Section 1115 of the federal Social Security Act.
|
0018| F. The legislative approvals required in this section
|
0019| may be obtained either by the full legislature, by a resolution
|
0020| adopted by both houses, or preliminarily by the designated
|
0021| legislative interim committee, subject to final approval by the
|
0022| full legislature. If the legislature does not act on the approval
|
0023| in the next regular session following the action taken by the
|
0024| designated legislative interim committee, the action taken by the
|
0025| committee shall be deemed to be approved by the full legislature.
|
0001| Section 8. NATIVE AMERICAN HEALTH SERVICES.--
|
0002| A. Native Americans enrolled in a managed health care
|
0003| plan offered through the medicaid program shall at all times
|
0004| retain the option of receiving health services directly from the
|
0005| Indian health service or health services provided by tribes under
|
0006| the federal Indian Self-Determination and Education Assistance
|
0007| Act, the federal urban Indian health program or the federal Indian
|
0008| children's program. The department shall ensure that the Indian
|
0009| health service receives the same payment it would have received
|
0010| for the services rendered if the patient did not participate in
|
0011| the managed health care plan.
|
0012| B. The department shall pursue alternative mechanisms
|
0013| for Native Americans in the medicaid managed care program to
|
0014| recognize their sovereignty, their right to self-determination and
|
0015| the dual responsibility of the federal and state governments.
|
0016| Section 9. HOSPITALS OTHER THAN THE UNIVERSITY OF NEW MEXICO
|
0017| HEALTH SCIENCES CENTER.--
|
0018| A. Any managed health care plan offered through the
|
0019| medicaid program shall be required to use under reasonable terms
|
0020| and conditions any hospital, except a hospital in an excluded
|
0021| metropolitan statistical area, that elects to participate in the
|
0022| plan, if the hospital meets all reasonable quality of care and
|
0023| service payment requirements imposed by the plan. The terms shall
|
0024| be no less favorable than those offered any other equivalent,
|
0025| similarly situated provider for the same services.
|
0001| B. The department shall assure continuity of general
|
0002| support for any hospital that provides for medical education or
|
0003| serves a disproportionately large indigent population. Within
|
0004| allowable federal law and regulations, the department shall ensure
|
0005| an adequate and diverse patient population necessary to preserve
|
0006| the health professional education programs in New Mexico.
|
0007| C. A managed health care plan offered through the
|
0008| medicaid program that offers specialized behavioral or
|
0009| developmental disability health services as provided in Section 7
|
0010| of the Medicaid Managed Care Act shall include participation by
|
0011| state-operated inpatient facilities. Payment rates for services
|
0012| provided by the state hospitals providing such specialized
|
0013| services shall be established by the department. The rates shall
|
0014| provide by regulation for payments that are reasonable for an
|
0015| efficiently operated facility providing similar services taking
|
0016| into account the severity of illness and shall include, as
|
0017| determined by the department, retrospective adjustment to account
|
0018| for adverse patient selection.
|
0019| D. A managed health care plan offered through the
|
0020| medicaid program may not limit the number or location of state
|
0021| facilities or hospitals, except hospitals in an excluded
|
0022| metropolitan statistical area, that elect to participate in the
|
0023| plan. A managed health care plan shall not offer providers or
|
0024| impose on patients financial or other incentives, penalties or
|
0025| barriers to affect the use of any hospital participating in its
|
0001| plan as provided for in Subsection A or C of this section.
|
0002| Section 10. UNIVERSITY OF NEW MEXICO HEALTH SCIENCES
|
0003| CENTER.--
|
0004| A. Any managed care health plan offered through the
|
0005| medicaid program shall be required to use the university of New
|
0006| Mexico health sciences center's hospitals and specialty services,
|
0007| as appropriate, including inpatient and outpatient services.
|
0008| Payment rates for services provided by the university of New
|
0009| Mexico health sciences center's hospitals and specialty services
|
0010| shall be established by the department. Such payment rates, which
|
0011| shall be adopted by regulation, shall provide for payments that
|
0012| are reasonable for an efficiently operated hospital or outpatient
|
0013| specialty facility providing similar services taking into account
|
0014| the severity of illness and shall provide, as determined by the
|
0015| department, for retrospective adjustment to account for adverse
|
0016| patient selection; provided, however, that nothing in this section
|
0017| shall prohibit the university of New Mexico health sciences center
|
0018| from negotiating alternative rates and payment methodologies with
|
0019| a managed health care plan offered through the medicaid program.
