0001| SENATE PUBLIC AFFAIRS COMMITTEE SUBSTITUTE FOR | 0002| SENATE BILL 1240 | 0003| 43rd legislature - STATE OF NEW MEXICO - first session, 1997 | 0004| | 0005| | 0006| | 0007| | 0008| | 0009| | 0010| | 0011| AN ACT | 0012| RELATING TO HEALTH CARE; ENACTING THE HEALTH CARE ACT TO | 0013| PROVIDE FOR COMPREHENSIVE STATEWIDE HEALTH CARE; PROVIDING FOR | 0014| HEALTH CARE PLANNING; ESTABLISHING PROCEDURES TO CONTAIN HEALTH | 0015| CARE COSTS; CREATING A COMMISSION; PROVIDING ITS POWERS AND | 0016| DUTIES; PROVIDING FOR HEALTH CARE DELIVERY REGIONS AND REGIONAL | 0017| COUNCILS. | 0018| | 0019| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0020| Section 1. SHORT TITLE.--This act may be cited as the | 0021| "Health Care Act" | 0022| Section 2. PURPOSE OF ACT.--The purposes of the Health | 0023| Care Act are to create a publicly financed statewide health | 0024| program to provide coverage for health care services for all | 0025| state residents and to control escalating health care costs. | 0001| Section 3. DEFINITIONS.--As used in the Health Care Act: | 0002| A. "beneficiary" means a person eligible for | 0003| coverage and benefits pursuant to the health plan; | 0004| B. "capital budget" means that portion of a budget | 0005| that establishes dollar amounts for expenditures for: | 0006| (1) acquisition or addition of substantial | 0007| improvements to real property; and | 0008| (2) acquisition of tangible personal property; | 0009| C. "capitation" means allocation of health plan | 0010| funds to a health care provider based on the number of | 0011| individuals whose health care must be covered by the provider, | 0012| with respect to all benefits available under the health plan, | 0013| for a calendar year or part of a calendar year; | 0014| D. "commission" means the health care commission | 0015| created pursuant to the Health Care Act; | 0016| E. "director" means the director of the commission; | 0017| F. "global budget" means the prospective operating | 0018| budget of a health facility, excluding the capital budget; | 0019| G. "group practice" means a health maintenance | 0020| organization, an association of health care providers that | 0021| provides one or more specialized health care services, such as | 0022| laboratory services, x-ray services, emergency care and | 0023| inpatient or outpatient hospital services, a tribally operated | 0024| health care center or tribal coalitions in partnership or under | 0025| contract with the Indian health service that is authorized | 0001| under federal law to provide health care to Native American | 0002| populations in the state; | 0003| H. "health care provider" means: | 0004| (1) a person licensed or certified in New | 0005| Mexico as a: | 0006| (a) physician; | 0007| (b) osteopathic physician; | 0008| (c) physician assistant or osteopathic | 0009| physician's assistant; | 0010| (d) chiropractic physician; | 0011| (e) dentist; | 0012| (f) psychologist, social worker; | 0013| professional clinical mental health counselor, professional mental | 0014| health counselor, marriage and family therapist or registered | 0015| mental health counselor; | 0016| (g) optometrist; | 0017| (h) podiatrist; | 0018| (i) pharmacist; | 0019| (j) pharmacist clinician; | 0020| (k) registered nurse or certified nurse | 0021| practitioner; | 0022| (l) visiting nurse service, private duty | 0023| registry or other certified home health agency; | 0024| (m) doctor of oriental medicine; | 0025| (n) physical therapist; | 0001| (o) massage therapist; | 0002| (p) occupational therapist; | 0003| (q) speech-language pathologist; | 0004| (r) audiologist; | 0005| (s) respiratory care practitioner; | 0006| (t) midwife; | 0007| (u) dietician or nutritionist; | 0008| (v) transportation service; or | 0009| (w) other practitioner of the healing arts | 0010| designated as a health care provider by the commission; | 0011| (2) a person licensed or certified by a | 0012| nationally recognized professional organization and designated as | 0013| a health care provider by the commission as a: | 0014| (a) prosthetist; | 0015| (b) orthotist; or | 0016| (c) oculist; or | 0017| (3) a group practice or transportation service | 0018| for that portion of the group practice or transportation service | 0019| that is paid pursuant to a fee schedule established by the | 0020| commission; | 0021| I. "health facility" means a clinic, general or | 0022| special hospital, outpatient facility, psychiatric hospital, | 0023| laboratory, skilled nursing facility or nursing facility. For the | 0024| purpose of determining global budgets, "health facility" includes | 0025| a group practice or transportation service; | 0001| J. "health plan" means the mechanism developed by the | 0002| commission for provision of health care services pursuant to the | 0003| Health Care Act; | 0004| K. "health plan budget" means all expenditures for the | 0005| health plan, including the costs of services and benefits | 0006| provided, administration, data gathering and other activities; | 0007| L. "implicit price deflator" means a measure of | 0008| inflation that is published in the United States department of | 0009| commerce survey of current business; | 0010| M. "major capital expenditure" means construction or | 0011| renovation of facilities or the purchase of diagnostic, treatment | 0012| or transportation equipment costing more than an amount | 0013| established by the legislature after the commission completes a | 0014| study and makes recommendations on this matter; | 0015| N. "person" means a legal entity; | 0016| O. "primary care provider" means a licensed physician, | 0017| osteopathic physician, nurse practitioner, physician assistant, | 0018| osteopathic physician's assistant, pharmacist clinician or other | 0019| provider certified by the commission as a primary care provider | 0020| after the commission's determination that the provider provides | 0021| the first level of health care for a beneficiary's health needs; | 0022| P. "provider budget" means the fee schedule | 0023| established by the commission each year to pay for health care | 0024| services provided by health care providers participating in the | 0025| health plan; and | 0001| Q. "transportation service" means the services of an | 0002| ambulance, helicopter or other conveyance that is equipped with | 0003| emergency supplies and equipment and is used to transport patients | 0004| to health care providers or health facilities. | 0005| Section 4. HEALTH CARE COMMISSION CREATED--VOTING AND | 0006| NONVOTING MEMBERS.-- | 0007| A. The "health care commission" is created as an | 0008| adjunct agency pursuant to the Executive Reorganization Act. The | 0009| general services department, the department of health and the | 0010| human services department shall cooperate with the commission and | 0011| assist it as needed. The commission consists of fifteen voting | 0012| members and nine nonvoting members. The voting members, all of | 0013| whom shall be appointed by the governor with the advice and | 0014| consent of the senate, are: | 0015| (1) four persons who represent consumer | 0016| interests, at least one of whom represents elderly consumer | 0017| interests; | 0018| (2) two persons who represent persons with | 0019| physical or mental impairments that limit one or more of their | 0020| major life activities; | 0021| (3) five persons who represent either health | 0022| care providers or health facilities; | 0023| (4) two persons who represent business ownership | 0024| interests, with one person representing employers of more than | 0025| fifteen persons and one person representing employers of fifteen | 0001| persons or fewer; and | 0002| (5) two persons who represent organized labor. | 0003| B. The voting members appointed shall reflect the | 0004| ethnic, gender, economic and geographic diversity of the state. | 0005| To ensure fair geographic representation of all areas of the | 0006| state, members shall be appointed from each of the state board of | 0007| education districts established by the 1991 Educational | 0008| Redistricting Act as follows: | 0009| (1) two from state board of education district | 0010| 