HB 295 — HEALTH SECURITY ACT

eh , e 17h N.

"health resource certification" means a system t u g e b l e ne d, 18gh of approval for major capital expenditures to be determined by n d d i = = lo ]h 19 commission rules;

a l r] b ,d i 20a º r O.

"health security plan" means the program that is e r = t e w d m a tn o created and administered by the commission for provision of md m 21: e d r e 22 health care pursuant to the Health Security Act;

cb r e t º o t n = .211659.3 s k m e - 4 - e a n e d r ce 23l P.u [ A d health care pursuant to the Health Security Act;

"majorP. capital expenditure" means construction e a n b 24 or renovation of facilities or the acquisition of diagnostic, u [ treatment or transportation equipment by a health care provider .211659.3 - 4 - or health facility that costs more than an amount recommended and established by the commission;

"major capital expenditure" means construction or renovation of facilities or the acquisition of diagnostic, treatment or transportation equipment by a health care provider or health facility that costs more than an amount recommended and established by the commission;

"primary care provider" means a health care provider who is a physician, osteopathic physician, nurse h practitioner, physician assistant, osteopathic physician's u » r assistant, pharmacist clinician or other health care provider t h g e l i certified by the commission to provide the first level of basic h r i s health care, including diagnostic and treatment services;

eh , e 17h services delivered at a primary clinic, telehealth site or t u g e b l e ne d, 18gh school-based health center;

and behavioral health services if n d d i = = lo ]h 19 those services are integrated into the provider's service a l r] b ,d i 20a º r array;

e r = t e w d m a tn o U.

"provider budget" means the authorized md m 21: e d r e 22 expenditures pursuant to payment mechanisms established by the c e r c 23 commission to pay for health care furnished by health care e a n b 24 providers participating in the health security plan;

b r e t º o t n = .211659.3 s k m e - 5 - e a n e d r e l u [ V.A d expenditures pursuant to payment mechanisms established by the commission to pay for health care furnished by health care providers participating in the health security plan;

"service"V. means a health care service or product .211659.3 - 5 - offered or provided to an individual for the purpose of preventing, alleviating, curing or healing human physical or mental illness or injury or substance use disorder;

"service" means a health care service or product offered or provided to an individual for the purpose of preventing, alleviating, curing or healing human physical or mental illness or injury or substance use disorder;

h SECTION 4.

[NEW MATERIAL ] HEALTH CARE COMMISSION g o t hr CREATED--GOVERNMENTAL INSTRUMENTALITY.--As of December 1, 2021, g e i k the "health care commission" is created as a public body, h r i s politic and corporate, constituting a governmental eh e, 17t, instrumentality.

e u g e nb dl 18e e h SECTION 5.

[NEW MATERIAL ] CREATION OF HEALTH CARE n d d i = = lo ]h 19 COMMISSION MEMBERSHIP NOMINATING COMMITTEE--MEMBERSHIP, TERMS a l r] b ,d i 20a º e AND DUTIES.-- r i = r t e w d m a tn o A.

AsHSEICºAs of May 6, 2021, the The»HSEIC "health cared commission m m: 21 e d r e 22 membership nominating committee" is created, consisting of ten c e r c 23 members, to reflect the geographic diversity of the state, as e a n b 24 follows:

ub [e (1)d threes membersº appointedo byt then speaker= of .211659.3 s k m e - 6 - e a n e d r e l u [ A d care commission membership nominating committee" is created, consisting of ten members, to reflect the housegeographic diversity of representatives;the state, as follows:

(1) three members appointed by the speaker of the house of representatives;

HSEICº By April 15, 2021, the The»HSEIC legislative council service shall provide the public with public notice to allow members of the public to request consideration of appointment to the nominating committee.

The notice shall be advertised and reported on a publicly h accessible website that the nominating committee establishes g o t hr and maintains, in media outlets throughout the state and g e i k through publication of a legal notice in major newspapers.

h r i s Publication of the legal notice shall occur once each week for h , t, the two weeks preceding AprilHSEICº eApril e 17 15, 2021.

the public notice e u g e b l e e h provided pursuant to this subsection.»HSEIC n d 18d i = = o h C.

At the first meeting of the nominating = = l ] 19b ,d i a º e committee, it shall elect a chair and any other officers it ar li = r it 20e w d m a n o deems necessary from its membership.

td em a: t D.

b e d s º o t n = .211659.3 s k m e - 7 - e a n e d r e l u [ A d D.

m m 21 e d r e 22 E.

A member shall serve until the member's c e r c 23 successor is appointed and qualified.

Successor members shall e a n b 24 be appointed by the appointing authority that made the initial u [ appointment to the nominating committee.

A member shall be .211659.3 - 7 - eligible for or enrolled in the health security plan.

(2) is a state employee who is appointed by h the governor and confirmed by the senate;

g o t hr (3) is an elected official;

g e i k (4) is a health care provider;

or h r i s (5) is an owner or operator of a health h , t, facility.

e u g e 17b l e e h F.

Appointed members of the nominating committee e e n d 18d i = = o h shall have substantial knowledge of the health care system as = = l ] 19b ,d i a º e demonstrated by education or experience.

ar li = r it 20e w d m a n o G.

The nominating committee shall advertise and td e a t report notice of its meetings and agendas at least seventy-two m m: 21 e d r e 22 hours before each meeting on a publicly accessible website that c e r c 23 the commission establishes and maintains, in media outlets e a n b 24 throughout the state and through publication of a legal notice u [ in major newspapers.

Publicationb ofe thed legals noticeº shallo t n = .211659.3 s k m e - 8 - occure oncea n e d r e l u [ A d report notice of its meetings and agendas at least seventy-two hours before each weekmeeting foron a publicly accessible website that the twocommission weeksestablishes immediatelyand precedingmaintains, in media outlets throughout the datestate and through publication of a meeting.legal notice in major newspapers.

Publication of the legal notice shall occur once each week for the two weeks immediately preceding the date of a meeting.

h I.

The New Mexico legislative council shall convene g o t hr the first meeting of the nominating committee on or before May g e i k 14, 2021 and thereafter at the call of the chair.

h r i s J.

The nominating committee shall actively solicit, h , t, accept and evaluate applications from qualified persons for e u g e 17b l e e h membership on the commission subject to the qualification e e n d 18d i = = o h requirements for commission membership pursuant to Section 6 of = = l ] 19b ,d i a º e the Health Security Act.

ar li = r it 20e w d m a n o K.

HSEICº No later than October 1, 2021, the nominatingd t e a t committee shall submit to the governor the names of the persons m m: 21 e d r e 22 recommended for appointment to the commission by a majority of c e r c 23 the nominating committee.

Immediatelyb aftere receivingd thes eº ao t n b= 24.211659.3 nominatings committee'sk nominations,m thee governor- may9 make- onee a n e d r e l u [ requestA ofd theThe»HSEIC nominating committee forshall submissionsubmit to the governor the names of .211659.3the -persons 9recommended -for additionalappointment names.to the commission by a majority of the nominating committee.

Immediately after receiving the nominating committee's nominations, the governor may make one request of the nominating committee for submission of additional names.

The legislative council service shall provide h staff to assist the nominating committee.

g o t hr SECTION 6.

[NEW MATERIAL ] APPOINTMENT OF COMMISSION g e i k MEMBERS--MEETINGS--QUALIFICATIONS--TERMS.-- h r i s A.

From the nominees submitted by the health care h , t, commission membership nominating committee, the governor shall e u g e 17b l e e h appoint fifteen members to the commission,commission HSEICº , and the initialn ed ed ni d= 18= o h initial commission shall be in place by December 2, 2021.2021»HSEIC.

Inl the] eventb =,d =i la ]º 19e In the event that the governor does not appoint a member to a commissionr ai l= r it 20e membershipw slotd bym Decembera 2,n 2021,o thecommission nominatingmembership committeeslot tHSEICº eby aDecember t2, shall2021»HSEIC, maked thatm appointment.:

mb e d s º o t n = .211659.3 s k m 21e - 10 - e a n e d r e 22l B.u [ A d the nominating committee shall make that appointment.

TheB. New Mexico legislative council shall convene c e r c 23 a first meeting of the commission by January 6, 2022.

AtThe theNew eMexico alegislative ncouncil bshall 24convene a first meeting of the commission,commission theHSEICº membersby shallJanuary elect6, from2022»HSEIC. u [ their membership a chair and a vice chair and any other .211659.3 - 10 - officers they deem necessary.

At the first meeting of the commission, the members shall elect from their membership a chair and a vice chair and any other officers they deem necessary.

Thereafter, all members h shall be appointed for terms of four years.

After initial g o t hr terms are served, no member shall serve more than two g e i k consecutive four-year terms.

A member may serve until a h r i s successor is appointed.

h , t, E.

