0001| SENATE BILL 964 | 0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997 | 0003| INTRODUCED BY | 0004| DEDE FELDMAN | 0005| | 0006| | 0007| | 0008| | 0009| | 0010| AN ACT | 0011| RELATING TO INSURANCE; REQUIRING COVERAGE FOR MINIMUM HOSPITAL | 0012| STAYS FOR MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE | 0013| TREATMENT OF BREAST CANCER; AMENDING AND ENACTING SECTIONS OF | 0014| THE NMSA 1978. | 0015| | 0016| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0017| Section 1. A new Section 59A-22-39.1 NMSA 1978 is enacted | 0018| to read: | 0019| "59A-22-39.1. [NEW MATERIAL] MASTECTOMIES AND LYMPH | 0020| NODE DISSECTION--MINIMUM HOSPITAL STAY COVERAGE REQUIRED.-- | 0021| A. Each individual and group health insurance | 0022| policy, health care plan and certificate of health insurance | 0023| delivered or issued for delivery in this state shall provide | 0024| coverage for not less than forty-eight hours of inpatient care | 0025| following a mastectomy and not less than twenty-four hours of | 0001| inpatient care following a lymph node dissection for the | 0002| treatment of breast cancer. | 0003| B. Nothing in this section shall be construed as | 0004| requiring the provision of inpatient coverage where the | 0005| attending physician and patient determine that a shorter period | 0006| of hospital stay is appropriate. | 0007| C. The provisions of this section shall not apply | 0008| to short-term travel, accident-only or limited or specified | 0009| disease policies. | 0010| D. Coverage for minimum inpatient hospital stays | 0011| for mastectomies and lymph node dissections for the treatment | 0012| of breast cancer may be subject to deductibles and co-insurance | 0013| consistent with those imposed on other benefits under the same | 0014| policy, plan or certificate." | 0015| Section 2. Section 59A-23-4 NMSA 1978 (being Laws 1984, | 0016| Chapter 127, Section 463, as amended) is amended to read: | 0017| "59A-23-4. OTHER PROVISIONS APPLICABLE.-- | 0018| A. No blanket or group health insurance policy or | 0019| contract shall contain any provision relative to notice or | 0020| proof of loss or the time for paying benefits or the time | 0021| within which suit may be brought upon the policy that in the | 0022| superintendent's opinion is less favorable to the insured than | 0023| would be permitted in the required or optional provisions for | 0024| individual health insurance policies as set forth in Chapter | 0025| 59A, Article 22 NMSA 1978. | 0001| B. The following provisions of Chapter 59A, Article | 0002| 22 NMSA 1978 shall also apply as to Chapter 59A, Article 23 | 0003| NMSA 1978 and blanket and group health insurance contracts: | 0004| (1) Section 59A-22-1 NMSA 1978, except | 0005| Subsection C thereof; and | 0006| (2) Section 59A-22-32 NMSA 1978. | 0007| C. The following provisions of Chapter 59A, Article | 0008| 22 NMSA 1978 shall also apply as to group health insurance | 0009| contracts: | 0010| (1) Section 59A-22-33 NMSA 1978; | 0011| (2) Section 59A-22-34 NMSA 1978; | 0012| (3) Section 59A-22-34.1 NMSA 1978; | 0013| (4) Section 59A-22-35 NMSA 1978; | 0014| (5) Section 59A-22-36 NMSA 1978; | 0015| (6) Section 59A-22-39 NMSA 1978; ~~[and]~~ | 0016| (7) Section 59A-22-39.1 NMSA 1978; and | 0017| ~~[(7)]~~ (8) Section 59A-22-40 NMSA 1978." | 0018| Section 3. Section 59A-23B-3 NMSA 1978 (being Laws 1991, | 0019| Chapter 111, Section 3, as amended) is amended to read: | 0020| "59A-23B-3. POLICY OR PLAN--DEFINITION--CRITERIA.-- | 0021| A. For purposes of the Minimum Healthcare | 0022| Protection Act, "policy or plan" means a healthcare benefit | 0023| policy or healthcare benefit plan that the insurer, fraternal | 0024| benefit society, health maintenance organization or nonprofit | 0025| healthcare plan chooses to offer to individuals, families or | 0001| groups of fewer than twenty members formed for purposes other | 0002| than obtaining insurance coverage and that meets the | 0003| requirements of Subsection B of this section. For purposes of | 0004| the Minimum Healthcare Protection Act, "policy or plan" shall | 0005| not mean a healthcare policy or healthcare benefit plan that an | 0006| insurer, health maintenance organization, fraternal benefit | 0007| society