1; | 0011| (2) one from state board of education district | 0012| 2; | 0013| (3) one from state board of education district | 0014| 3; | 0015| (4) two from state board of education district | 0016| 4; | 0017| (5) two from state board of education district | 0018| 5; | 0019| (6) one from state board of education district | 0020| 6; | 0021| (7) two from state board of education district | 0022| 7; | 0023| (8) two from state board of education district | 0024| 8; | 0025| (9) one from state board of education district | 0001| 9; and | 0002| (10) one from state board of education district | 0003| 10. | 0004| C. The initial voting members of the commission shall | 0005| be appointed by the governor by July 1, 1998. The terms of the | 0006| initial voting members appointed shall be staggered as follows: | 0007| five members shall be appointed for a term of four years; five | 0008| members shall be appointed for a term of three years; and five | 0009| members shall be appointed for a term of two years. Thereafter, | 0010| all members shall be appointed for terms of four years. After | 0011| initial terms are served, no member shall serve more than three | 0012| consecutive four-year terms. | 0013| D. A voting member may be removed from the commission | 0014| only for incompetence, neglect of duty or malfeasance in office. | 0015| No voting member shall be removed without having first been given | 0016| notice of hearing and an opportunity to be heard. The supreme | 0017| court has exclusive original jurisdiction over proceedings to | 0018| remove a voting member. The supreme court's decision on removal | 0019| shall be final. | 0020| E. A majority of the commission's voting members | 0021| constitutes a quorum for the transaction of business. Annually | 0022| the commission shall elect its chairman and any other officers it | 0023| deems necessary. | 0024| F. Voting members shall receive per diem and mileage | 0025| in accordance with the provisions of the Per Diem and Mileage Act. | 0001| G. The commission is composed of the following nine | 0002| nonvoting members: | 0003| (1) the secretary of health; | 0004| (2) the secretary of human services; | 0005| (3) the secretary of children, youth and | 0006| families; | 0007| (4) the secretary of taxation and revenue; | 0008| (5) a person designated by the New Mexico office | 0009| of Indian affairs, after consultation with the federal Indian | 0010| health service; | 0011| (6) two members of the house of representatives, | 0012| including one member of the majority party and one member of the | 0013| minority party, appointed by the speaker of the house; and | 0014| (7) two members of the senate, including one | 0015| member of the majority party and one member of the minority party, | 0016| appointed by the committees' committee of the senate, or, if the | 0017| senate appointments are made in the interim, by the president pro | 0018| tempore of the senate after consultation with and agreement of a | 0019| majority of the members of the committees' committee. | 0020| H. The governor shall recommend to the legislature by | 0021| January 1, 1998 whether or not the members of the commission | 0022| should be compensated. | 0023| Section 5. CONFLICT OF INTEREST.-- | 0024| A. Except for nonvoting members and members appointed | 0025| to represent health facilities or health care providers, no | 0001| commission member or a member of his immediate family shall have | 0002| any financial interest, direct or indirect, in a person providing | 0003| health care services or health insurance. | 0004| B. The commission shall adopt a conflict of interest | 0005| disclosure statement for use by all members that requires | 0006| disclosure of financial interests of the member or a member of his | 0007| immediate family in a person providing the health care services or | 0008| health insurance. | 0009| C. No member of the commission shall vote on any | 0010| matter in which he or a member of his immediate family has a | 0011| financial interest, except that members representing health | 0012| facilities or health care providers may vote on matters that | 0013| pertain generally to health facilities or health care providers. | 0014| D. If there is a question about a conflict of interest | 0015| of a member, the commission shall vote on whether to allow the | 0016| member to vote. | 0017| Section 6. DIRECTOR--STAFF--CONTRACTS--BUDGETS.-- | 0018| A. To assist in carrying out its duties, the | 0019| commission shall appoint and set the salary of a "director", | 0020| subject to the provisions of Section 10-9-5 NMSA 1978. The | 0021| director shall serve at the pleasure of the commission. | 0022| B. The director may employ those persons necessary to | 0023| administer and implement the provisions of the Health Care Act. | 0024| Employees are subject to the provisions of the Personnel Act. | 0025| C. The director and his staff shall implement the | 0001| Health Care Act in accordance with that act and the policies and | 0002| regulations adopted by the commission. The director may delegate | 0003| authority to employees and may organize the staff into units to | 0004| facilitate its work. | 0005| D. If the director determines that commission staff or | 0006| another state agency does not have the resources or expertise to | 0007| perform a necessary task, the commission may contract with a | 0008| person that has a demonstrated capability to perform the task. If | 0009| claims processing is provided by contract, that contract shall | 0010| require that all work shall be performed entirely in New Mexico. | 0011| All contracts shall be reviewed at least every two years to ensure | 0012| that they continue to meet the criteria and performance standards | 0013| of the contract and the needs of the commission. | 0014| E. The director may contract with consultants that the | 0015| director deems necessary to advise him or the commission in | 0016| carrying out the provisions of the Health Care Act. | 0017| F. The director shall prepare an annual budget and | 0018| plan of operation for the commission. He shall submit both to the | 0019| commission for its approval before implementation. | 0020| Section 7. COMMISSION--GENERAL POWERS AND DUTIES.--The | 0021| commission shall: | 0022| A. adopt a five-year program of operation to implement | 0023| the provisions of the Health Care Act; | 0024| B. provide a program to educate the public, health | 0025| care providers and health facilities about the health plan and the | 0001| persons eligible to receive its benefits; | 0002| C. study and adopt the most cost-effective methods of | 0003| providing health care services to all beneficiaries, according | 0004| high priority to increased reliance on: | 0005| (1) preventive and primary care that shall | 0006| include immunization and screening examinations; | 0007| (2) providing health care services in rural or | 0008| undeserved areas of the state; | 0009| (3) in-home and community-based alternatives to | 0010| institutional care; and | 0011| (4) case management services when appropriate; | 0012| D. establish compensation mechanisms for health care | 0013| providers and adopt standards and procedures for negotiating and | 0014| entering into contracts with participating health care providers; | 0015| E. establish a health plan budget; | 0016| F. establish global budgets for health facilities and | 0017| adopt: | 0018| (1) standards and procedures for determining | 0019| base budgets and annual global budgets for health facilities; and | 0020| (2) a capital expenditure program that requires | 0021| prior approval for major capital expenditures by health | 0022| facilities; | 0023| G. negotiate and enter into health care reciprocity | 0024| agreements with other states and foreign countries and negotiate | 0025| and enter into health care agreements with out-of-state health | 0001| care providers and health facilities; | 0002| H. develop a payment system for health care providers | 0003| and health facilities that ensures continuity of payments to | 0004| enable the providers and facilities to meet their financial | 0005| obligations as they become due; | 0006| I. establish