A person shall not serve on the commission if e u g e b l e e h that person:

en ed 17d i = = o h (1) has, within the previous twenty-four el e] nb d,d 18i a º e months, served as a member of the nominating committee;

= = l ] 19 (2) has, or is a member of the household of a a l r i 20= personr who has, during the previous twenty-four months, been t e aw td employedm by,a servedn aso an(2) agenthas, or officeris of or had a mmember mof 21the ehousehold dof r e 22 controlling interest in a persond thatm is: licensed to provide c e r c 23 health insurance;

b e ad s º o t n b= 24.211659.3 (3)s isk m e - 11 - e a staten employeee whod isr appointede byl u [ theA governord andperson confirmedwho byhas, during the senate;previous twenty-four months, been employed by, served as an agent or officer of or had a controlling interest in a person that is licensed to provide health insurance;

.211659.3(3) -is 11a -state (4)employee who is anappointed electedby official;the governor and confirmed by the senate;

(4) is an elected official;

In the event that the governor does not appoint a member to the vacancy h within thirty days, the nominating committee shall appoint a g o t hr member to fill the vacancy.

g e i k G.

The fifteen members of the commission shall h r i s include:

h , t, (1) five persons who represent either health e u g e b l e e h care providers or health facilities;

en ed 17d i = = o h (2) six persons who represent consumer el e] nb d,d 18i a º e interests;

and =r i = lr ]t 19e w d m a n o (3) four persons who represent employer ad lm r: i 20 interests;

providedb thate ad persons whoº representso a health care t en a= t.211659.3 providers ork am healthe facility- shall12 not- servee as a membern who m m 21 e d r e 22l representsu employer[ interests.A d interests;

cprovided ethat ra cperson 23who H.represents a health care provider or a health facility shall not serve as a member who represents employer interests.

AH. person appointed to the commission who does e a n b 24 not represent a health care provider or a health facility shall u [ have a knowledge of the health care system as demonstrated by .211659.3 - 12 - experience or education.

A person appointed to the commission who does not represent a health care provider or a health facility shall have a knowledge of the health care system as demonstrated by experience or education.

h (4) two from public education commission g o t hr district 4;

g e i k (5) two from public education commission h r i s district 5;

h , t, (6) one from public education commission e u g e b l e e h district 6;

en ed 17d i = = o h (7) two from public education commission el e] nb d,d 18i a º e district 7;

=r i = lr ]t 19e w d m a n o (8) two from public education commission ad lm r: i 20 district 8;

tb e ad ts (9)º oneo fromt publicn education= commission.211659.3 ms k m 21e - 13 - e a n e d r e 22l u [ A d district 9;8;

and(9) c e r c 23 (10) one from public education commission e a n b 24 district 10.9;

uand [(10) J.one from public education commission district 10.

TheJ. presence of a majority of the commission's .211659.3 - 13 - members constitutes a quorum for the transaction of business.

The presence of a majority of the commission's members constitutes a quorum for the transaction of business.

Additionally, members shall be compensated at the rate of two hundred dollars ($200) for each day of a meeting or h training event actually attended not to exceed compensation for g o t hr one hundred twenty meetings for a two-year period occurring in g e i k a term.

h r i s L.

The commission shall establish an electronic h , t, mail or "email" system for use by members in the conduct of e u g e b l e e h commission business.

Commission business shall be exclusively en ed 17d i = = o h conducted on the commission's email system.

el e] nb d,d 18i a º e SECTION 7.

[NEW MATERIAL ] CONFLICT OF INTEREST-- =r i = lr ]t 19e w d m a n o DISCLOSURE BY MEMBERS AND DISQUALIFICATION FROM VOTING ON ad lm r: i 20 CERTAIN MATTERS.-- t e a t A.

Theb commission shall adopt a conflict-of- m m 21 e d rs eº 22o interestt disclosuren statement= for.211659.3 uses byk allm members that c e r- c14 23- requires disclosure of a financial interest, whether or not a e a n be 24d controllingr interest,e ofl the member or a member of the member's u [ householdA ind aCERTAIN personMATTERS.-- providingA. health care or health .211659.3 - 14 - insurance.

The commission shall adopt a conflict-of- interest disclosure statement for use by all members that requires disclosure of a financial interest, whether or not a controlling interest, of the member or a member of the member's household in a person providing health care or health insurance.

[NEW MATERIAL ] COMMISSION CODE OF CONDUCT-- MEMBER DISCIPLINE--REMOVAL.--The commission shall adopt and promulgate a code of conduct and procedures to be observed by h members in the execution of their duties.

The commission may u » r remove a member for a violation of the commission code of t h g e l i conduct or a violation of the Health Security Act by a two- h r i s thirds' majority vote of all of the members at a meeting where h , e h all members, except the member who is the subject of the vote, t u g e b l e e , gh are present.

A member shall not be removed without proceedings en ed 17d i = = o h consisting of at least one ten-day notice of hearing and an el e] nb d,d 18i a º r opportunity to be heard.

Removal proceedings shall be before =e r = lt ]e 19w d m a n o the commission and in accordance with procedures the commission ad lm r: i 20 has adopted and promulgated.

b r e t º o t n = .211659.3 s k m e - 15 - e a tn SECTIONe 9.d r e l u [ A d has adopted and promulgated.

[NEWSECTION MATERIAL9. ] APPLICATION OF CERTAIN STATE m m 21 e d r e 22 LAWS TO COMMISSION.--The commission and regional councils c e r c 23 created pursuant to the Health Security Act:

e[NEW aMATERIAL] nAPPLICATION bOF 24CERTAIN A.STATE LAWS TO COMMISSION.--The commission and regional councils created pursuant to the Health Security Act:

shallA. be subject to and shall comply with the u [ provisions of the:

.211659.3shall -be 15subject -to (1)and Openshall Meetingscomply Act;with the provisions of the:

(1) Open Meetings Act;

shall not be subject to the provisions of the h Procurement Code or the Personnel Act.

g o t hr SECTION 10.

[NEW MATERIAL ] CHIEF EXECUTIVE OFFICER-- g e i k STAFF--CONTRACTS--BUDGETS.-- h r i s A.

The commission shall appoint and set the salary h , t, of a "chief executive officer".

The chief executive officer e u g e b l e e h shall serve at the pleasure of the commission and has authority en ed 17d i = = o h to carry on the day-to-day operations of the commission and the el e] nb d,d 18i a º e health security plan.

=r i = lr ]t 19e w d m a n o B.

The chief executive officer shall employ those ad lm r: i 20 persons necessary to administer and implement the provisions of t e a t the Health Security Act.

mb e d s º o t n = .211659.3 s k m 21e - 16 - e a n e d r e 22l C.u [ A d persons necessary to administer and implement the provisions of the Health Security Act.

TheC. chief executive officer and the chief c e r c 23 executive officer's staff shall implement the Health Security e a n b 24 Act in accordance with that act and the rules adopted by the u [ commission.

The chief executive officer mayand delegatethe authoritychief .211659.3executive -officer's 16staff -shall toimplement employeesthe andHealth maySecurity organizeAct thein staffaccordance intowith unitsthat toact facilitateand itsthe work.rules adopted by the commission.

The chief executive officer may delegate authority to employees and may organize the staff into units to facilitate its work.

A contract shall be reviewed by the h commission or the chief executive officer to ensure that it u » r meets the criteria, performance standards, expectations and t h g e l i needs of the commission.

h r i s E.

The chief executive officer shall prepare and h , e h submit an annual budget request and plan of operation to the t u g e b l e e , gh commission for its approval.

The chief executive officer shall en ed 17d i = = o h provide at least quarterly status reports on the budget and el e] nb d,d 18i a º r advise of a potential shortfall as soon as practicably =e r = lt ]e 19w d m a n o possible.

ad lm r: i 20 F.

Ab contractr fore claims processing functions shall t eº ao t requiren that= all.211659.3 works fork claims processing, customer service, m m 21 e d- r17 - e 22a medicaln and utilization review, financial audit and c e d r c 23 reimbursement and related claims adjudication functions be e al nu b[ 24A performedd entirelyF. in New Mexico.

ToA thecontract extentfor practicable,claims uprocessing [functions allshall otherrequire that all work shallfor claims processing, customer service, medical and utilization review, financial audit and reimbursement and related claims adjudication functions be performed entirely in New Mexico.

.211659.3To -the 17extent -practicable, SECTIONall 11.other work shall be performed in New Mexico.