or nonprofit healthcare plan chooses to offer outside | 0008| the authority of the Minimum Healthcare Protection Act. | 0009| B. A policy or plan shall meet the following | 0010| criteria: | 0011| (1) the individual, family or group obtaining | 0012| coverage under the policy or plan has been without healthcare | 0013| insurance, a health services plan or employer-sponsored | 0014| healthcare coverage for the six-month period immediately | 0015| preceding the effective date of its coverage under a policy or | 0016| plan, provided that the six-month period shall not apply to: | 0017| (a) a group that has been in existence | 0018| for less than six months and has been without healthcare | 0019| coverage since the formation of the group; | 0020| (b) an employee whose healthcare | 0021| coverage has been terminated by an employer; | 0022| (c) a dependent who no longer qualifies | 0023| as a dependent under the terms of the contract; or | 0024| (d) an individual and an individual's | 0025| dependents who no longer have healthcare coverage as a result | 0001| of termination or change in employment of the individual or by | 0002| reason of death of a spouse or dissolution of a marriage, | 0003| notwithstanding rights the individual or individual's | 0004| dependents may have to continue healthcare coverage on a self- | 0005| pay basis pursuant to the provisions of the federal | 0006| Consolidated Omnibus Budget Reconciliation Act of 1985; | 0007| (2) the policy or plan includes the following | 0008| managed care provisions to control costs: | 0009| (a) an exclusion for services that are | 0010| not medically necessary or are not covered by preventive health | 0011| services; and | 0012| (b) a procedure for preauthorization of | 0013| elective hospital admissions by the insurer, fraternal benefit | 0014| society, health maintenance organization or nonprofit | 0015| healthcare plan; and | 0016| (3) subject to a maximum limit on the cost of | 0017| healthcare services covered in any calendar year of not less | 0018| than fifty thousand dollars ($50,000), the policy or plan | 0019| provides the following minimum healthcare services to covered | 0020| individuals: | 0021| (a) inpatient hospitalization coverage | 0022| or home care coverage in lieu of hospitalization or a | 0023| combination of both, not to exceed twenty-five days of coverage | 0024| inclusive of any deductibles, co-payments or co-insurance, | 0025| provided that a period of inpatient hospitalization coverage | 0001| shall precede any home care coverage; | 0002| (b) prenatal care, including a minimum | 0003| of one prenatal office visit per month during the first two | 0004| trimesters of pregnancy, two office visits per month during the | 0005| seventh and eighth months of pregnancy and one office visit per | 0006| week during the ninth month and until term, provided that | 0007| coverage for each office visit shall also include prenatal | 0008| counseling and education and necessary and appropriate | 0009| screening, including history, physical examination and the | 0010| laboratory and diagnostic procedures deemed appropriate by the | 0011| physician based upon recognized medical criteria for the risk | 0012| group of which the patient is a member; | 0013| (c) obstetrical care, including | 0014| physicians' and certified nurse midwives' services, delivery | 0015| room and other medically necessary services directly associated | 0016| with delivery; | 0017| (d) well-baby and well-child care, | 0018| including periodic evaluation of a child's physical and | 0019| emotional status, a history, a complete physical examination, a | 0020| developmental assessment, anticipatory guidance, appropriate | 0021| immunizations and laboratory tests in keeping with prevailing | 0022| medical standards, provided that such evaluation and care shall | 0023| be covered when performed at approximately the age intervals of | 0024| birth, two weeks, two months, four months, six months, nine | 0025| months, twelve months, fifteen months, eighteen months, two | 0001| years, three years, four years, five years and six years; | 0002| (e) coverage for low-dose screening | 0003| mammograms for determining the presence of breast cancer, | 0004| provided