a system to collect and analyze health | 0007| care data and other data necessary to improve the quality, | 0008| efficiency and effectiveness of health care services and to | 0009| control costs of health care services in New Mexico, and at a | 0010| minimum the system shall include data on: | 0011| (1) mortality, including accidental causes of | 0012| death, and natality; | 0013| (2) morbidity; | 0014| (3) health behavior; | 0015| (4) physical and psychological impairment and | 0016| disability; | 0017| (5) health care services system costs and health | 0018| care services availability, utilization and revenues; | 0019| (6) environmental factors; | 0020| (7) availability, adequacy and training of | 0021| health care services personnel; | 0022| (8) demographic factors; | 0023| (9) social and economic conditions affecting | 0024| health; and | 0025| (10) other factors determined by the commission; | 0001| J. standardize data collection and specific methods of | 0002| measurement across databases and use scientific sampling or | 0003| complete enumeration for reporting health information; | 0004| K. establish a health care services delivery system | 0005| that is efficient to administer and that eliminates unnecessary | 0006| administrative costs; | 0007| L. adopt rules and regulations necessary to implement | 0008| and monitor a state formulary to provide prescription drugs, | 0009| medicine, durable medical equipment and supplies, eyeglasses, | 0010| hearing aids, oxygen and related services; | 0011| M. study and evaluate the adequacy and quality of | 0012| health care services furnished pursuant to the Health Care Act, | 0013| the cost of each type of service and the effectiveness of cost- | 0014| containment measures in the health plan; | 0015| N. study and monitor the migration of persons to New | 0016| Mexico to determine if persons with costly health care needs are | 0017| moving to New Mexico to receive health care services, and if | 0018| migration appears to threaten the financial stability of the | 0019| health plan, recommend to the legislature changes in eligibility | 0020| requirements, premiums or other statutory changes that may be | 0021| necessary to maintain the financial integrity of the health plan; | 0022| O. study and evaluate the cost of health care provider | 0023| professional liability and health care provider professional | 0024| liability insurance and recommend statutory changes to the | 0025| legislature as necessary; | 0001| P. establish and approve changes in coverage benefits | 0002| and benefit standards in the health plan; | 0003| Q. conduct necessary investigations and inquiries and | 0004| compel by subpoena the submission of testimony, information and | 0005| documents that the commission considers necessary to carry out its | 0006| duties; | 0007| R. adopt rules and regulations necessary to implement, | 0008| administer and monitor the operation of the health plan; | 0009| S. meet as needed, but no less than once every three | 0010| months; and | 0011| T. report annually to the legislature and the governor | 0012| on the commission's activities and the operation of the health | 0013| plan and include in the annual report: | 0014| (1) a summary of information about health care | 0015| needs, health care services, health care expenditures, revenues | 0016| received and projected revenues and other relevant issues relating | 0017| to the health plan and the five-year program; and | 0018| (2) recommendations on methods to control health | 0019| care costs and improve access to and the quality of health care | 0020| for state residents, as well as recommendations for legislative | 0021| action if any are found to be necessary. | 0022| Section 8. COMMISSION--AUTHORITY.--The commission has the | 0023| authority necessary to carry out all duties and responsibilities | 0024| required of it pursuant to the Health Care Act, whether that | 0025| authority is expressly provided in that act or is necessarily | 0001| implied. The commission may delegate its general authority to the | 0002| director except for specific authority or direction that is | 0003| granted to the commission by a provision of the Health Care Act | 0004| and authority, which is expressly reserved in the commission, to | 0005| take the following actions: | 0006| A. sue and defend suits brought against it, subject to | 0007| the provisions of the Tort Claims Act; | 0008| B. enter into contracts; | 0009| C. approve its budget and plan of operation; | 0010| D. approve the health plan and make changes in the | 0011| health plan; | 0012| E. adopt regulations, written policies and procedures | 0013| to implement the health plan and the provisions of the Health Care | 0014| Act; | 0015| F. issue subpoenas to persons to appear and testify | 0016| before the commission and to produce documents and other | 0017| information, and enforce this subpoena power through an action in | 0018| the district court of Santa Fe county; | 0019| G. make reports and recommendations to the | 0020| legislature; | 0021| H. apply for program waivers from any governmental | 0022| entity; and | 0023| I. accept grants, apply for and receive loans and | 0024| accept donations. | 0025| Section 9. ADVISORY BOARDS.-- | 0001| A. The commission may establish advisory boards to | 0002| assist it in performing its duties. | 0003| B. The commission shall establish a "health care | 0004| provider advisory board" to advise and assist the commission in | 0005| all decisions requiring the expertise of health care providers. | 0006| Each noncommission member shall represent a different licensed | 0007| health profession. | 0008| C. No more than two advisory board members shall have | 0009| any financial interest, direct or indirect, in a person providing | 0010| health care services or a person providing health insurance. | 0011| D. The commission may appoint commission members and | 0012| up to five additional persons to serve on an advisory board it | 0013| creates. Advisory board members who are not commission members | 0014| may be paid per diem and mileage in accordance with the provisions | 0015| of the Per Diem and Mileage Act. | 0016| E. Staff and technical assistance for an advisory | 0017| board shall be provided by the commission as necessary. | 0018| Section 10. HEALTH CARE DELIVERY REGIONS.--The commission | 0019| shall establish health care delivery regions in the state, based | 0020| on geography and health care resources. The regions may have | 0021| differential fee schedules, global budgets, capital expenditure | 0022| allocations or other features to encourage the provision of health | 0023| care services in rural and other underserved areas. | 0024| Section 11. REGIONAL COUNCILS.-- | 0025| A. The commission shall create regional councils in | 0001| the health care delivery regions of the state. | 0002| B. The regional councils shall be composed of at least | 0003| one of the commission members who lives in the region and five | 0004| other members appointed by the commission. No more than two | 0005| council members shall have any financial interest, direct or | 0006| indirect, in a person providing health care services or a person | 0007| providing health insurance. | 0008| C. Members of a regional council may be paid per diem | 0009| and mileage in accordance with the provisions of the Per Diem and | 0010| Mileage Act. | 0011| D. The regional councils shall hold public hearings to | 0012| receive comments, suggestions and recommendations from the public | 0013| regarding regional health care needs. The councils shall report | 0014| to the commission at times specified by the commission to ensure | 0015| that regional concerns are considered in the development and | 0016| update of the five-year program, fee schedules, global budgets and | 0017| capital expenditure allocations. | 0018| E. Staff and technical assistance for the regional | 0019| councils shall be provided by the commission. | 0020| Section 12. COMMISSION, COUNCILS AND ADVISORY BOARDS-- | 0021| MEETINGS.--All meetings of the commission, councils and advisory | 0022| boards shall be conducted pursuant to the provisions of the Open | 0023| Meetings Act. | 0024| Section 13. RULES AND REGULATIONS.