[NEWSECTION MATERIAL11. ] COMMISSION--GENERAL DUTIES.-- The commission shall:

[NEW MATERIAL] COMMISSION--GENERAL DUTIES.-- The commission shall:

byHSEICºby February 10, 2022,2022,»HSEIC obtain legal counsel to advise the commission in the execution of its h duties;

g o t hr C.

byHSEICºby April 1, 2022,2022,»HSEIC adopt and g e i k promulgate rules for the procurement of goods and services.

h r i s With the exception of audit-related services, rules relating to h , t, e u g the procurement of goods and services shall provide for a e b l e e h preference for New Mexico vendors;

n d d i = = o h D.

propose health security plan premium rates and el e] 17b ,d i a º e employer contribution rates to the superintendent;

er i = r t e nw d 18m a n o E.

pursuant to federal law, apply for any federal =d =m l: ] 19 waiver that the commission deems necessary to implement the a l r i 20 health security plan;

b e d s º o t n = .211659.3 s k m e - 18 - e a tn F.e d r e l u [ A d waiver that the commission deems necessary to implement the health security plan;

designF. the health security plan to fulfill the m m 21 e d r e 22 purposes of and conform with the provisions of the Health c e r c 23 Security Act;

edesign athe nhealth bsecurity 24plan G.to fulfill the purposes of and conform with the provisions of the Health Security Act;

provideG. a program to educate the public, health u [ care providers and health facilities about the health security .211659.3 - 18 - plan and the persons eligible to receive its benefits;

provide a program to educate the public, health care providers and health facilities about the health security plan and the persons eligible to receive its benefits;

h (3) in-home and community-based alternatives g o t hr to institutional health care;

and g e i k (4) care coordination services when h r i s appropriate;

h , t, I.

establish annual health security plan budgets e u g e b l e e h and budgets for those projected future periods that the n d d i = = o h commission believes appropriate;

el e] 17b ,d i a º e J.

establish and maintain sufficient reserves to er i = r t e nw d 18m a n o provide for catastrophic and unforeseen expenditures;

=d =m l: ] 19 K.

establishb capitale budgetsd fors healthº facilities,o at ln r= i.211659.3 20s limitedk tom capitale expenditures- subject19 to- the Health Security t e a tn Act,e andd includer ande adoptl inu establishing[ thoseA budgets:d K.

mestablish mcapital 21budgets efor dhealth rfacilities, elimited 22to (1)capital standardsexpenditures andsubject proceduresto forthe determiningHealth cSecurity eAct, rand cinclude 23and theadopt budgets;in establishing those budgets:

and(1) estandards aand nprocedures b 24 (2) a requirement for priordetermining approval by the ubudgets; [ commission for major capital expenditures by a health facility;

.211659.3and -(2) 19a -requirement L.for prior approval by the commission for major capital expenditures by a health facility;

L.

h N.

establish, in conjunction with state agencies u » r similarly charged, a comprehensive system to collect and t h g e l i analyze health care data, including claims data and other data, h r i s necessary to improve the quality, efficiency and effectiveness h , e h of health care and to control costs of health care in New t u g e b l e e , gh Mexico, which system shall include data on:

n d d i = = o h (1) mortality, including accidental causes of el e] 17b ,d i a º r death, and natality;

e r = t e nw d 18m a n o (2) morbidity;

=d =m l: ] 19 (3) health behavior;

ab l r ie 20t (4)º physicalo andt psychologicaln impairment= and.211659.3 ts k m e - 20 - e a tn disability;e d r e l u [ A d (3) health behavior;

m(4) mphysical 21 e d r e 22 (5) health care system costs and healthpsychological careimpairment c e r c 23 availability, utilization and revenues;disability;

e(5) ahealth ncare bsystem 24costs (6)and environmentalhealth factors;care availability, utilization and revenues;

u(6) [environmental (7)factors; availability, adequacy and training of .211659.3 - 20 - health care personnel;

(7) availability, adequacy and training of health care personnel;

h P.

foster a health care delivery system that is g o t hr efficient to administer and that eliminates unnecessary g e i k administrative costs;

h r i s Q.

adopt rules necessary to implement and monitor a h , t, preferred drug list, bulk purchasing or other mechanism to e u g e b l e e h provide prescription drugs and a pricing procedure for n d d i = = o h nonprescription drugs, durable medical equipment and supplies, el e] 17b ,d i a º e eyeglasses, hearing aids and oxygen;

er i = r t e nw d 18m a n o R.

establish a pharmacy and therapeutics committee =d =m l: ] 19 to:

ab le rd is 20º (1)o researcht federaln and= state.211659.3 incentivess andk tm e a- t21 discount- programse fora then purchase, manufacture or supply of m m 21 e d r e 22l drugs,u biologics[ andA medicald equipmentto: and supplies to maximize c e r c 23 the health security plan's savings potential through these e a n b 24 incentives and programs;

u(1) [research (2)federal establishand astate formularyincentives of drugs and .211659.3discount -programs 21for -the biologicspurchase, thatmanufacture isor insupply accordanceof withdrugs, clinicalbiologics bestand practicesmedical forequipment safety,and efficacysupplies andto effectivenessmaximize while,the inhealth strictsecurity observanceplan's ofsavings thosepotential bestthrough practices,these maximizingincentives fiscaland soundness;programs;

(2) establish a formulary of drugs and biologics that is in accordance with clinical best practices for safety, efficacy and effectiveness while, in strict observance of those best practices, maximizing fiscal soundness;

(5) recommend therapeutic classes of drugs, h including specific drugs within each class to be included in u » r the preferred drug list;

t h g e l i (6) identify appropriate exclusions from the h r i s preferred drug list;

and h , e h (7) conduct periodic clinical reviews of t u g e b l e e , gh preferred, nonpreferred and new drugs;

n d d i = = o h S.

study and evaluate the adequacy and quality of el e] 17b ,d i a º r health care furnished pursuant to the Health Security Act, the e r = t e nw d 18m a n o cost of each type of service and the effectiveness of cost- =d =m l: ] 19 containment measures in the health security plan;

b r e t º o t n = .211659.3 s k m e - 22 - e a ln e d r ie 20l T.u [ A d containment measures in the health security plan;

inT. conjunction with the human services t e a t department, apply to the United States department of health and m m 21 e d r e 22 human services for all waivers of requirements under health c e r c 23 care programs established pursuant to the federal Social e a n b 24 Security Act that are necessary to enable the health security u [ plan to receive federal payments for services rendered to .211659.3 - 22 - medicaid or medicare beneficiaries;

in conjunction with the human services department, apply to the United States department of health and human services for all waivers of requirements under health care programs established pursuant to the federal Social Security Act that are necessary to enable the health security plan to receive federal payments for services rendered to medicaid or medicare beneficiaries;

provided, however, that agreements negotiated with the federal Indian health service or tribal governments shall not impair treaty h obligations of the United States government and that other u » r agreements negotiated shall not impair portability or other t h g e l i aspects of the health care coverage;

h r i s V.

seek an amendment to the federal Employee h , e h Retirement Income Security Act of 1974 to exempt New Mexico t u g e b l e e , gh from the provisions of that act that relate to health care n d d i = = o h services or health insurance, or apply to the appropriate el e] 17b ,d i a º r federal agency for waivers of any requirements of that act if e r = t e nw d 18m a n o congress provides for waivers to enable the commission to =d =m l: ] 19 extend coverage through the Health Security Act to as many New a l r i 20 Mexicans as possible;

provided,b however,r thate the amendment or t eº ao t waivern requested= shall.211659.3 nots impairk portabilitym ore other- aspects23 m- me 21a n e d r e 22l ofu [ A d extend coverage through the healthHealth careSecurity coverage;Act to as many New Mexicans as possible;

cprovided, ehowever, rthat cthe 23amendment W.or waiver requested shall not impair portability or other aspects of the health care coverage;

analyzeW. developments in federal law and e a n b 24 regulation relevant to the health security plan, and provide u [ updates and any legislative recommendations to the legislature .211659.3 - 23 - that the commission deems necessary pursuant to those developments;

analyze developments in federal law and regulation relevant to the health security plan, and provide updates and any legislative recommendations to the legislature that the commission deems necessary pursuant to those developments;

seek to maximize federal contributions and payments for health care services provided in New Mexico and ensure that the contributions of the federal government for h health care services in New Mexico will not decrease in u » r relation to other states as a result of any health care t h g e l i efficiencies or improvements or savings;

h r i s Z.

study and monitor the migration of persons to h , e h New Mexico to determine if persons with costly health care t u g e b l e e , gh needs are moving to New Mexico to receive health care and, if n d d i = = o h migration appears to threaten the financial stability of the el e] 17b ,d i a º r health security plan, recommend to the legislature changes in e r = t e nw d 18m a n o eligibility requirements, premiums or other changes that may be =d =m l: ] 19 necessary to maintain the financial integrity of the health a l r i 20 security plan;

b r e t º o t n = .211659.3 s k m e - 24 - e a tn AA.e d r e l u [ A d necessary to maintain the financial integrity of the health security plan;

collaborateAA. with state agencies and experts to m m 21 e d r e 22 study and evaluate health care workforce data and research, and c e r c 23 information solicited from health care providers and health e a n b 24 care workforce experts, on the effect of the health security u [ plan on the state's provider community.

