0001|                           SENATE BILL 1137
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0002|     43rd legislature - STATE OF NEW MEXICO - first session, 1997
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0003|                            INTRODUCED BY
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0004|                         MARY JANE M. GARCIA
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0005|     
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0006|                                   
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0007|     
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0008|                                   
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0009|     
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0010|                                AN ACT
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0011|     RELATING TO HEALTH CARE; ADDRESSING MEDICAID MANAGED CARE, THE
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0012|     UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER AND OTHER
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0013|     PROVIDERS.
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0014|     
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0015|     BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0016|          Section 1.  A new section of the Public Assistance Act is
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0017|     enacted to read:
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0018|          "[<u>NEW MATERIAL</u>]  MEDICAID MANAGED CARE--UNIVERSITY OF
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0019|     NEW MEXICO HEALTH SCIENCES CENTER--AUTHORIZATION FOR CONTRACTS
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0020|     DIRECTLY WITH PUBLIC AGENCIES, HOSPITALS, ESSENTIAL COMMUNITY
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0021|     PROVIDERS AND PROVIDER SERVICE NETWORKS.--
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0022|               A.  A managed health care plan offered through the
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0023|     medicaid program shall include participation by the university
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0024|     of New Mexico health sciences center.  The human services
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0025|     department shall administer a program to ensure the
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0001|     participation includes delivery of primary care and tertiary
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0002|     care services and to attempt to ensure, to the extent permitted
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0003|     by federal law, that the medicaid patient population served by
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0004|     the university of New Mexico health sciences center remains at
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0005|     least at a level similar to that served by the university of
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0006|     New Mexico health sciences center prior to implementation of
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0007|     the medicaid managed health care program.
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0008|               B.  A managed health care plan offered through the
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0009|     medicaid program shall provide payments to the university of
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0010|     New Mexico health sciences center at rates that are reasonable
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0011|     and adequate to meet costs incurred by efficiently and
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0012|     economically operated facilities, taking into account the
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0013|     disproportionately greater severity of illness and injury
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0014|     experienced by the patient population served.
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0015|               C.  The human services department shall administer a
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0016|     program and cooperate with the university of New Mexico health
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0017|     sciences center to ensure an adequate and diverse patient
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0018|     population necessary to preserve the health sciences center's
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0019|     educational programs.  The human services department shall also
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0020|     assure continuity of general support under the state medicaid
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0021|     program to the university of New Mexico health sciences center
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0022|     for medical education and for serving a disproportionately
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0023|     large indigent patient population. 
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0024|               D.  In administering the medicaid program or a
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0025|     managed health care system for the program, the human services
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0001|     department may contract directly with a government agency or
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0002|     public body, public nonprofit hospital, the university of New
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0003|     Mexico health sciences center, an essential community provider
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0004|     or a provider service network.  In doing so, the human services
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0005|     department is not required to contract with any such entity
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0006|     only through arrangements with a health care insurer.
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0007|          E.  For the purposes of this section:
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0008|                    (1)  "enrollee", "patient" or "consumer" means
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0009|     an individual who is entitled to receive health care benefits
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0010|     from a managed health care plan; 
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0011|                    (2)  "essential community provider" means a
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0012|     person that provides a significant portion of its health or
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0013|     health-related services to medically needy indigent patients,
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0014|     including uninsured, underserved or special needs populations;
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0015|                    (3)  "health care facility" means an
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0016|     institution providing health care services, including a
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0017|     hospital or other licensed inpatient center, an ambulatory
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0018|     surgical or treatment center, a skilled nursing center, a
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0019|     residential treatment center, a home health agency, a
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0020|     diagnostic, laboratory or imaging center and a rehabilitation
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0021|     or other therapeutic health setting;
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0022|                    (4)  "health care insurer" means a person that
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0023|     has a valid certificate of authority in good standing under the
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0024|     New Mexico Insurance Code to act as an insurer, a health
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0025|     maintenance organization, a nonprofit health care plan or a
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0001|     prepaid dental plan;
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0002|                    (5)  "health care professional" means a
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0003|     physician or other health care practitioner, including a
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0004|     pharmacist, who is  licensed, certified or otherwise authorized
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0005|     by the state to provide health services consistent with state
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0006|     law; 
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0007|                    (6)  "health care provider" or "provider" means
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0008|     a person that is licensed or otherwise authorized by the state
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0009|     to furnish health care services and includes health care
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0010|     professionals, health care facilities and essential community
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0011|     providers; 
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0012|                    (7)  "health care services" includes physical
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0013|     health services or community-based mental health or
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0014|     developmental disability services, including services for
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0015|     developmental delay;
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0016|                    (8)  "managed health care plan" or "plan" means
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0017|     a health benefit plan of a health care insurer or a provider
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0018|     service network that either requires an enrollee to use, or
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0019|     creates incentives, including financial incentives, for an
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0020|     enrollee to use health care providers managed, owned, under
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0021|     contract with or employed by the health care insurer.  "Managed
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0022|     health care plan" or "plan" does not include a traditional fee-
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0023|     for-service indemnity plan or a plan that covers only short-
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0024|     term travel, accident-only, limited benefit, student health
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0025|     plan or specified disease policies;
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0001|                    (9)  "person" means an individual or other
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0002|     legal entity; 
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0003|                    (10)  "primary health care clinic" means a
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0004|     nonprofit community-based entity established to provide the
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0005|     first level of basic or general health care needs, including
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0006|     diagnostic and treatment services, for residents of a health
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0007|     care underserved area as that area is defined in regulation
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0008|     adopted by the department of health; and 
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0009|                    (11)  "provider service network" means two or
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0010|     more health care providers affiliated for the purpose of
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0011|     providing health care services to enrollees on a capitated or
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0012|     similar prepaid, flat-rate basis." 
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0013|                              
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