-- | 0025| A. The commission shall adopt regulations necessary to | 0001| carry out the duties of the commission and the provisions of the | 0002| Health Care Act. | 0003| B. No regulation affecting any person outside the | 0004| commission shall be adopted, amended or repealed without a public | 0005| hearing on the proposed action before the commission or a hearing | 0006| officer designated by the commission. The hearing officer may be | 0007| a member of the commission's staff. The hearing shall be held in | 0008| Santa Fe unless the commission determines that it would be in the | 0009| interest of those affected to hold the hearing elsewhere in the | 0010| state. Notice of the subject matter of the regulation, the action | 0011| proposed to be taken, the time and place of the hearing, the | 0012| manner in which interested persons may present their views and the | 0013| method by which copies of the proposed regulation or an amendment | 0014| or repeal of an existing regulation may be obtained shall be | 0015| published once at least thirty days prior to the hearing date in a | 0016| newspaper of general circulation and mailed at least thirty days | 0017| prior to the hearing date to all persons who have made a written | 0018| request for advance notice of hearing. | 0019| C. All rules and regulations adopted by the commission | 0020| shall be filed in accordance with the State Rules Act. | 0021| Section 14. HEALTH PLAN.-- | 0022| A. After notice and public hearing, including taking | 0023| public comment and the reports of the regional councils, the | 0024| commission shall adopt a health plan. | 0025| B. The health plan shall be designed to provide | 0001| comprehensive, necessary and appropriate health care benefits, | 0002| including preventive health care and primary, secondary and | 0003| tertiary health care for acute and chronic conditions. The health | 0004| plan may provide for certain health care services to be phased in | 0005| as the health plan budget allows. | 0006| C. The commission shall specify the health care | 0007| services to be included as covered by the health plan but shall | 0008| include: | 0009| (1) preventive health services; | 0010| (2) health care provider services; | 0011| (3) health facility inpatient and outpatient | 0012| services; | 0013| (4) laboratory tests and imaging procedures; | 0014| (5) in-home, community-based and institutional | 0015| long-term care services; | 0016| (6) prescription drugs; | 0017| (7) inpatient and outpatient mental health | 0018| services; | 0019| (8) drug and substance abuse services; | 0020| (9) preventive and prophylactic dental services, | 0021| including an annual dental examination and cleaning; | 0022| (10) vision appliances, including medically | 0023| necessary contact lenses; | 0024| (11) medical supplies, durable medical equipment | 0025| and selected assistive devices, including hearing and speech | 0001| assistance devices; and | 0002| (12) experimental or investigational procedures | 0003| or treatments as specified by the commission. | 0004| D. Covered services shall not include: | 0005| (1) surgery for cosmetic purposes other than for | 0006| reconstructive purposes; | 0007| (2) medical examinations and medical reports | 0008| prepared for purchasing or renewing life insurance or | 0009| participating as a plaintiff or defendant in a civil action for | 0010| the recovery or settlement of damages; and | 0011| (3) orthodontic services and cosmetic dental | 0012| services except those cosmetic dental services necessary for | 0013| reconstructive purposes. | 0014| E. The health plan shall specify the services to be | 0015| covered and the amount, scope and duration of benefits. The plan | 0016| shall include a maximum amount or percentage for administrative | 0017| costs, and this maximum, if a percentage, may change in relation | 0018| to the total costs of services provided under the health plan. | 0019| F. The commission shall specify the terms and | 0020| conditions for participation of health care providers and health | 0021| facilities in the health plan. | 0022| G. The health plan shall contain provisions to control | 0023| health care costs so that beneficiaries receive comprehensive | 0024| health services, consistent with budget constraints, including | 0025| needed health care services in rural and other underserved areas. | 0001| H. The health plan shall phase in beneficiaries as | 0002| their participation becomes possible through contracts, waivers or | 0003| federal legislation. The health plan may provide for certain | 0004| preventive health care services to be offered to all New Mexicans | 0005| regardless of eligibility. | 0006| I. The five-year program shall be reviewed by the | 0007| regional councils and the commission annually and revised as | 0008| necessary. Revisions shall be adopted by the commission in | 0009| accordance with Section 13 of the Health Care Act. In projecting | 0010| services under the health plan, the commission shall take all | 0011| reasonable steps to ensure that long-term care, mental health | 0012| services and dental care are provided at the earliest practical | 0013| times consistent with budget constraints. | 0014| Section 15. LONG-TERM CARE.-- | 0015| A. Long-term care may include: | 0016| (1) home- and community-based services, | 0017| including personal assistance and attendant care; | 0018| (2) hospice care; and | 0019| (3) institutional care. | 0020| B. No later than one year after appointment of the | 0021| director, the commission shall appoint an advisory "long-term care | 0022| committee" made up of representatives of health care consumers, | 0023| providers and administrators to develop a plan for integrating | 0024| long-term care into the health plan. The committee shall report | 0025| its plan to the commission no later than one year from its | 0001| appointment. Committee members may receive per diem and mileage | 0002| as provided in the Per Diem and Mileage Act. | 0003| C. The long-term care component of the health plan | 0004| shall provide for service coordination, case management and | 0005| noninstitutional services where appropriate. | 0006| D. Nothing in this section affects long-term care | 0007| services paid through federal programs or private insurance | 0008| subject to the provisions of Sections 34 and 35 of the Health Care | 0009| Act. | 0010| E. Nothing in this section precludes the commission | 0011| from including long-term care services from the inception of the | 0012| health plan. | 0013| Section 16. MENTAL HEALTH SERVICES.-- | 0014| A. Mental health services may include: | 0015| (1) services for acute and chronic conditions; | 0016| (2) home- and community-based services; and | 0017| (3) institutional care. | 0018| B. No later than one year after appointment of the | 0019| director, the commission shall appoint an advisory "mental health | 0020| services committee" made up of representatives of mental health | 0021| care consumers, providers and administrators to develop a plan for | 0022| integrating mental health services into the health plan. The | 0023| committee shall report its plan to the commission no later than | 0024| one year from its appointment. Committee members may receive per | 0025| diem and mileage as provided in the Per Diem and Mileage Act. | 0001| C. The mental health services component of the health | 0002| plan shall provide for service coordination, case management and | 0003| noninstitutional services where appropriate. | 0004| D. Nothing in this section affects mental health | 0005| services paid through federal programs or private insurance | 0006| subject to the provisions of Sections 34 and 35 of the Health Care | 0007| Act. | 0008| E. Nothing in this section precludes the commission | 0009| from including mental health services from the inception of the | 0010| health plan. | 0011| Section 17. MEDICAID COVERAGE--JOINT POWERS AGREEMENTS.