Thiscollaborate shallwith includestate theagencies .211659.3and -experts 24to - study and evaluationevaluate ofhealth thecare supplyworkforce ofdata and research, and information solicited from health care providers inand thehealth statecare andworkforce providers'experts, abilityon tothe provideeffect high-qualityof the health caresecurity underplan on the healthstate's securityprovider plan;community.

This shall include the study and evaluation of the supply of health care providers in the state and providers' ability to provide high-quality health care under the health security plan;

establish and approve changes in coverage services and service standards in the health security plan in h compliance with federal and state law;

g o t hr DD.

g e i k EE.

adopt rules necessary to implement, administer h r i s and monitor the operation of the health security plan;

h , t, FF.

e u g e b l e e h (1) serve on the Native American advisory n d d i = = o h board established pursuant to Subsection A of Section 13 of the el e] 17b ,d i a º e Health Security Act;

er ei n d 18 (2) assist the commission in developing and = =r lt ]e 19w ensuringd implementationm of communication and collaboration a ln ro i(2) 20assist between the commission andin Newdeveloping Mexico Indian nations, tribes t e a t and pueblosd inm the: state;

mb e d s º o t n = .211659.3 s k m 21e - 25 - e a n e d r e 22l (3)u serve[ asA ad contactensuring personimplementation betweenof thecommunication cand ecollaboration rbetween cthe 23 commission and New Mexico Indian nations, tribes and pueblos;pueblos in the state;

e(3) aserve nas ba 24contact andperson ubetween [ (4) ensure that training is provided to the .211659.3commission -and 25New -Mexico staffIndian ofnations, thetribes commission,and whichpueblos; may include training in:

and (4) ensure that training is provided to the staff of the commission, which may include training in:

report at least once annually to the legislature and the governor on the commission's activities and h the operation of the health security plan and include in the u » r annual report:

t h g e l i (1) a summary of information about health care h r i s needs, health care services, health care expenditures, revenues h , e h received and projected revenues and other relevant issues t u g e b l e e , gh relating to the health security plan;

and n d d i = = o h (2) recommendations on methods to control el e] 17b ,d i a º r health care costs and improve access to and the quality of e r = t e nw d 18m a n o health care for state residents, as well as recommendations for =d =m l: ] 19 legislative action;

andb r e t º o t n = .211659.3 s k m e - 26 - e a ln e d r ie 20l HH.u [ A d legislative action;

provide at least one annual training for its t e a t members on health care coverage, policy and financing.HH.

mprovide mat 21least eone dannual rtraining efor 22its SECTIONmembers 12.on health care coverage, policy and financing.

[NEWSECTION MATERIAL12. ] COMMISSION--AUTHORITY.--The c e r c 23 commission has the authority necessary to carry out the powers e a n b 24 and duties pursuant to the Health Security Act.

The[NEW commissionMATERIAL u] [COMMISSION--AUTHORITY.--The retainscommission responsibilityhas forthe itsauthority dutiesnecessary butto maycarry delegateout .211659.3the -powers 26and -duties authoritypursuant to the chiefHealth executiveSecurity officer;Act.

The commission retains responsibility for its duties but may delegate authority to the chief executive officer;

issue subpoenas to persons to appear and testify h before the commission and to produce documents and other g o t hr information relevant to the commission's inquiry and enforce g e i k this subpoena power through an action in a state district h r i s court;

h , t, E.

make reports and recommendations to the e u g e b l e e h legislature;

n d d i = = o h F.

subject to the prohibitions and restrictions of el e] 17b ,d i a º e Section 21 of the Health Security Act, apply for program er i = r t e nw d 18m a n o waivers from any governmental entity if the commission =d =m l: ] 19 determines that the waivers are necessary to ensure the a l r i 20 participation by the greatest possible number of beneficiaries;

b e d s º o t n = .211659.3 s k m e - 27 - e a tn G.e d r e l u [ A d determines that the waivers are necessary to ensure the participation by the greatest possible number of beneficiaries;

applyG. for and accept grants, loans and m m 21 e d r e 22 donations;

capply efor rand caccept 23grants, H.loans and donations;

acquireH. or lease real property and make e a n b 24 improvements on it and acquire by lease or by purchase tangible u [ and intangible personal property;

.211659.3acquire -or 27lease -real I.property and make improvements on it and acquire by lease or by purchase tangible and intangible personal property;

I.

participate as a qualified entity in the h programs of the New Mexico finance authority;

g o t hr N.

enter into agreements with an employer, group or g e i k other plan to provide health care services for the employer's h r i s employees or retirees;

provided, however, that nothing in the h , t, Health Security Act shall be construed to reduce or eliminate e u g e b l e e h services to which the employee or retiree is entitled;

and n d d i = = o h O.

enter into contracts with similar entities or el e] 17b ,d i a º e other states of the United States for the performance of common er i = r t e nw d 18m a n o administrative functions.

=d =m l: ] 19 SECTION 13.

[NEWb MATERIALe ]d ADVISORYs BOARDS.--º o t n = .211659.3 s k m e - 28 - e a ln e d r ie 20l A.u [ A d SECTION 13.

The[NEW commissionMATERIAL] shallADVISORY establishBOARDS.-- theA. following in t e a t matters requiring the expertise and knowledge of the advisory m m 21 e d r e 22 boards' members:

cThe ecommission rshall cestablish 23the (1)following atin leastmatters threerequiring healththe careexpertise providerand eknowledge a n b 24 advisory boards, composed of health care providers to reflect u [ the diversity of health care professions and subspecialties, .211659.3 - 28 - including one primary care provider advisory board;boards' members:

(1) at least three health care provider advisory boards, composed of health care providers to reflect the diversity of health care professions and subspecialties, including one primary care provider advisory board;

h (a) a tribal government advisory board, u » r composed of representatives of the governments of New Mexico t h g e l i Indian nations, tribes and pueblos, to make recommendations to h r i s the commission regarding agreements between the commission and h , e h tribal governments;

and t u g e b l e e , gh (b) at least one advisory board composed n d d i = = o h of members of Indian nations, tribes and pueblos living in New el e] 17b ,d i a º r Mexico tribal jurisdictions and those living off-reservation.

e r = t e nw d 18m a n o B.

In addition to the advisory boards established =d =m l: ] 19 pursuant to Subsection A of this section, the commission may a l r i 20 establish additional advisory boards to assist the commission t e a t in performing its duties.

mb r e t º o t n = .211659.3 s k m 21e - 29 - e a n e d r e 22l C.u [ A d pursuant to Subsection A of this section, the commission may establish additional advisory boards to assist the commission in performing its duties.

ExceptC. for the tribal government advisory board c e r c 23 established pursuant to Subparagraph (a) of Paragraph (3) of e a n b 24 Subsection A of this section, the commission shall not appoint u [ to an advisory board:

.211659.3Except -for 29the -tribal (1)government moreadvisory thanboard twoestablished memberspursuant to Subparagraph (a) of Paragraph (3) of Subsection A of this section, the commission;commission shall not appoint to an advisory board:

(1) more than two members of the commission;

Except for the members of the health care provider advisory board, the health facility advisory board and the advisory boards established pursuant to Paragraph (3) of h Subsection A of this section, no more than two members of any u » r advisory board shall represent or have a controlling interest, t h g e l i direct or indirect, in a health care provider or a health h r i s facility.

h , e h E.

Advisory board members may be paid per diem and t u g e b l e e , gh mileage equal to the rate at which state legislators are n d d i = = o h reimbursed in accordance with the provisions of the Per Diem el e] 17b ,d i a º r and Mileage Act.

e r = t e nw d 18m a n o F.

Staff and technical assistance for advisory =d =m l: ] 19 boards shall be provided by the commission as necessary.

b r e t º o t n = .211659.3 s k m e - 30 - e a ln e d r ie 20l SECTIONu 14.[ A d boards shall be provided by the commission as necessary.

[NEWSECTION MATERIAL14. ] HEALTH CARE DELIVERY t e a t REGIONS.--The commission shall establish health care delivery m m 21 e d r e 22 regions in the state, based on geography and health care c e r c 23 resources.

The[NEW regionsMATERIAL] mayHEALTH haveCARE differentialDELIVERY feeREGIONS.--The schedules,commission eshall aestablish nhealth bcare 24delivery budgets,regions capitalin expenditure allocations or other features to u [ encourage the provisionstate, ofbased healthon caregeography in rural and other .211659.3 - 30 - underserved areas or to tailor otherwise the delivery of health care toresources. fit the needs of a region or a part of a region.

The regions may have differential fee schedules, budgets, capital expenditure allocations or other features to encourage the provision of health care in rural and other underserved areas or to tailor otherwise the delivery of health care to fit the needs of a region or a part of a region.

h B.