|
0020| B. The department shall assure continuity of general
|
0021| support for the university of New Mexico health sciences center
|
0022| for medical education and a disproportionately large indigent
|
0023| population. Within allowable federal law and regulations, the
|
0024| department shall ensure an adequate and diverse patient population
|
0025| necessary to preserve the health professional education programs
|
0001| in New Mexico.
|
0002| C. A managed health care plan shall not offer providers
|
0003| or impose on patients financial or other incentives, penalties or
|
0004| barriers to affect the use of the university of New Mexico health
|
0005| sciences center's hospitals or specialty services, including
|
0006| inpatient and outpatient specialty services.
|
0007| Section 11. PRIMARY HEALTH CARE CLINICS' PARTICIPATION.--
|
0008| A. A managed health care plan offered through the
|
0009| medicaid program shall be required to use under reasonable terms
|
0010| and conditions any primary health care clinic that elects to
|
0011| participate in the plan, if the primary health care clinic meets
|
0012| all reasonable quality of care and service payment requirements
|
0013| imposed by the plan. The terms shall be no less favorable than
|
0014| those offered to any other equivalent, similarly situated provider
|
0015| for the same services.
|
0016| B. A managed health care plan offered through the
|
0017| medicaid program may not limit the number or location of primary
|
0018| health care clinics that elect to participate in the plan. A
|
0019| managed health care plan shall not offer providers or impose on
|
0020| patients financial or other incentives, penalties or barriers to
|
0021| affect the use of any primary health care clinic participating in
|
0022| its plan.
|
0023| C. The department shall provide timely payments at least
|
0024| quarterly to each federal qualified health center under the
|
0025| federal Social Security Act, as defined in 42 U.S.C. Section
|
0001| 1396d(1)(2), to cover the difference between the payment that
|
0002| should have been received pursuant to the provisions of 42 U.S.C.
|
0003| Section 1396a(a)(13)(E) and the payments from the managed health
|
0004| care plan offered through the medicaid program that were received
|
0005| by the federally qualified health center. The full amount of that
|
0006| difference shall be paid by the department in fiscal year 1998.
|
0007| To the extent allowable by federal law and regulations, the
|
0008| department's payment for that difference shall be reduced by one-
|
0009| third annually from the full level of the difference provided in
|
0010| fiscal year 1998 such that by July 1, 2000, no differential
|
0011| payment based on federally qualified health center status shall be
|
0012| required.
|
0013| D. Nothing in Subsection C of this section shall
|
0014| prohibit a federally qualified health center from negotiating
|
0015| alternative rates and payment methodologies with a managed health
|
0016| care plan offered through the medicaid program.
|
0017| Section 12. AUTHORIZATION FOR MEDICAID MANAGED CARE
|
0018| CONTRACTS DIRECTLY WITH PUBLIC AGENCIES, HOSPITALS, HEALTH CARE
|
0019| PROVIDERS AND PROVIDER SERVICE NETWORKS.--In administering the
|
0020| medicaid program or a managed health care system for the program,
|
0021| the department may contract directly with a government agency or
|
0022| public body, health care provider or provider service network
|
0023| belonging to and participating in the provider service network
|
0024| guaranty association. In doing so, the department is not required
|
0025| to contract with any such entity only through arrangements with a
|
0001| health care insurer.
|
0002| Section 13. PLAN ARRANGEMENTS WITH HEALTH CARE PROVIDERS--
|
0003| FAIR DISCLOSURE TO ENROLLEES--PROTECTIONS FOR PROVIDERS.--
|
0004| A. A managed health care plan offered through the
|
0005| medicaid program may not contract with a health care provider to
|
0006| limit the provider's disclosure to an enrollee, or any person
|
0007| acting on behalf of the enrollee, of any information that relates
|
0008| to the enrollee's medical condition or treatment options.