-- | 0012| The commission may enter into joint powers agreements with the | 0013| human services department in accordance with the Joint Powers | 0014| Agreements Act for the purpose of furthering the goals of the | 0015| Health Care Act. These agreements may provide for certain | 0016| medicaid functions to be administered by the commission to allow | 0017| the commission to implement the health plan. | 0018| Section 18. HEALTH PLAN COVERAGE--CONDITIONS OF ELIGIBILITY | 0019| FOR BENEFICIARIES--NONRESIDENT STUDENTS--ELIGIBILITY CARD-- | 0020| PENALTIES.-- | 0021| A. An individual is eligible as a beneficiary of the | 0022| health plan if the individual has been physically present in New | 0023| Mexico for one year prior to the date of application for | 0024| enrollment in the health plan and if the individual has a present | 0025| intention to remain in New Mexico and not to reside elsewhere. A | 0001| dependent of an eligible individual is included as a beneficiary. | 0002| An individual is not eligible for coverage if he is covered for | 0003| the same or similar benefits pursuant to a private or governmental | 0004| health insurance policy or plan, but he becomes eligible when that | 0005| coverage terminates or agreements or waivers are accomplished | 0006| under which coverage under the health plan is available. | 0007| Individuals covered under the following governmental programs | 0008| shall not be brought into coverage through agreements or waivers: | 0009| (1) federal retiree health plan beneficiaries; | 0010| (2) Indian health service beneficiaries, but | 0011| individuals who are covered by tribal providers that are in | 0012| partnership with or have contracts with the Indian health service | 0013| may be brought under coverage through agreement between the tribal | 0014| providers and the commission; | 0015| (3) active duty military personnel; and | 0016| (4) individuals covered by the federal civilian | 0017| health and medical plan for the uniformed services. | 0018| B. An educational institution shall purchase coverage | 0019| under the health plan for its nonresident students through fees | 0020| assessed to these students. The governing body of an educational | 0021| institution shall set the fees at the amount determined by the | 0022| commission. | 0023| C. A nonresident student at an educational institution | 0024| may demonstrate health insurance or plan coverage by proof of | 0025| coverage under a policy or plan in another state that is | 0001| acceptable to the commission. The fee that students shall be | 0002| assessed shall be specified by the commission. | 0003| D. The commission shall adopt regulations to determine | 0004| proof of an individual's eligibility for the health plan or a | 0005| student's proof of nonresident health insurance or plan coverage. | 0006| E. The commission shall adopt regulations to provide a | 0007| method for the purging of eligibility when a beneficiary is no | 0008| longer eligible for coverage. | 0009| F. A beneficiary shall receive a card as proof of | 0010| eligibility. The card shall be electronically readable and shall | 0011| contain a picture or electronic image, information that identifies | 0012| the beneficiary for treatment and electronic billing and payment | 0013| and any other information the commission deems necessary. | 0014| G. The eligibility card is not transferable. A | 0015| beneficiary who lends his card to another and an individual who | 0016| uses another's card shall be jointly and severally be liable to | 0017| the commission for the full cost of the health care services | 0018| provided to the user. The liability shall be paid in full within | 0019| ten days of billing. Liabilities created pursuant to this section | 0020| shall be collected by the taxation and revenue department in the | 0021| same manner as delinquent taxes are collected pursuant to the Tax | 0022| Administration Act. | 0023| H. A beneficiary who lends his card to another or an | 0024| individual who uses another's card a second time is guilty of a | 0025| misdemeanor and shall be sentenced pursuant to the provisions of | 0001| Section 31-19-1 NMSA 1978. A third or subsequent conviction is a | 0002| fourth degree felony and the offender shall be sentenced pursuant | 0003| to the provisions of Section 31-18-15 NMSA 1978. | 0004| Section 19. PRIMARY CARE PROVIDER--RIGHT TO CHOOSE--ACCESS | 0005| TO SERVICES.-- | 0006| A. Except as provided in the Workers' Compensation | 0007| Act, a beneficiary has the right to choose a primary care | 0008| provider. If he does not choose a primary care provider, one | 0009| shall be assigned to him under procedures in regulations adopted | 0010| by the commission. | 0011| B. The primary care provider shall be responsible for | 0012| providing health care services other than services in medical | 0013| emergencies. If the expertise of another health care provider is | 0014| needed, the primary care provider shall make a referral to the | 0015| appropriate specialty. Except as provided in Subsections C and E | 0016| of this section, health care provider specialists shall be paid | 0017| pursuant to the health plan only if the patient has been referred | 0018| by the patient's primary care provider. Nothing in this | 0019| subsection prevents a beneficiary from obtaining the services of a | 0020| health care provider specialist and paying the specialist for | 0021| services provided. | 0022| C. The commission shall by regulation specify the | 0023| conditions under which a beneficiary may select a specialist as a | 0024| primary care provider. The commission shall set primary care | 0025| provider rates for specialists when serving as primary care | 0001| providers. | 0002| D. The commission shall by regulation specify how | 0003| often and under what conditions a beneficiary may change his | 0004| primary care provider. | 0005| E. The commission shall by regulation specify when and | 0006| under what circumstances a beneficiary may self-refer, including | 0007| self-referral to chiropractors, acupuncturists, mental health | 0008| professionals and other health care providers who are not primary | 0009| care providers. | 0010| Section 20. DISCRIMINATION PROHIBITED.--No health care | 0011| provider or health facility shall discriminate against or refuse | 0012| to furnish health care services to a beneficiary on the basis of | 0013| race, color, income level, national origin, religion, gender, | 0014| sexual orientation, disabling condition or payment status. | 0015| Nothing in this section shall require a health care provider or | 0016| health facility to provide services to a beneficiary if the | 0017| provider or facility is not qualified to provide the needed | 0018| services and does not offer them to the general public. | 0019| Section 21. GRIEVANCE PROCEDURES.--The commission shall | 0020| adopt regulations to cover and shall implement a prompt and fair | 0021| grievance procedure to respond to complaints of applicants, | 0022| beneficiaries, health care providers and health facilities. | 0023| Section 22. UTILIZATION REVIEW.-- | 0024| A. The commission shall adopt regulations to cover and | 0025| shall implement a comprehensive utilization review program. The | 0001| procedures and standards used in the program shall be disclosed in | 0002| writing to applicants, beneficiaries, health care providers and | 0003| health facilities at the time of application to or participation | 0004| in the health plan. | 0005| B. The decision of the health plan to approve or deny | 0006| health care services for payment shall be made in a timely manner. | 0007| A final decision to deny payment for services shall be made by a | 0008| health care professional having appropriate and adequate | 0009| qualifications to make the decision. The utilization review | 0010| program shall be designed to ensure that beneficiaries have proper | 0011| access to health care services, including referrals to necessary | 0012| specialists. A decision made in the utilization review program | 0013| shall be subject to the grievance procedures under regulations | 0014| adopted pursuant to Section 21 of the Health Care Act. | 0015| Section 23. MONITORING HEALTH CARE PROVIDER PRACTICES.