The regional councils shall be composed of the g o t hr commission members who live in the region and five other g e i k members who live in the region and are appointed by the h r i s commission.

No more than two noncommission council members h , t, shall have a controlling interest, direct or indirect, in a e u g e b l e e h person providing health care.

The commission shall not appoint n d d i = = o h to a regional council an individual who is, or whose household el e] 17b ,d i a º e contains an individual who is, employed by or is an officer of er i = r t e nw d 18m a n o or has a controlling interest in a person licensed to provide =d =m l: ] 19 health insurance, directly or as an agent of a health insurer.

b e d s º o t n = .211659.3 s k m e - 31 - e a ln e d r ie 20l C.u [ A d health insurance, directly or as an agent of a health insurer.

MembersC. of a regional council may be paid per t e a t diem and mileage equal to the rate at which state legislators m m 21 e d r e 22 are reimbursed in accordance with the provisions of the Per c e r c 23 Diem and Mileage Act.

eMembers of a nregional bcouncil 24may D.be paid per diem and mileage equal to the rate at which state legislators are reimbursed in accordance with the provisions of the Per Diem and Mileage Act.

TheD. regional councils shall hold public hearings u [ to receive comments, suggestions and recommendations from the .211659.3 - 31 - public regarding regional health care needs.

The regional councils shall hold public hearings to receive comments, suggestions and recommendations from the public regarding regional health care needs.

[NEW MATERIAL ] RULEMAKING.-- h A.

The commission shall adopt rules necessary to g o t hr carry out the duties of the commission and the provisions of g e i k the Health Security Act.

h r i s B.

The commission shall not adopt, amend or repeal h , t, any rule affecting a person outside the commission without a e u g e b l e e h public hearing on the proposed action before the commission or n d d i = = o h a hearing officer designated by the commission.

The hearing el e] 17b ,d i a º e officer may be a member of the commission's staff.

The hearing er i = r t e nw d 18m a n o shall be held in a county whose location the commission =d =m l: ] 19 determines would be in the interest of those affected.

Noticeb ae ld rs iº 20o oft then subject= matter.211659.3 ofs thek rule,m thee action- proposed32 to- be t e a tn taken, the time and place of the hearing, the manner in which m m 21 e d r e 22l interested persons may present their views and the method by c e r c 23 which copies of the proposed rule or an amendment or repeal of e a n b 24 an existing rule may be obtained shall be published once at u [ leastA thirtyd daysdetermines priorwould tobe thein hearing date on a publicly .211659.3 - 32 - accessible website that the commissioninterest establishesof andthose maintainsaffected. and in media outlets throughout the state.

Notice of the subject matter of the rule, the action proposed to be taken, the time and place of the hearing, the manner in which interested persons may present their views and the method by which copies of the proposed rule or an amendment or repeal of an existing rule may be obtained shall be published once at least thirty days prior to the hearing date on a publicly accessible website that the commission establishes and maintains and in media outlets throughout the state.

h SECTION 17.

[NEW MATERIAL ] HEALTH SECURITY PLAN.-- u » r A.

The commission shall design the health security t h g e l i plan to provide comprehensive, necessary and appropriate health h r i s care services, including the "minimum essential health h , e h benefits" required under federal and state law.

The commission t u g e b l e e , gh may establish additional preventive health care and primary, n d d i = = o h secondary and tertiary health care for acute and chronic el e] 17b ,d i a º r conditions.

e r = t e nw d 18m a n o B.

=d =m l: ] 19 (1) surgery for cosmetic purposes other than a l r i 20 for reconstructive purposes;

tb r e a t (2)º medicalo examinationst andn medical= reports.211659.3 ms k m 21 e d- r33 - e 22a preparedn fore purchasingd orr renewing life insurance or c e rl cu 23[ participatingA asd a(1) plaintiffsurgery orfor defendantcosmetic inpurposes aother civilthan action for ereconstructive apurposes; n b 24 the recovery or settlement of damages;

(2) medical examinations and umedical [reports (3)prepared orthodonticfor servicespurchasing andor cosmeticrenewing dentallife .211659.3insurance -or 33participating -as servicesa exceptplaintiff thoseor cosmeticdefendant dentalin servicesa necessarycivil action for reconstructivethe purposes.recovery or settlement of damages;

and (3) orthodontic services and cosmetic dental services except those cosmetic dental services necessary for reconstructive purposes.

The health security plan shall ensure that beneficiaries receive comprehensive, high-quality health care h consistent with available revenue and budget constraints.

g o t hr F.

The health security plan shall phase in g e i k eligibility for beneficiaries as their participation becomes h r i s possible through contracts, waivers or federal legislation.

h , t, The health security plan may provide for certain preventive e u g e b l e e h health care to be offered to all New Mexicans regardless of a n d d i = = o h person's eligibility to participate as a beneficiary.

el e] 17b ,d i a º e SECTION 18.

[NEW MATERIAL ] LONG-TERM CARE.-- er i = r t e nw d 18m a n o A.

No later than one year after the effective date =d = l ] 19 of the operation of the health security plan, the commission a l r i 20 shall appoint an advisory "long-term care committee" made up of t e a t representatives of health care consumers, family members of m m: 21 e d r e 22 consumers, providers and administrators to develop a plan for c e r c 23 integrating a continuum of long-term care services and supports e a n b 24 into the health security plan, including home-based care u [ settings as well as facility-based care settings.

Theb e d s º o t n = .211659.3 s k m e - 34 - committeee a n e d r e l u [ A d of the operation of the health security plan, the commission shall reportappoint itsan planadvisory "long-term care committee" made up of representatives of health care consumers, family members of consumers, providers and administrators to develop a plan for integrating a continuum of long-term care services and supports into the commissionhealth nosecurity laterplan, thanincluding onehome-based yearcare fromsettings itsas appointment.well as facility-based care settings.

The committee shall report its plan to the commission no later than one year from its appointment.

Nothing in this section affects long-term care services paid through private insurance or state or federal h programs subject to the provisions of Section 40 of the Health u » r Security Act.

t h g e l i SECTION 19.

[NEW MATERIAL ] BEHAVIORAL HEALTH SERVICES-- h r i s PARITY.-- h , e h A.

The commission shall appoint an advisory t u g e b l e e , gh "behavioral health services committee" made up of n d d i = = o h representatives of behavioral health care consumers, family el e] 17b ,d i a º r members of consumers, providers and administrators to develop a e r = t e nw d 18m a n o systemic plan for coordinating behavioral health services =d =m l: ] 19 within the health security plan.

Theb committeer shalle reportt aº lo rt in 20= its.211659.3 plans tok them commissione no- later35 than- onee yeara fromn itse td r e al tu appointment.[ A d within the health security plan.

CommitteeThe memberscommittee mayshall receivereport perits diemplan andto mthe mcommission 21no elater dthan rone eyear 22from mileageits asappointment. provided in the Per Diem and Mileage Act.

cCommittee emembers rmay creceive 23per B.diem and mileage as provided in the Per Diem and Mileage Act.

TheB. commission shall ensure that the health e a n b 24 security plan conforms to federal and state behavioral health u [ services parity laws.

.211659.3The -commission 35shall -ensure C.that the health security plan conforms to federal and state behavioral health services parity laws.

C.

Nothing in this section limits behavioral health services paid through private insurance or state or federal h health coverage programs.

g o t hr SECTION 20.

[NEW MATERIAL ] MEDICAID COVERAGE-- g e i k AGREEMENTS.--The commission shall enter into appropriate h r i s agreements with the human services department, another state h , t, agency or a federal agency for the purpose of furthering the e u g e b l e e h goals of the Health Security Act.

These agreements may provide n d d i = = o h for certain services provided pursuant to the medicaid program el e] 17b ,d i a º e under Title 19 or Title 21 of the federal Social Security Act er i = r t e nw d 18m a n o and any waiver or provision of that act to be administered by =d =m l: ] 19 the commission to implement the health security plan.

b e d s º o t n = .211659.3 s k m e - 36 - e a ln e d r ie 20l SECTIONu 21.[ A d the commission to implement the health security plan.

[NEWSECTION MATERIAL21. ] HEALTH SECURITY PLAN t e a t COVERAGE--CONDITIONS OF ELIGIBILITY FOR BENEFICIARIES-- m m 21 e d r e 22 EXCLUSIONS.-- c e r c 23 A.

An[NEW individualMATERIAL] isHEALTH eligibleSECURITY asPLAN aCOVERAGE--CONDITIONS beneficiaryOF ofELIGIBILITY eFOR aBENEFICIARIES-- nEXCLUSIONS.-- bA. 24 the health security plan if the individual has been physically u [ present in New Mexico for one year prior to the date of .211659.3 - 36 - application for enrollment in the health security plan and if the individual has a current intention to remain in New Mexico and not to reside elsewhere.