|
0009| B. A health care provider shall not be penalized, or
|
0010| have a contract with a managed health care plan terminated,
|
0011| because the provider offers a referral to, or discusses medically
|
0012| necessary or appropriate care with, an enrollee or any person
|
0013| acting on behalf of the enrollee. A health care provider may not
|
0014| be prohibited by a plan from discussing all treatment options with
|
0015| an enrollee.
|
0016| C. A health care provider shall not be adversely
|
0017| affected by a managed health care plan for discussing with an
|
0018| enrollee financial incentives or financial arrangements between
|
0019| the provider and the plan.
|
0020| D. A managed health care plan offered through the
|
0021| medicaid program shall not include in any of its contracts with
|
0022| health care providers any provisions that offer an inducement,
|
0023| financial or otherwise, to provide less than medically necessary
|
0024| health care services. A managed health care plan shall inform its
|
0025| enrollees in writing of the financial arrangements between the
|
0001| plan and participating providers if those arrangements include an
|
0002| incentive or bonus for restricting the amount of health care
|
0003| services provided to the enrollee.
|
0004| Section 14. GENERAL POLICY DEVELOPMENT OF THE MEDICAID
|
0005| MANAGED CARE SYSTEM.--
|
0006| A. The department, in conjunction with the commission,
|
0007| shall continue to study and propose how to refine the medicaid
|
0008| managed care program to improve the value derived from public
|
0009| resources and to further the health policy of New Mexico as
|
0010| provided in Section 9-7-11.1 NMSA 1978. This shall include
|
0011| consideration of:
|
0012| (1) the benefit structure as provided for in Senate
|
0013| Joint Memorial 50 of the second session of the forty-second
|
0014| legislature in 1996;
|
0015| (2) cost containment and purchasing methods;
|
0016| (3) the desirability of a directly state-operated
|
0017| managed care system for medicaid in certain regions of the state;
|
0018| and
|
0019| (4) a waiver from the federal government pursuant
|
0020| to Section 1115 of the federal Social Security Act.
|
0021| B. The department and the commission shall report
|
0022| annually to the designated legislative interim committee on the
|
0023| progress and recommendations relevant to the considerations
|
0024| specified in this section.
|
0025| Section 15. MONITORING AND REPORTING.--
|
0001| A. The department shall ensure that any managed health
|
0002| care plan offered through the medicaid program provides quality
|
0003| health care consistent with nationally recognized and New Mexico
|
0004| specific standards.
|
0005| B. The department shall establish appropriate standards
|
0006| to be met by any managed health care plan participating in the
|
0007| medicaid program to ensure and monitor the quality of care
|
0008| provided. By the use of nationally recognized standards and
|
0009| electronic reporting, all reasonable efforts shall be made to
|
0010| contain the administrative costs of both the participating managed
|
0011| health care plans and the department for its oversight
|
0012| responsibilities. The department shall ensure that:
|
0013| (1) plans report on the basis of the latest adopted
|
0014| national health plan employer data and information set measures,
|
0015| or other nationally recognized equivalent measures, and the mental
|
0016| health statistics improvement project in the case of behavioral
|
0017| health services, for the enrolled medicaid population in the
|
0018| managed health care plan;
|
0019| (2) at least annually a standardized patient
|
0020| satisfaction survey is publicly reported;
|
0021| (3) at least annually an assessment of enrollees'
|
0022| access to services, including waiting time to receive services and
|
0023| geographic availability consistent with contract terms, is
|
0024| publicly reported;
|
0025| (4) a quality improvement plan is adopted by the
|
0001| board of each managed health care plan and that there is evidence
|
0002| of an effective quality improvement program, including the
|
0003| participation by and monitoring of contract providers;
|
0004| (5) there is credentialing of all providers and
|
0005| evidence of malpractice coverage, including contract providers,
|
0006| participating in the managed health care plan; and
|
0007| (6) there is broad participation of the provider
|
0008| network in quality improvement and utilization management
|
0009| processes.