-- | 0016| A. The commission shall adopt regulations to establish | 0017| and implement a continuous quality improvement program that | 0018| monitors the quality and appropriateness of health care services | 0019| provided by the health plan. The commission shall set standards | 0020| and review benefits to ensure that effective, cost-efficient and | 0021| appropriate health care services are rendered. | 0022| B. The commission shall review and adopt professional | 0023| practice guidelines developed by state and national medical and | 0024| specialty organizations, the United States agencies for health | 0025| care policy and research and other organizations as it deems | 0001| necessary to promote the quality and cost-effectiveness of health | 0002| care services provided through the health plan. | 0003| C. The quality improvement program shall include an | 0004| ongoing system for monitoring patterns of practice. The | 0005| commission shall appoint an advisory group consisting of health | 0006| care providers, representatives of health facilities and other | 0007| knowledgeable persons to advise the commission and staff on health | 0008| care practice issues. The advisory group shall provide to the | 0009| commission recommended standards and guidelines to be followed in | 0010| making determinations on practice issues. | 0011| D. The commission shall establish a system of peer | 0012| education for health care providers or health facilities | 0013| determined to be engaging in aberrant patterns of practice. If | 0014| the commission determines that peer education efforts have failed, | 0015| the commission may refer the matter to the appropriate licensing | 0016| or certifying board. | 0017| E. The commission shall provide by regulation the | 0018| procedures for recouping payments or withholding payments for | 0019| health care services determined by the commission to be medically | 0020| unnecessary. In addition, the commission may provide by | 0021| regulation for the assessment of administrative penalties for up | 0022| to three times the amount of excess payments if it finds that | 0023| excessive billings were part of an aberrant pattern of practice. | 0024| Administrative penalties shall be deposited in the current school | 0025| fund. | 0001| F. After consultation with the peer review advisory | 0002| group, the commission may suspend or revoke a health care | 0003| provider's or health facility's privilege to provide health care | 0004| services under the health plan for aberrant patterns of practice, | 0005| including overutilization, unnecessary referrals, attempts to | 0006| unbundle health care services or other practices that the | 0007| commission deems a violation of the Health Care Act or regulations | 0008| adopted pursuant to that act. As used in this section, "unbundle" | 0009| means to divide a service into components in an attempt to | 0010| increase or with the effect of increasing compensation from the | 0011| health plan. | 0012| G. The commission shall report a suspension or | 0013| revocation to practice under the Health Care Act to the | 0014| appropriate licensing or certifying board. | 0015| H. The commission shall report cases of suspected | 0016| fraud by a health care provider or a health facility to the | 0017| attorney general or to the district attorney of the county where | 0018| the health care provider or health facility operates for | 0019| investigation and prosecution. | 0020| Section 24. HEALTH PLAN BUDGET.-- | 0021| A. Each year, the commission shall develop a health | 0022| plan budget. The budget shall establish the total amount to be | 0023| spent by the plan for covered health care services in the next | 0024| year. The budget shall include administrative budgets, provider | 0025| budgets and global budgets. | 0001| B. Unless otherwise provided in the general | 0002| appropriation act or other act of the legislature, the health plan | 0003| budget shall be within projected annual revenues. | 0004| C. In developing the health plan budget, the | 0005| commission shall provide that credit be taken in that budget for | 0006| all revenues produced for health care services and facilities in | 0007| the state pursuant to any law other than the Health Care Act. | 0008| Section 25. PROVIDER BUDGET--PAYMENTS TO HEALTH CARE | 0009| PROVIDER--CO-PAYMENTS.-- | 0010| A. Consistent with budget constraints, the health plan | 0011| shall provide payment for all covered health care services | 0012| rendered by health care providers. A variety of payment plans, | 0013| including fee-for-service, compensation caps and capitated | 0014| payments may be adopted by the commission. Payment plans shall be | 0015| negotiated with providers as provided by regulation. In the event | 0016| that negotiation fails to develop an acceptable payment plan, the | 0017| disputing parties shall submit the payment plan to mediation. The | 0018| commission shall adopt regulations governing the procedures for | 0019| mediation. If the disputed payment plan is not resolved in | 0020| mediation, the disputing parties shall submit the payment plan to | 0021| binding arbitration pursuant to the Uniform Arbitration Act and | 0022| regulations to be adopted by the commission. | 0023| B. Different or supplemental payment rates may be | 0024| adopted to provide incentives to help ensure the delivery of | 0025| needed health care services in rural and other underserved areas | 0001| throughout the state. | 0002| C. The annual percentage increase in provider budgets | 0003| shall be no greater than the percentage increase in the implicit | 0004| price deflator using one year prior to implementation of the | 0005| health plan as the baseline year. | 0006| D. Payment, or the offer of payment whether or not | 0007| that offer is accepted, to a health care provider for services | 0008| covered by the health plan shall be payment in full for those | 0009| services. A health care provider shall not charge a beneficiary | 0010| any additional amounts for services covered by the plan. | 0011| E. The commission may set co-payments if co-payment is | 0012| determined to be an effective cost-control measure. No co-payment | 0013| shall be required for preventive care or if it creates a barrier | 0014| to medically necessary care. When a co-payment is required, the | 0015| health care provider shall not waive the co-payment. | 0016| Section 26. GLOBAL BUDGET--PAYMENTS TO HEALTH FACILITIES-- | 0017| CO-PAYMENTS.-- | 0018| A. A health facility shall negotiate an annual global | 0019| budget with the commission. The global budget shall be based on a | 0020| base budget of past performance and projected changes upward or | 0021| downward in costs and services anticipated for the next year. If | 0022| a negotiated annual global budget is not reached, a health | 0023| facility shall submit the budget to mediation. The commission | 0024| shall adopt regulations governing the procedures for mediation. | 0025| If the disputed budget is not resolved in mediation, the health | 0001| facility shall submit the budget to binding arbitration pursuant | 0002| to the Uniform Arbitration Act and regulations adopted by the | 0003| commission. The initial base budget for a health facility shall | 0004| be based on a twelve-month period that is no later than the year | 0005| the health plan is implemented, appropriately adjusted by the | 0006| implicit price deflator not to exceed five percent a year from | 0007| 1996 to the first global budget. Thereafter, increases in global | 0008| budgets are limited by the implicit price deflator. | 0009| B. Different or supplemental payment rates may be | 0010| adopted to provide incentives to help ensure the delivery of | 0011| needed health care services in rural and other underserved areas | 0012| throughout the state. | 0013| C. Each health care provider employed by a globally | 0014| budgeted health facility shall be paid from the budget allocation | 0015| in a manner determined by the health facility. | 0016| | 0017| D. The commission may set co-payments if co-payment is | 0018| determined to be an effective cost-control measure. No co-payment | 0019| shall be required for preventive care or if it creates a barrier | 0020| to medically necessary care. When a co-payment is required, the | 0021| health facility shall not waive the co-payment. | 0022| Section 27. HEALTH RESOURCE CERTIFICATE--COMMISSION | 0023| REGULATIONS--REQUIREMENT FOR REVIEW.