that the mammogram coverage shall include one baseline | 0005| mammogram for persons age thirty-five through thirty-nine | 0006| years, one biennial mammogram for persons age forty through | 0007| forty-nine years and one annual mammogram for persons age fifty | 0008| years and over, and further provided that the mammogram | 0009| coverage shall only be subject to deductibles and co-insurance | 0010| requirements consistent with those imposed on other benefits | 0011| under the same policy or plan; | 0012| (f) coverage for cytologic screening, to | 0013| include a Papanicolaou test and pelvic exam for asymptomatic as | 0014| well as symptomatic women; ~~[and]~~ | 0015| (g) a basic level of primary and | 0016| preventive care, including, but not limited to, no less than | 0017| seven physician, nurse practitioner, nurse midwife or physician | 0018| assistant office visits per calendar year, including any | 0019| ancillary diagnostic or laboratory tests related to the office | 0020| visit; and | 0021| (h) coverage for not less than forty- | 0022| eight hours of inpatient care following a mastectomy and not | 0023| less than twenty-four hours of inpatient care following a lymph | 0024| node dissection for the treatment of breast cancer, provided | 0025| that nothing in this subparagraph shall be construed as | 0001| requiring the provision of inpatient coverage where the | 0002| attending physician and patient determine that a shorter period | 0003| of hospital stay is appropriate and further provided that | 0004| coverage for minimum inpatient hospital stays for mastectomies | 0005| and lymph node dissections for the treatment of breast cancer | 0006| may be subject to deductibles and co-insurance consistent with | 0007| those imposed on other benefits under the same policy or plan. | 0008| C. A policy or plan may include the following | 0009| managed care and cost control features to control costs: | 0010| (1) a panel of providers who have entered into | 0011| written agreements with the insurer, fraternal benefit society, | 0012| health maintenance organization or nonprofit healthcare plan to | 0013| provide covered healthcare services at specified levels of | 0014| reimbursement, provided that any such written agreement shall | 0015| contain a provision relieving the individual, family or group | 0016| covered by the policy or plan from any obligation to pay for | 0017| any healthcare service performed by the provider that is | 0018| determined by the insurer, fraternal benefit society, health | 0019| maintenance organization or nonprofit healthcare plan not to be | 0020| medically necessary; | 0021| (2) a requirement for obtaining a second | 0022| opinion before elective surgery is performed; | 0023| (3) a procedure for utilization review by the | 0024| insurer, fraternal benefit society, health maintenance | 0025| organization or nonprofit healthcare plan; and | 0001| (4) a maximum limit on the cost of healthcare | 0002| services covered in any calendar year of not less than fifty | 0003| thousand dollars ($50,000). | 0004| D. Nothing contained in Subsection C of this | 0005| section shall prohibit an insurer, fraternal benefit society, | 0006| health maintenance organization or nonprofit healthcare plan | 0007| from including in the policy or plan additional managed care | 0008| and cost control provisions that the superintendent of | 0009| insurance determines to have the potential for controlling | 0010| costs in a manner that does not cause discriminatory treatment | 0011| of individuals, families or groups covered by the policy or | 0012| plan. | 0013| E. Notwithstanding any other provisions of law, a | 0014| policy or plan shall not exclude coverage for losses incurred | 0015| for a preexisting condition more than six months from the | 0016| effective date of coverage. The policy or plan shall not | 0017| define a preexisting condition more restrictively than a | 0018| condition for which medical advice was given or treatment | 0019| recommended by or received from a physician within six months | 0020| before the effective date of coverage. | 0021| F. No medical group, independent practice | 0022| association or health professional employed by or contracting | 0023| with an insurer, fraternal benefit society, health maintenance | 0024| organization or nonprofit healthcare plan shall maintain any | 0025| action against any insured person, family or group member for | 0001| sums owed by an insurer, fraternal benefit society, health | 0002| maintenance organization or nonprofit healthcare plan, for sums | 0003| higher than those agreed to pursuant to a policy or plan." | 0004| Section 4. A new Section 59A-46-41.1 NMSA 1978 is enacted | 0005| to read: | 0006| "59A-46-41.1. [NEW MATERIAL] MASTECTOMIES AND LYMPH | 0007| NODE DISSECTION--MINIMUM HOSPITAL STAY COVERAGE REQUIRED.