An individual is eligible as a beneficiary of the health security plan if the individual has been physically present in New Mexico for one year prior to the date of application for enrollment in the health security plan and if the individual has a current intention to remain in New Mexico and not to reside elsewhere.

and h (3) individuals covered by the federal active g o t hr and retired military health programs.

g e i k C.

Federal Indian health service or tribally h r i s operated health care agreements, contracts and programs shall h , t, not be brought into coverage except through agreements with:

e u g e b l e e h (1) an Indian nation, tribe or pueblo;

n d d i = = o h (2) a consortium of Indian nations, tribes or el e] 17b ,d i a º e pueblos;

or er i = r t e nw d 18m a n o (3) a federal Indian health service agency =d =m l: ] 19 subject to the approval of any Indian nation, tribe or pueblo a l r i 20 that the agency serves.

b e d s º o t n = .211659.3 s k m e - 37 - e a tn D.e d r e l u [ A d subject to the approval of any Indian nation, tribe or pueblo that the agency serves.

IfD. an individual is ineligible due to the m m 21 e d r e 22 residence requirement, the individual may become eligible by c e r c 23 paying the premium required by the health security plan for e a n b 24 coverage for the period of time up to the date the individual u [ fulfills that requirement if the individual is an employee who .211659.3 - 37 - physically resides and intends to reside in the state because of employment offered to the individual in New Mexico while the individual was residing elsewhere as demonstrated by furnishing that evidence of those facts required by rule adopted by the commission.

If an individual is ineligible due to the residence requirement, the individual may become eligible by paying the premium required by the health security plan for coverage for the period of time up to the date the individual fulfills that requirement if the individual is an employee who physically resides and intends to reside in the state because of employment offered to the individual in New Mexico while the individual was residing elsewhere as demonstrated by furnishing that evidence of those facts required by rule adopted by the commission.

An employer or group plan that provides health care benefits for its employees and members after retirement, including coverage for payment of health care supplementary coverage if the retiree is eligible for medicare, may agree to h participate in the health security plan;

provided that there is u » r no loss of benefits under the retiree health benefit coverage.

t h g e l i An employer or group plan that participates in the health h r i s security plan shall contribute to the health security plan for h , e h the benefit of the retiree, and the agreement shall ensure that t u g e b l e e , gh the health benefit coverage for the retiree shall be restored n d d i = = o h in the event of the retiree's ineligibility for health security el e] 17b ,d i a º r plan coverage.

e r = t e nw d 18m a n o F.

The commission shall prescribe by rule =d =m l: ] 19 conditions under which other persons in the state may be a l r i 20 eligible for coverage pursuant to the health security plan.

b r e t º o t n = .211659.3 s k m e - 38 - e a tn SECTIONe 22.d r e l u [ A d conditions under which other persons in the state may be eligible for coverage pursuant to the health security plan.

[NEWSECTION MATERIAL22. ] HEALTH SECURITY PLAN COVERAGE m m 21 e d r e 22 OF NONRESIDENT STUDENTS.-- c e r c 23 A.

Except[NEW asMATERIAL provided] inHEALTH SubsectionSECURITY BPLAN ofCOVERAGE thisOF eNONRESIDENT aSTUDENTS.-- nA. b 24 section, an educational institution shall purchase coverage u [ under the health security plan for its nonresident students .211659.3 - 38 - through fees assessed to those students covered under the health security plan.

Except as provided in Subsection B of this section, an educational institution shall purchase coverage under the health security plan for its nonresident students through fees assessed to those students covered under the health security plan.

h C.

The commission shall adopt rules to determine g o t hr proof of an individual's eligibility for the health security g e i k plan or a student's proof of nonresident health care coverage.

h r i s SECTION 23.

[NEW MATERIAL ] REMOVING INELIGIBLE PERSONS.-- h , t, The commission shall adopt rules to provide procedures for e u g e b l e e h removing persons no longer eligible for coverage.

n d d i = = o h SECTION 24.

[NEW MATERIAL ] ELIGIBILITY CARD--USE-- el e] 17b ,d i a º e PENALTIES FOR MISUSE.-- er i = r t e nw d 18m a n o A.

A beneficiary shall receive a card as proof of =d =m l: ] 19 eligibility.

Theb carde shalld bes electronicallyº readableo andt an l= r.211659.3 is 20k shallm containe a- photograph39 or- electronic image of the t e a tn beneficiary, information that identifies the beneficiary for m m 21 e d r e 22l treatmentu and[ billing,A paymentd andeligibility. other information the c e r c 23 commission deems necessary.

The usecard ofshall abe beneficiary'selectronically socialreadable eand shall contain a nphotograph bor 24electronic securityimage numberof asthe anbeneficiary, identificationinformation numberthat isidentifies notthe permitted.beneficiary for treatment and billing, payment and other information the commission deems necessary.

uThe [use B.of a beneficiary's social security number as an identification number is not permitted.

B.

A .211659.3 - 39 - beneficiary who lends the beneficiary's card to another and an individual who uses another's card shall be jointly and severally liable to the commission for the full cost of the health care provided to the user.

A beneficiary who lends the beneficiary's card h to another or an individual who uses another's card after being g o t hr determined liable pursuant to Subsection B of this section of a g e i k previous misuse is guilty of a misdemeanor and shall be h r i s sentenced pursuant to the provisions of Section 31-19-1 NMSA h , t, 1978.

A third or subsequent conviction is a fourth degree e u g e b l e e h felony, and the offender shall be sentenced pursuant to the n d d i = = o h provisions of Section 31-18-15 NMSA 1978.

el e] 17b ,d i a º e SECTION 25.

[NEW MATERIAL ] PRIMARY CARE PROVIDER--RIGHT er i = r t e nw d 18m a n o TO CHOOSE--ACCESS TO SERVICES.-- =d =m l: ] 19 A.

Exceptb ase providedd ins theº Workers'o Compensationt an l= r.211659.3 is 20k Act,m ae beneficiary- has40 the- righte to choose a primaryn caree td r e al tu provider.[ A d A.

mExcept mas 21provided ein dthe rWorkers' eCompensation 22Act, B.a beneficiary has the right to choose a primary care provider.

TheB. primary care provider is responsible for c e r c 23 providing health care provider services to the patient except e a n b 24 for services:

uThe [primary (1)care inprovider medicalis emergencies;responsible for providing health care provider services to the patient except for services:

and(1) .211659.3 - 40 - (2) for which a primary care provider determines that specialist services are required, in whichmedical caseemergencies; the primary care provider shall advise the patient of the need for and the type of specialist services.

and (2) for which a primary care provider determines that specialist services are required, in which case the primary care provider shall advise the patient of the need for and the type of specialist services.

The commission shall specify by rule the conditions under which a beneficiary may select a specialist as h a primary care provider.

g o t hr E.

The commission shall establish by rule the g e i k circumstances under which a beneficiary may not self-refer;

h r i s provided that commission rules shall allow a beneficiary to h , t, self-refer to a chiropractic physician, a doctor of oriental e u g e b l e e h medicine or a behavioral health service provider.

n d d i = = o h SECTION 26.

[NEW MATERIAL ] DISCRIMINATION PROHIBITED.--A el e] 17b ,d i a º e health care provider or health facility shall not discriminate er i = r t e nw d 18m a n o against or refuse to furnish health care to a beneficiary on =d =m l: ] 19 the basis of age, race, color, income level, national origin, a l r i 20 religion, gender, sexual orientation, disabling condition or t e a t payment status.

Nothingb ine thisd sections shallº requireo at healthn m= m.211659.3 21s ek dm r e 22- care41 provider- ore healtha facilityn toe provided servicesr to a c e rl cu 23[ beneficiaryA ifd the providerbasis orof facilityage, israce, notcolor, qualifiedincome tolevel, enational aorigin, nreligion, bgender, 24sexual provideorientation, thedisabling neededcondition services or doespayment notstatus. offer them to the u [ general public.

.211659.3Nothing -in 41this -section SECTIONshall 27.require a health care provider or health facility to provide services to a beneficiary if the provider or facility is not qualified to provide the needed services or does not offer them to the general public.

SECTION 27.