-- | 0024| A. The commission shall adopt regulations pertaining | 0025| to when a health facility or health care provider must apply for a | 0001| health resource certificate, how the application will be reviewed, | 0002| how the certificate will be granted, how an expedited review is | 0003| conducted and other matters relating to health resource projects. | 0004| B. No health facility or health care provider shall | 0005| undertake a capital project or obligate a health facility or | 0006| health care provider to undertake a project without first | 0007| obtaining a health resource certificate, except as provided in | 0008| Subsection F of this section. | 0009| C. No health facility or health care provider shall | 0010| acquire through rental, lease or comparable arrangement or through | 0011| donation all or a part of a capital project that would have | 0012| required review if the acquisition had been by purchase unless the | 0013| project is granted a health resource certificate. | 0014| D. No health facility or health care provider shall | 0015| engage in component purchasing in order to avoid the provisions of | 0016| this section. | 0017| E. The commission shall grant a health resource | 0018| certificate for a capital project only when the project is | 0019| determined to be needed. | 0020| F. This section does not apply to: | 0021| (1) the purchase, construction or renovation of | 0022| office space for health care providers; | 0023| (2) a capital project for which a binding | 0024| contractual obligation was incurred prior to the effective date of | 0025| this section; | 0001| (3) expenditures incurred solely in preparation | 0002| for a capital project, including architectural design, surveys, | 0003| plans, working drawings and specifications and other related | 0004| activities, but those expenditures shall be included in the cost | 0005| of a project for the purpose of determining whether a health | 0006| resource certificate is required; | 0007| (4) acquisition of an existing health facility, | 0008| equipment or practice of a health care provider that does not | 0009| result in a new service being provided or in increased bed | 0010| capacity; | 0011| (5) capital expenditures for nonclinical | 0012| services when the nonclinical services are the primary purpose of | 0013| the expenditure; and | 0014| (6) the replacement of equipment with equipment | 0015| that has the same function and that does not result in the | 0016| offering of new services. | 0017| G. No later than January 1, 1999, the commission shall | 0018| report to the appropriate committees of the legislature on the | 0019| capital needs of health facilities, including facilities of state | 0020| and local governments, with a focus on underserved geographic | 0021| areas with substantially below-average health facilities and | 0022| investment per capita as compared to the state average. The | 0023| report shall also describe geographic areas where the distance to | 0024| health facilities imposes a barrier to care. The report shall | 0025| include a section on health care transportation needs, including | 0001| capital, personnel and training needs. The report shall make | 0002| recommendations for legislation to amend the Health Care Act by | 0003| adding to that act dollar limitations to apply in denying or | 0004| approving capital expenditures. | 0005| Section 28. ACTUARIAL REVIEW--AUDITS.-- | 0006| A. The commission shall provide for an annual | 0007| independent actuarial review of the health plan and any funds of | 0008| the commission or the plan. | 0009| B. The commission shall provide by regulation for | 0010| independent financial audits of health care providers and health | 0011| facilities. | 0012| C. The commission, through its staff or by contract, | 0013| shall perform announced and unannounced audits, including | 0014| financial, operational, management and electronic data processing | 0015| audits of health care providers and health facilities. The | 0016| auditor shall report directly to the commission. A copy of the | 0017| audit report shall be given to the state auditor. | 0018| D. Actuarial reviews, financial audits and internal | 0019| audits are public documents after they have been released by the | 0020| commission. | 0021| Section 29. STANDARD CLAIM FORMS FOR INSURANCE PAYMENT.-- | 0022| The commission shall adopt standard claim forms that shall be used | 0023| by all health care providers and health facilities that seek | 0024| payment through the health plan or from private persons, including | 0025| private insurance companies, for health care services rendered in | 0001| the state. Each claim form may indicate whether a person is | 0002| eligible for federal or other insurance programs for payment. | 0003| Each claim form shall include data elements required by the | 0004| commission. | 0005| Section 30. COMPUTERIZED SYSTEM.--The commission shall | 0006| require that all health care providers and health facilities | 0007| participate in the health plan's computer network that provides | 0008| for electronic transfer of payments to health care providers and | 0009| health facilities; transmittal of reports, including patient data | 0010| and other statistical reports; billing data, with specificity as | 0011| to procedures or services provided to individual patients; and any | 0012| other information required or requested by the commission. | 0013| Section 31. REPORTS REQUIRED--CONFIDENTIAL INFORMATION.-- | 0014| A. The commission, through the state health | 0015| information system, shall require reports by all health care | 0016| providers and health facilities of information needed to allow the | 0017| commission to evaluate the health plan, cost-containment measures, | 0018| utilization review, health facility global budgets, health care | 0019| provider fees and any other information the commission deems | 0020| necessary to carry out its duties under the Health Care Act. | 0021| B. The commission shall establish uniform reporting | 0022| requirements for health care providers and health facilities. | 0023| C. Information confidential pursuant to other | 0024| provisions of law shall be confidential under the Health Care Act. | 0025| Within the constraints of confidentiality, reports of the | 0001| commission are public documents. | 0002| Section 32. OMBUDSMAN PROGRAM.-- | 0003| A. The commission shall establish an ombudsman program | 0004| to take complaints and to provide timely and knowledgeable | 0005| assistance to: | 0006| (1) eligible persons and applicants about their | 0007| rights and responsibilities and the coverages provided in | 0008| accordance with the Health Care Act; and | 0009| (2) health care providers and health facilities | 0010| about status of claims, payments and other pertinent information | 0011| relevant to the claims payment process. | 0012| B. The commission shall establish a toll-free | 0013| telephone line for the ombudsman programs and shall have ombudsmen | 0014| available throughout the state to assist beneficiaries, | 0015| applicants, health care providers and health facilities in person. | 0016| Section 33. REIMBURSEMENT FOR OUT-OF-STATE SERVICES--HEALTH | 0017| PLAN'S RIGHT TO SUBROGATION AND PAYMENT FROM OTHER INSURANCE | 0018| PLANS--CHARGES FOR NON-COVERED PERSONS.