N.M. Stat. § 59A-46-2 — NM Code / Chapter 59A / Article 46 / Section 59A-46-2
§ 59A-46-2. Definitions
Status: in_force

As used in the Health Maintenance Organization Law:

A. “ basic health care services ” means medically necessary services consisting of preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory, diagnostic and therapeutic radiological services and services of pharmacists and pharmacist clinicians;

B. “ capitated basis ” means fixed per member per month payment or percentage of premium payment wherein the provider assumes the full risk for the cost of contracted services without regard to the type, value or frequency of services provided and includes the cost associated with operating staff model facilities;

C. “ carrier ” means a health maintenance organization, an insurer, a nonprofit health care plan or other entity responsible for the payment of benefits or provision of services under a group contract;

D. “ copayment ” means an amount an enrollee must pay in order to receive a specific service that is not fully prepaid;

E. “ credentialing ” means the process of obtaining and verifying information about a provider and evaluating that provider when that provider seeks to become a participating provider;

F. “ deductible ” means the amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment;

G. “ direct services ” means services rendered to an individual by a carrier or a health care practitioner, facility or other provider, which services include case management, disease management, health education and promotion, preventive services, quality incentive payments to providers and any proportion of an assessment that covers services rather than administration and for which a carrier does not receive a tax credit pursuant to the Medical Insurance Pool Act; provided that “direct services” does not include care coordination, utilization review or management or any other activity designed to manage utilization or services;

H. “ enrollee ” means an individual who is covered by a health maintenance organization;

I. “ evidence of coverage ” means a policy, contract or certificate showing the essential features and services of the health maintenance organization coverage that is given to the subscriber by the health maintenance organization or by the group contract holder;

J. “ extension of benefits ” means the continuation of coverage under a particular benefit provided under a contract or group contract following termination with respect to an enrollee who is totally disabled on the date of termination;

K. “ grievance ” means a written complaint submitted in accordance with the health maintenance organization's formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization relative to the enrollee;

L. “ group contract ” means a contract for health care services that by its terms limits eligibility to members of a specified group and may include coverage for dependents;

M. “ group contract holder ” means the person to whom a group contract has been issued;

N. “ health care services ” means any services included in the furnishing to any individual of medical, mental, dental, pharmaceutical or optometric care or hospitalization or nursing home care or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing or healing human physical or mental illness or injury;

O. “ health maintenance organization ” means a person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments or deductibles, including a carrier that issues:

(1) a short-term contract;

(2) an excepted benefit policy or contract intended to supplement major medical coverage, including medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies; or

(3) a policy for long-term care or disability income;

P. “ health maintenance organization agent ” means a person who solicits, negotiates, effects, procures, delivers, renews or continues a policy or contract for health maintenance organization membership or who takes or transmits a membership fee or premium for such a policy or contract, other than for that person, or a person who advertises or otherwise makes any representation to the public as such;

Q. “ individual contract ” means a contract for health care services issued to and covering an individual and it may include dependents of the subscriber;

R. “ insolvent ” or “ insolvency ” means that the organization has been declared insolvent and placed under an order of liquidation by a court of competent jurisdiction;

S. “ managed hospital payment basis ” means agreements in which the financial risk is related primarily to the degree of utilization rather than to the cost of services;

T. “ net worth ” means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt;

U. “ participating provider ” means a provider as defined in Subsection Z of this section that, under an express contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization;

V. “ person ” means an individual or other legal entity;

W. “ pharmacist ” means a person licensed as a pharmacist pursuant to the Pharmacy Act; 1

X. “ pharmacist clinician ” means a pharmacist who exercises prescriptive authority pursuant to the Pharmacist Prescriptive Authority Act;

Y. “ premium ” means all income received from individuals and private and public payers or sources for the procurement of health coverage, including capitated payments, self-funded administrative fees, self-funded claim reimbursements, recoveries from third parties or other carriers and interests less any premium tax paid pursuant to Section 59A-6-2 NMSA 1978 and fees associated with participating in a health insurance exchange that serves as a clearinghouse for insurance;

Z. “ provider ” means a physician, pharmacist, pharmacist clinician, hospital or other person licensed or otherwise authorized to furnish health care services;

AA. “ replacement coverage ” means the benefits provided by a succeeding carrier;

BB. “ short-term contract ” means a nonrenewable health maintenance organization contract covering a resident of the state, regardless of where the contract is delivered, that:

(1) has a maximum specified duration of not more than three months after the effective date of the contract; and

(2) is issued only to individuals who have not been enrolled in a health maintenance organization contract that provides the same or similar nonrenewable coverage from any carrier within the three months preceding enrollment in the short-term contract;

CC. “ subscriber ” means an individual whose employment or other status, except family dependency, is the basis for eligibility for enrollment in the health maintenance organization or, in the case of an individual contract, the person in whose name the contract is issued; and

DD. “ uncovered expenditures ” means the costs to the health maintenance organization for health care services that are the obligation of the health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organization's insolvency and for which no alternative arrangements have been made that are acceptable to the superintendent.