The service claim review system shall include an internal and external appeals process for adverse h determinations of service claims, including:

g o t hr (a) a determination that a service is g e i k not medically necessary;

h r i s (b) a denial of coverage for a service h , t, because it is determined to be experimental, investigational or e u g e b l e e h inappropriate;

and n d d i = = o h (c) any other determination that results el e] 17b ,d i a º e in a denial of, or partial payment for, a service claim;

er ei n d 18 (2) expedited appeals of adverse = =r lt ]e 19w determinationsd ofm service claims, including the grounds for a ln ro i(2) 20 expedited appeals andof theadverse timed linesm for: hearing and decisions t e a t on expedited appeals;

mb e d s º o t n = .211659.3 s k m 21e - 42 - e a n e d r e 22l (3)u procedures[ andA evidentiaryd rulesdeterminations relatingof cservice eclaims, rincluding cthe 23grounds tofor expedited appeals and the internaltime appealslines process;for hearing and decisions on expedited appeals;

e(3) aprocedures nand bevidentiary 24rules (4)relating a beneficiary's right to continue to u [ receive services that are the subjectinternal ofappeals anprocess; appeal and that the .211659.3 - 42 - beneficiary was receiving before the beneficiary filed the appeal;

(4) a beneficiary's right to continue to receive services that are the subject of an appeal and that the beneficiary was receiving before the beneficiary filed the appeal;

The commission shall adopt and promulgate rules to provide beneficiaries with a prompt and fair grievance h procedure for resolving patient complaints and for addressing u » r patient questions and concerns relating to any aspect of the t h g e l i health security plan not relating to the service claim review h r i s system.

h , e h C.

Within a reasonable time after enrollment and at t u g e b l e e , gh subsequent periodic times as the commission deems appropriate, n d d i = = o h the health security plan shall provide beneficiaries with el e] 17b ,d i a º r written materials that contain, in a clear, conspicuous and e r = t e nw d 18m a n o readily understandable form, a full disclosure of:

=d =m l: ] 19 (1) the health security plan's covered a l r i 20 services, limitations and exclusions;

b r e t º o t n = .211659.3 s k m e - 43 - e a tn (2)e conditionsd ofr eligibility;e l u [ A d (1) the health security plan's covered services, limitations and exclusions;

m(2) mconditions 21of eeligibility; d r e 22 (3) prior authorization requirements;

c(3) eprior rauthorization crequirements; 23 (4) rights to appeals of adverse service claim e a n b 24 determinations and to grievance procedures, including:

u(4) [rights (a) a beneficiary's right to haveappeals aof .211659.3adverse - 43 - service claim denial,determinations reductionand orto terminationgrievance communicatedprocedures, promptlyincluding: in writing;

(a) a beneficiary's right to have a service claim denial, reduction or termination communicated promptly in writing;

(d) a beneficiary's right to continue to h receive services that are the subject of an appeal and that the g o t hr beneficiary was receiving before the beneficiary filed the g e i k appeal;

and h r i s (e) a beneficiary's right to have the h , t, outcome of an appeal or grievance communicated promptly in e u g e b l e e h writing;

and n d d i = = o h (5) a beneficiary's right to emergency el e] 17b ,d i a º e services that are immediately available without prior er ei n d 18 authorization requirements and appropriate out-of-state = =r lt ]e 19w emergencyd servicesm thata aren noto subjectauthorization torequirements additionaland costsappropriate toout-of-state ad lm r: i 20 the beneficiary.

b e d s º o t n = .211659.3 s k m e - 44 - e a tn D.e d r e l u [ A d emergency services that are not subject to additional costs to the beneficiary.

TheD. superintendent shall adopt and promulgate m m 21 e d r e 22 rules to establish an external appeals process for review of c e r c 23 beneficiary service claim appeals in accordance with the e a n b 24 provisions of the Health Security Act.

uThe [superintendent E.shall adopt and promulgate rules to establish an external appeals process for review of beneficiary service claim appeals in accordance with the provisions of the Health Security Act.

TheE. superintendent shall appoint one or more .211659.3 - 44 - qualified individuals to review external service claim appeals.

The superintendent shall appoint one or more qualified individuals to review external service claim appeals.

Upon completion of the external service claim appeal review, the superintendent shall prepare a detailed h statement of compensation due each appointee and shall present u » r the statement to the beneficiary and the commission.

t h g e l i G.

The decision to approve or deny a service claim h r i s based on a technicality shall be made in a timely manner and h , e h shall not exceed time limits established by rule of the t u g e b l e e , gh commission.

n d d i = = o h H.

The fact of and the specific reasons for a el e] 17b ,d i a º r denial of a service claim shall be communicated promptly in e r = t e nw d 18m a n o writing to both the provider and the beneficiary involved.

=d =m l: ] 19 SECTION 28.

[NEWb MATERIALr ]e QUALITYt OFº CARE--HEALTHo CAREt an l= r.211659.3 is 20k PROVIDERm ANDe HEALTH- FACILITIES--PRACTICE45 STANDARDS.--- t e a tn A.e d r e l u [ A d SECTION 28.

The[NEW commissionMATERIAL] shallQUALITY adoptOF rulesCARE--HEALTH toCARE establishPROVIDER mAND mHEALTH 21FACILITIES--PRACTICE eSTANDARDS.-- dA. r e 22 and implement a quality improvement program that monitors the c e r c 23 quality and appropriateness of health care provided by the e a n b 24 health security plan, including evidence-based medicine, best u [ practices, outcome measurements, consumer education and patient .211659.3 - 45 - safety.

The commission shall adopt rules to establish and implement a quality improvement program that monitors the quality and appropriateness of health care provided by the health security plan, including evidence-based medicine, best practices, outcome measurements, consumer education and patient safety.

Pursuant to the quality improvement h program, the commission shall review and adopt professional u » r practice guidelines developed by state and national medical and t h g e l i specialty organizations, federal agencies for health care h r i s policy and research and other organizations as it deems h , e h necessary to promote the quality and cost-effectiveness of t u g e b l e e , gh health care provided through the health security plan.

n d d i = = o h C.

The commission shall appoint a "health care el e] 17b ,d i a º r practice advisory committee" consisting of health care e r = t e nw d 18m a n o providers, health facilities and other knowledgeable persons to =d =m l: ] 19 advise the commission and staff on health care practice issues.

ab l r ie 20 The committee shall include both health care providers and t eº ao t healthn facilities= from.211659.3 countiess havingk eightym thousande or- fewer46 m- me 21a n e d r e 22l inhabitantsu as[ ofA thed mostadvise recentthe federalcommission decennial census and cstaff eon r c 23 health care providerspractice andissues. health facilities from counties e a n b 24 having more than eighty thousand inhabitants as of the most u [ recent federal decennial census.

The committee mayshall appointinclude .211659.3both -health 46care -providers subcommittees and taskhealth forcesfacilities tofrom addresscounties practicehaving issueseighty thousand or fewer inhabitants as of athe specificmost recent federal decennial census and health care providerproviders disciplineand orhealth afacilities specificfrom kindcounties having more than eighty thousand inhabitants as of healththe facility;most recent federal decennial census.

The committee may appoint subcommittees and task forces to address practice issues of a specific health care provider discipline or a specific kind of health facility;

With the advice of the health care practice advisory committee, the commission shall establish a system of h peer education for health care providers or health facilities u » r determined to be engaging in patterns of practice that do not t h g e l i meet professional practice guidelines established pursuant to h r i s Subsection B of this section.

If the commission determines h , e h that peer education efforts have failed, the commission may t u g e b l e e , gh refer the matter to the appropriate licensing or certifying n d d i = = o h board.

el e] 17b ,d i a º r E.

The commission may provide by rule for the e r = t e nw d 18m a n o assessment of administrative penalties for up to three times =d =m l: ] 19 the amount of excess payments upon a finding that excessive a l r i 20 billing has occurred.

Administrativeb penaltiesr shalle bet º o t n = .211659.3 s k m e - 47 - e a tn depositede ind r e l u [ A d the currentamount schoolof fund.excess payments upon a finding that excessive billing has occurred.

mAdministrative mpenalties 21shall ebe ddeposited rin ethe 22current F.school fund.

AfterF. consultation with the health care practice c e r c 23 advisory committee, the commission may suspend or revoke a e a n b 24 health care provider's or health facility's authorization to be u [ paid for health care provided under the health security plan .211659.3 - 47 - based upon evidence clearly supporting a determination by the commission that the provider or facility engages in patterns of practice, including inappropriate utilization, that do not meet professional practice guidelines established pursuant to Subsection B of this section.

After consultation with the health care practice advisory committee, the commission may suspend or revoke a health care provider's or health facility's authorization to be paid for health care provided under the health security plan based upon evidence clearly supporting a determination by the commission that the provider or facility engages in patterns of practice, including inappropriate utilization, that do not meet professional practice guidelines established pursuant to Subsection B of this section.

h H.

The commission shall report cases of suspected u » r fraud by a health care provider or a health facility to the t h g e l i attorney general for investigation and prosecution.

The office h r i s of the attorney general has independent authority to h , e h investigate and prosecute suspected fraud without a prior t u g e b l e e , gh commission report of fraud.

n d d i = = o h SECTION 29.