|
0010| C. Except as provided elsewhere in the Medicaid Managed
|
0011| Care Act, the department shall prepare and submit to the
|
0012| designated legislative interim committee by October 1 of each year
|
0013| a public report that shall include for each managed health care
|
0014| plan offered through the medicaid program a summary of the
|
0015| following:
|
0016| (1) the quality of care provided, including
|
0017| enrollee satisfaction, grievances, disenrollments and changes in
|
0018| plan enrollment;
|
0019| (2) the numbers and demographics of medicaid
|
0020| enrollees;
|
0021| (3) the medical loss ratio and a breakdown of the
|
0022| expenditures by specific service type, including the percent of
|
0023| capitated payments for administrative expenses, and the profits
|
0024| earned;
|
0025| (4) changes in the provider service network and the
|
0001| turnover of primary care and specialty providers;
|
0002| (5) additional benefits offered;
|
0003| (6) utilization management activities, including
|
0004| the number of out-of-network approvals, denials for services and
|
0005| appeals;
|
0006| (7) any additional information determined by the
|
0007| department to be relevant to quality, outcomes, financing and
|
0008| utilization required to be reported by each managed health care
|
0009| plan to the department; and
|
0010| (8) compliance with the provisions of the Medicaid
|
0011| Managed Care Act.
|
0012| D. Except as provided elsewhere in the Medicaid Managed
|
0013| Care Act, the department shall prepare and submit to the
|
0014| designated legislative interim committee by October 1 of each year
|
0015| a public report that shall address:
|
0016| (1) the efficiency and effectiveness of the
|
0017| medicaid managed care program in general, including overall
|
0018| compliance with the Medicaid Managed Care Act;
|
0019| (2) trends in expenditures in the medicaid program;
|
0020| (3) impact of the medicaid managed care program on
|
0021| health services infrastructure, health services availability
|
0022| throughout the state and health professionals' supply and
|
0023| distribution;
|
0024| (4) impact of the medicaid managed care program on
|
0025| health services access for indigent persons;
|
0001| (5) program revisions to be made based on the
|
0002| review of the program and input of the state medicaid advisory
|
0003| committee, providers and public; and
|
0004| (6) legislative recommendations for the medicaid
|
0005| managed care program to further the health policy of New Mexico.
|
0006| E. The department shall provide for a yearly independent
|
0007| analysis of medicaid managed care that includes an assessment of
|
0008| the quality and outcomes of care received by medicaid enrollees in
|
0009| each managed care plan and a comparison with commercial enrollees.
|
0010| F. The department shall implement an information system
|
0011| to provide for the collection of patient-level encounter data to
|
0012| monitor the analysis provided in Subsections C, D and E of this
|
0013| section; provide for actuarially sound cost projections; assist in
|
0014| the development of standards of care and appropriate service
|
0015| provisions for enrollees; and provide sufficient information for
|
0016| the department to effectively and efficiently manage, operate and
|
0017| administer the medicaid program. In cooperation with the
|
0018| commission and the health information alliance established under
|
0019| the Health Information System Act, the department shall pursue an
|
0020| integrated statewide health data network with streamlined
|
0021| administrative transactions, provider reporting and access to
|
0022| information and consumer education. The department shall require
|
0023| that every managed care plan offered through the medicaid program
|
0024| develop information system capacity to meet these requirements and
|
0025| the minimum requirements established pursuant to the Health
|
0001| Information System Act.
|
0002| Section 16. ENFORCEMENT.--
|
0003| A. The department or a person who suffers a loss as a
|
0004| result of a violation of a provision in the Medicaid Managed Care
|
0005| Act may bring an action to recover actual damages or the sum of
|
0006| one hundred dollars ($100), whichever is greater. When the trier
|
0007| of fact finds that the party charged with the violation acted
|
0008| willfully, the court may award up to three times actual damages or
|
0009| three hundred dollars ($300), whichever is greater, to the party
|
0010| complaining of the violation.
|
0011| B. A person likely to be damaged by a denial of a right
|
0012| protected in the Medicaid Managed Care Act may be granted an
|
0013| injunction under the principles of equity and on terms that the
|
0014| court considers reasonable. Proof of monetary damages or intent
|
0015| to violate a right is not required.