-- | 0019| A. If a beneficiary needs health care services out of | 0020| state, those services shall be covered at the same rate that would | 0021| apply if the services were received in New Mexico. Additional | 0022| charges for those services shall not be paid by the health plan | 0023| unless the commission has negotiated a reciprocity or other | 0024| agreement with the other state or foreign country or with the out- | 0025| of-state health care provider or health facility. | 0001| B. The health plan shall make reasonable efforts to | 0002| ascertain any legal liability of third parties who are or may be | 0003| liable to pay all or part of the health care services costs of | 0004| injury, disease or disability of a beneficiary. | 0005| C. When the health plan makes payments on behalf of a | 0006| beneficiary, the health plan is subrogated to any right of the | 0007| beneficiary against a third party for recovery of amounts paid by | 0008| the health plan. | 0009| D. By operation of law, an assignment to the health | 0010| plan of the rights of a beneficiary: | 0011| (1) is conclusively presumed to be made of: | 0012| (a) a payment for health care services from | 0013| any person, firm or corporation, including an insurance carrier; | 0014| and | 0015| (b) a monetary recovery for damages for | 0016| bodily injury, whether by judgment, contract for compromise or | 0017| settlement; | 0018| (2) shall be effective to the extent of the | 0019| amount of payments by the health plan; and | 0020| (3) shall be effective as to the rights of any | 0021| other beneficiaries whose rights can legally be assigned by the | 0022| beneficiary. | 0023| Section 34. PRIVATE HEALTH INSURANCE COVERAGE LIMITED.-- | 0024| A. After the health plan is effective, no person shall | 0025| provide private health insurance to a beneficiary for a health | 0001| care service that is covered by the health plan except for retiree | 0002| health insurance plans that do not enter into contracts with the | 0003| health plan. | 0004| B. Nothing in this section shall be construed to | 0005| affect insurance coverage pursuant to the federal Employee | 0006| Retirement Income Security Act of 1974 unless the state obtains a | 0007| congressional exemption or a waiver from the federal government. | 0008| Businesses that are covered by the provisions of that act may | 0009| elect to participate in the health plan. | 0010| Section 35. FEDERAL HEALTH INSURANCE PROGRAM WAIVERS-- | 0011| REIMBURSEMENT TO HEALTH PLAN FROM FEDERAL AND OTHER HEALTH | 0012| INSURANCE PROGRAMS.-- | 0013| A. The commission, in conjunction with the human | 0014| services department, shall: | 0015| (1) apply to the United States department of | 0016| health and human services for all waivers of requirements under | 0017| health care programs established pursuant to the federal Social | 0018| Security Act, as amended, that are necessary to enable the state | 0019| to deposit federal payments for services covered by the health | 0020| plan into the plan's fund and to be the supplemental payer of | 0021| benefits for persons receiving medicare benefits; | 0022| (2) identify other federal programs that provide | 0023| federal funds for payment of health care services to individuals | 0024| and apply for any waivers or enter into any agreements that are | 0025| necessary to enable the state to deposit federal payments for | 0001| health care services covered by the health plan into the plan's | 0002| fund; provided, however, agreements negotiated with the Indian | 0003| health service shall not impair treaty obligations of the United | 0004| States government and other agreements negotiated shall not impair | 0005| portability or other aspects of the health care coverage; and | 0006| (3) seek an amendment to the federal Employee | 0007| Retirement Income Security Act of 1974 to exempt New Mexico from | 0008| the provisions of that act that relate to health care services or | 0009| health insurance, or the commission shall apply to the appropriate | 0010| federal agency for waivers of any requirements of that act if | 0011| congress provides for waivers to enable the commission to extend | 0012| coverage through the Health Care Act to as many New Mexicans as | 0013| possible. | 0014| B. The commission shall seek payment to the health | 0015| plan from medicaid, medicare or any other federal or other | 0016| insurance program for any reimbursable payment provided under the | 0017| plan. | 0018| C. The commission shall seek to maximize federal | 0019| contributions and payments for health care services provided in | 0020| New Mexico and shall ensure that the contributions of the federal | 0021| government for health care services in New Mexico will not | 0022| decrease in relation to other states as a result of any waivers, | 0023| exemptions or agreements. | 0024| Section 36. INSURANCE--COMMISSION APPROVAL.--No person | 0025| shall insure himself or his employees after July 1, 1999 unless | 0001| the coverage terminates on the date that the insureds are eligible | 0002| for coverage under the health plan. Nothing in this section | 0003| prohibits insurance coverage for health care services not covered | 0004| by the health plan or for individuals not eligible for coverage | 0005| under the health plan. | 0006| Section 37. INSURANCE RATES--COMMISSION AND SUPERINTENDENT | 0007| OF INSURANCE DUTIES.-- | 0008| A. The commission shall work closely with the | 0009| superintendent of insurance to identify health care cost savings | 0010| that have been achieved as a result of implementation of the | 0011| health plan. The commission and the superintendent shall identify | 0012| savings by insurance companies on payments made for medical | 0013| services through motor vehicle liability insurance, homeowners' | 0014| insurance, workers' compensation insurance or other insurance | 0015| policies that have a medical payment component. The commission | 0016| and the superintendent shall report their findings to the | 0017| legislature. | 0018| B. The superintendent shall lower insurance premiums | 0019| associated with medical benefits on all types of insurance | 0020| policies written in New Mexico that have a medical payment | 0021| component as soon as data indicate health care savings have been | 0022| achieved as a result of operation of the health plan. | 0023| Section 38. FINANCING THE HEALTH PLAN.-- | 0024| A. The legislative finance committee, in cooperation | 0025| with the New Mexico health policy commission, shall determine | 0001| financing options for the health plan. In making its | 0002| determinations the committee shall be guided by the following | 0003| requirements and assumptions: | 0004| (1) the health plan budget shall be no greater | 0005| than the health care expenditures projected for the 1998 calendar | 0006| year would have been had the health plan been in effect; | 0007| (2) benefits to be costed in determining the | 0008| financing options shall be equivalent to basic health care | 0009| coverage afforded state employees; and | 0010| (3) options shall set minimum and maximum levels | 0011| of premium payments and employer contributions and include a | 0012| system for reasonable co-payments except for preventive care and | 0013| for those beneficiaries at or below one hundred percent of the | 0014| poverty level. | 0015| B. The legislative finance committee shall prepare a | 0016| report of its determinations with the specific options and | 0017| recommendations no later than December 15, 1997. The report shall | 0018| be submitted for consideration for legislative implementation to | 0019| the second session of the forty-third legislature. | 0020| Section 39. TEMPORARY PROVISION--TRANSITION PERIOD | 0021| ARRANGEMENTS--PUBLICLY FUNDED HEALTH CARE SERVICE PLANS.-- | 0022| A. A person who, on the date benefits are available | 0023| under the Health Care Act health plan, receives health care | 0024| benefits under private contract or collective bargaining agreement | 0025| entered into prior to July 1, 1999 shall continue to receive those | 0001| benefits until the contract or agreement expires or unless the | 0002| contract or agreement is renegotiated to provide participation in | 0003| the health plan. | 0004| B. A person covered by a health care services plan | 0005| that has its premiums paid for in any part by public money, | 0006| including money from the state, a political subdivision, state | 0007| educational institution, public school or other entity that | 0008| receives public money to pay health insurance premiums, shall be | 0009| covered by the Health Care Act health plan on the effective date | 0010| that benefits are available under the plan. | 0011| Section 40. EFFECTIVE DATE.--The effective date of the | 0012| provisions of this act is July 1, 1997. | 0013|  |