[NEW MATERIAL ] HEALTH CARE PROVIDER AND el e] 17b ,d i a º r HEALTH FACILITY RIGHTS--DISPUTE RESOLUTION--GRIEVANCE e r = t e nw d 18m PROCEDURES--RULEMAKING.--a =n =o lPROCEDURES--RULEMAKING.-- ]d 19m A.:

b r e t º o t n = .211659.3 s k m e - 48 - e a n e d r e l u [ A d A.

a l r i 20 (1) adopt a gag rule or practice that t e a t prohibits a health care provider or health facility from m m 21 e d r e 22 discussing a treatment option with a beneficiary even if the c e r c 23 health security plan does not approve of the option;

e a n b 24 (2) include in any of its contracts with u [ health care providers or health facilities any provisions that .211659.3 - 48 - offer an inducement, financial or otherwise, to provide less than medically necessary services to a beneficiary;

If the health security plan proposes to make an adverse determination affecting the participation of a health care provider or health care facility in the health security h plan, it shall explain in writing the rationale for its u » r proposed adverse determination and deliver reasonable advance t h g e l i written notice to the provider or facility prior to the h r i s proposed effective date of the termination.

h , e h C.

The commission shall adopt and promulgate rules t u g e b l e e , gh to implement a dispute resolution system and include in each n d d i = = o h contract with a health care provider or a health facility a el e] 17b ,d i a º r dispute resolution provision to permit the provider or facility e r = t e nw d 18m a n o to dispute:

=d =m l: ] 19 (1) a denial of, or partial payment for, a a l r i 20 service that the health care provider or health facility has t e a t rendered to a beneficiary;

orb mr me 21t eº do rt en 22= (2).211659.3 thes existencek ofm adequatee cause- to49 c- e ra cn 23e terminated ther provider'se orl facility'su participation[ inA thed e(1) a ndenial bof, 24or planpartial whenpayment for, a service that the terminationhealth iscare madeprovider foror cause.health facility has rendered to a beneficiary;

uor [(2) D.the existence of adequate cause to terminate the provider's or facility's participation in the plan when the termination is made for cause.

TheD. commission shall adopt and promulgate rules .211659.3 - 49 - to implement procedures pursuant to which a health care provider or a health facility may file a grievance relating to administration of the plan.

The commission shall adopt and promulgate rules to implement procedures pursuant to which a health care provider or a health facility may file a grievance relating to administration of the plan.

or (2) the choice of health care providers and h health facilities under the plan.

g o t hr E.

As used in this section, "adverse determination" g e i k means any of the following actions against a health care h r i s provider or health facility:

h , t, (1) restriction of or termination from e u g e b l e e h participation in the health security plan;

n d d i = = o h (2) the recoupment of payment;

or el e] 17b ,d i a º e (3) the assessment of an administrative er i = r t e nw d 18m a n o penalty.

=d =m l: ] 19 SECTION 30.

[NEWb MATERIALe ]d HEALTHs SECURITYº PLANo BUDGET--t an l= r.211659.3 is 20k PREMIUMm RATES--EMPLOYERe CONTRIBUTIONS.--- t50 - e a tn A.e d r e l u [ A d SECTION 30.

Annually,[NEW theMATERIAL] commissionHEALTH shallSECURITY developPLAN aBUDGET-- healthPREMIUM mRATES--EMPLOYER mCONTRIBUTIONS.-- 21A. e d r e 22 security plan budget.

TheAnnually, budget shall be the commission'scommission cshall edevelop r c 23 recommendation for the total amount to be spent by the plan for e a n b 24 covered health caresecurity servicesplan inbudget. the next fiscal year.

uThe [budget B.shall be the commission's recommendation for the total amount to be spent by the plan for covered health care services in the next fiscal year.

TheB. superintendent shall adopt and promulgate .211659.3 - 50 - rules for the review of proposed health security plan premium rates and employer contribution rates proposed by the commission.

The superintendent shall adopt and promulgate rules for the review of proposed health security plan premium rates and employer contribution rates proposed by the commission.

h (4) procedures pursuant to which the g o t hr commission or a member of the public may obtain a g e i k redetermination of the superintendent's findings;

and h r i s (5) procedures pursuant to which the h , t, commission or a member of the public may appeal a e u g e b l e e h redetermination of the superintendent's findings in a court of n d d i = = o h competent jurisdiction.

el e] 17b ,d i a º e C.

In developing the health security plan budget, er i = r t e nw d 18m a n o the commission shall provide that credit be taken in the budget =d =m l: ] 19 for all revenues produced for health care in the state pursuant a l r i 20 to any law other than the Health Security Act.

b e d s º o t n = .211659.3 s k m e - 51 - e a tn D.e d r e l u [ A d for all revenues produced for health care in the state pursuant to any law other than the Health Security Act.

TheD. health security plan shall include a maximum m m 21 e d r e 22 amount or percentage for administrative costs, and this c e r c 23 maximum, if a percentage, may change in relation to the total e a n b 24 costs of services provided under the health security plan.

ForThe uhealth [security theplan sixthshall andinclude subsequenta calendarmaximum yearsamount ofor operationpercentage offor theadministrative .211659.3costs, -and 51this -maximum, healthif securitya plan,percentage, administrativemay costschange shallin notrelation exceedto fivethe percenttotal costs of services provided under the health security planplan. budget.

For the sixth and subsequent calendar years of operation of the health security plan, administrative costs shall not exceed five percent of the health security plan budget.

The commission shall negotiate payment with providers as provided by rule and in accordance with federal antitrust h law.

In the event that negotiation fails to develop an g o t hr acceptable payment plan and except as otherwise provided in g e i k federal law, the disputing parties shall submit the dispute for h r i s resolution pursuant to Section 29 of the Health Security Act.

h , t, B.

Supplemental payment rates may be adopted to e u g e b l e e h provide incentives to help ensure the delivery of needed health n d d i = = o h care in rural and other underserved areas throughout the state.

el e] 17b ,d i a º e C.

An annual percentage increase in the amount er ei n d 18 allocated for provider payments in the budget shall be no = = l ] 19 greater than the annual percentage increase in the consumer a l r i 20 price index for medical care prices published by the bureau of t e aw td labor statistics of the federal department of labor using the m ma 21n eo dallocated rfor eprovider 22payments year prior to the year in which the healthbudget securityshall planbe isno cd em r: c 23 implemented as the baseline year.

Theb annuale limitationd ins º o t n = .211659.3 s k m e - 52 - e a n be 24d thisr subsectione mayl beu adjusted[ upA ord downgreater than the annual percentage increase in the consumer price index for medical care prices published by the commissionbureau uof [labor basedstatistics onof athe showingfederal department of speciallabor andusing unusualthe circumstancesyear prior to the year in awhich .211659.3the -health 52security -plan hearingis beforeimplemented as the commission.baseline year.

The annual limitation in this subsection may be adjusted up or down by the commission based on a showing of special and unusual circumstances in a hearing before the commission.

A health facility shall negotiate an annual h operating budget with the commission.

The operating budget g o t hr shall be based on a base operating budget of past performance g e i k and projected changes upward or downward in costs and services h r i s anticipated for the next year.

If a negotiated annual h , t, operating budget is not agreed upon, a health facility shall e u g e b l e e h submit the budget to dispute resolution pursuant to Section 29 n d d i = = o h of the Health Security Act.

An annual percentage increase in el e] 17b ,d i a º e the amount allocated for a health facility operating budget er i = r t e nw d 18m a n o shall be no greater than the change in the annual consumer =d =m l: ] 19 price index for medical care prices, published annually by the a l r i 20 bureau of labor statistics of the federal department of labor.

tb e ad ts Theº annualo limitationt inn this= subsection.211659.3 mays bek adjustedm upe or- m53 m- 21e a n e d r e 22l downu by[ theA commissiond basedprice onindex afor showingmedical ofcare specialprices, andpublished cannually eby rthe cbureau 23of unusuallabor circumstancesstatistics inof athe hearingfederal beforedepartment theof commission.labor.

eThe annual limitation in this subsection may be adjusted up or down by the commission based on a nshowing bof 24special B.and unusual circumstances in a hearing before the commission.

SupplementalB. payment rates may be adopted to u [ provide incentives to help ensure the delivery of needed health .211659.3 - 53 - care services in rural and other underserved areas throughout the state.

Supplemental payment rates may be adopted to provide incentives to help ensure the delivery of needed health care services in rural and other underserved areas throughout the state.

The commission may establish a copayment h schedule if a required copayment is determined to be an u » r effective cost-control measure;

provided that the commission t h g e l i shall not require a member of an Indian nation, tribe or pueblo h r i s to make copayments.

A copayment shall not be required for h , e h preventive health care services, as the commission defines t u g e b l e e , gh "preventive health care services" by rule in accordance with n d d i = = o h state and federal law.

When a copayment is required, a health el e] 17b ,d i a º r care provider or health facility shall not waive it, and if it e r = t e nw d 18m a n o remains uncollected, the provider or facility shall demonstrate =d =m l: ] 19 a good-faith effort to collect the copayment.