|
0016| C. To protect and enforce an enrollee's or a health care
|
0017| provider's rights in a managed health care plan offered through
|
0018| the medicaid program, an enrollee and a health care provider
|
0019| participating in or eligible to participate in a medicaid managed
|
0020| health care plan shall each be treated as a third-party
|
0021| beneficiary of the managed health care plan contract between the
|
0022| health care insurer and the party with which the insurer directly
|
0023| contracts. An enrollee or a health care provider may sue to
|
0024| enforce the rights provided in the contract that governs the
|
0025| managed health care plan.
|
0001| D. The relief provided in this section is in addition to
|
0002| other remedies available against the same conduct under the common
|
0003| law or other statutes of this state.
|
0004| E. In any class action filed under this section, the
|
0005| court may award damages to the named plaintiffs as provided in
|
0006| this section and may award members of the class the actual damages
|
0007| suffered by each member of the class as a result of the unlawful
|
0008| practice.
|
0009| F. A person shall not be required to complete available
|
0010| grievance procedures or exhaust administrative remedies prior to
|
0011| seeking relief in court regarding a complaint that may be filed
|
0012| under this section.
|
0013| Section 17. PENALTY.--In addition to any other penalties
|
0014| provided by law, the secretary may impose a civil administrative
|
0015| penalty of up to twenty-five thousand dollars ($25,000) for each
|
0016| violation of the Medicaid Managed Care Act. An administrative
|
0017| penalty shall be imposed by written order of the secretary after
|
0018| holding a hearing as provided for in the Public Assistance Appeals
|
0019| Act.
|
0020| Section 18. REGULATIONS.--The department may adopt
|
0021| regulations it deems necessary or appropriate to administer the
|
0022| provisions of the Medicaid Managed Care Act.
|
0023| Section 19. APPLICABILITY.--The provisions of the Medicaid
|
0024| Managed Care Act apply to all contracts for medicaid managed care
|
0025| entered into by the department after July 1, 1997, but do not
|
0001| apply to or invalidate terms in contracts that were entered into
|
0002| prior to July 1, 1997, provided those contracts are completed by
|
0003| July 1, 1999.
|
0004| Section 20. EFFECTIVE DATE.--The effective date of the
|
0005| provisions of this act is July 1, 1997.
|
0006|
|
0007|
|
0008| FORTY-THIRD LEGISLATURE HB 1269/a
|
0009| FIRST SESSION, 1997
|
0010|
|
0011|
|
0012| March 18, 1997
|
0013|
|
0014| Mr. President:
|
0015|
|
0016| Your FINANCE COMMITTEE, to whom has been referred
|
0017|
|
0018| HOUSE APPROPRIATION AND FINANCE COMMITTEE SUBSTITUTE
|
0019| FOR HOUSE BILL 1269, as amended
|
0020|
|
0021| has had it under consideration and reports same with recommendation
|
0022| that it DO PASS, amended as follows:
|
0023|
|
0024| 1. On page 13, line 10, strike "or developmental disability".
|
0025|
|
0001| 2. On page 14, lines 1 and 2, strike "or developmental
|
0002| disability".
|
0003|
|
0004| 3. On page 14, lines 16 and 17, strike "or developmental
|
0005| disability".
|
0006|
|
0007| 4. On page 14, line 21, strike "or developmental disability".
|
0008|
|
0009|
|
0010| Respectfully submitted,
|
0011|
|
0012|
|
0013|
|
0014| __________________________________
|
0015| Ben D. Altamirano, Chairman
|
0016|
|
0017|
|
0018|
|
0019|
|
0020|
|
0021|
|
0022|
|
0023|
|
0024|
|
0025|
|
0001|
|
0002|
|
0003|
|
0004|
|
0005|
|
0006|
|
0007|
|
0008|
|
0009|
|
0010|
|
0011| Adopted_______________________ Not Adopted_______________________
|
0012| (Chief Clerk) (Chief Clerk)
|
0013|
|
0014|
|
0015| Date ________________________
|
0016|
|
0017|
|
0018| The roll call vote was 9 For 0 Against
|
0019| Yes: 9
|
0020| No: None
|
0021| Excused: McKibben, Smith
|
0022| Absent: None
|
0023|
|
0024|
|
0025| H1269FC1
|
0001|
|