-- | 0008| A. Each individual and group health maintenance | 0009| contract delivered or issued for delivery in this state shall | 0010| provide coverage for not less than forty-eight hours of | 0011| inpatient care following a mastectomy and not less than twenty- | 0012| four hours of inpatient care following a lymph node dissection | 0013| for the treatment of breast cancer. | 0014| B. Nothing in this section shall be construed as | 0015| requiring the provision of inpatient coverage where the | 0016| attending physician and patient determine that a shorter period | 0017| of hospital stay is appropriate. | 0018| C. Coverage for minimum inpatient hospital stays | 0019| for mastectomies and lymph node dissections for the treatment | 0020| of breast cancer may be subject to deductibles and co-insurance | 0021| consistent with those imposed on other benefits under the same | 0022| contract." | 0023| | 0024| | 0025| FORTY-THIRD LEGISLATURE | 0001| FIRST SESSION, 1997 | 0002| | 0003| | 0004| March 16, 1997 | 0005| | 0006| Mr. President: | 0007| | 0008| Your PUBLIC AFFAIRS COMMITTEE, to whom has been | 0009| referred | 0010| | 0011| SENATE BILL 964 | 0012| | 0013| has had it under consideration and reports same with | 0014| recommendation that it DO PASS, and thence referred to the | 0015| CORPORATIONS & TRANSPORTATION COMMITTEE. | 0016| | 0017| Respectfully submitted, | 0018| | 0019| | 0020| | 0021| | 0022| __________________________________ | 0023| Shannon Robinson, Chairman | 0024| | 0025| | 0001| | 0002| Adopted_______________________ Not | 0003| Adopted_______________________ | 0004| (Chief Clerk) (Chief Clerk) | 0005| | 0006| | 0007| Date ________________________ | 0008| | 0009| | 0010| The roll call vote was 6 For 0 Against | 0011| Yes: 6 | 0012| No: 0 | 0013| Excused: Adair, Boitano, Vernon | 0014| Absent: None | 0015| | 0016| | 0017| | 0018| | 0019| S0964PA1 | 0020| | 0021| FORTY-THIRD LEGISLATURE | 0022| FIRST SESSION, 1997 | 0023| | 0024| | 0025| March 17, 1997 | 0001| | 0002| Mr. President: | 0003| | 0004| Your CORPORATIONS & TRANSPORTATION COMMITTEE, to | 0005| whom has been referred | 0006| | 0007| SENATE BILL 964 | 0008| | 0009| has had it under consideration and reports same with | 0010| recommendation that it DO PASS. | 0011| | 0012| Respectfully submitted, | 0013| | 0014| | 0015| | 0016| | 0017| __________________________________ | 0018| Roman M. Maes, III, Chairman | 0019| | 0020| | 0021| | 0022| Adopted_______________________ Not | 0023| Adopted_______________________ | 0024| (Chief Clerk) (Chief Clerk) | 0025| | 0001| | 0002| | 0003| Date ________________________ | 0004| | 0005| | 0006| The roll call vote was 6 For 0 Against | 0007| Yes: 6 | 0008| No: 0 | 0009| Excused: Fidel, Howes, McKibben, Robinson | 0010| Absent: None | 0011| | 0012| | 0013| S0964CT1 | 0014| State of New Mexico | 0015| House of Representatives | 0016| | 0017| FORTY-THIRD LEGISLATURE | 0018| FIRST SESSION, 1997 | 0019| | 0020| | 0021| March 21, 1997 | 0022| | 0023| | 0024| Mr. Speaker: | 0025| | 0001| Your CONSUMER AND PUBLIC AFFAIRS COMMITTEE, to | 0002| whom has been referred | 0003| | 0004| SENATE BILL 964 | 0005| | 0006| has had it under consideration and reports same with | 0007| recommendation that it DO PASS. | 0008| | 0009| Respectfully submitted, | 0010| | 0011| | 0012| | 0013| | 0014| Gary King, Chairman | 0015| | 0016| | 0017| Adopted Not Adopted | 0018| | 0019| (Chief Clerk) (Chief Clerk) | 0020| | 0021| Date | 0022| | 0023| The roll call vote was 6 For 0 Against | 0024| Yes: 6 | 0025| Excused: Rios, Sandel, Vigil, Trujillo | 0001| Absent: None | 0002| | 0003| | 0004| G:\BILLTEXT\BILLW_97\S0964 |