New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 22 - MANAGED HEALTH CARE PLAN COMPLIANCE › Section 13.10.22.12 - CONTRACTS WITH PROVIDERS IN THE STATE OF NEW MEXICO

Current through Register Vol. 35, No. 13, July 16, 2024
This section shall apply only to health care professionals
				  practicing in and health care facilities located in the state of New
				  Mexico.
A. A health care insurer
				shall, either directly or indirectly, enter into contracts with participating
				professionals and health care facilities through which health care services are
				provided on a recurring basis to its covered persons. The health care insurer
				shall file an annual certificate with the superintendent certifying that all
				health care professional contracts and contracts with health care facilities
				located in the state of New Mexico through which health care services are being
				provided on a recurring basis meet the criteria of this section.
B. Each contract shall contain a description
				of the specific health care services for which the health care professional or
				health care facility will be responsible, including any limitations or
				conditions on such services.
C.
				Each contract shall contain the specific hold harmless provision specifying
				protection of covered persons set forth as follows: "Health care
				professional/health care facility agrees that in no event, including but not
				limited to nonpayment by the health insuring corporation, insolvency of the
				health insuring corporation, or breach of this agreement, shall health care
				professional/health care facility bill, charge, collect a deposit from, seek
				remuneration or reimbursement from, or have any recourse against, a subscriber,
				enrollee, covered person, or person acting on behalf of the covered person, for
				health care services provided pursuant to this agreement. This does not
				prohibit health care professional/health care facility from collecting
				co-insurance, deductibles, or copayments as specifically provided in the
				evidence of coverage, or fees for uncovered health care services delivered on a
				fee-for-service basis to persons referenced above, nor from any recourse
				against the health insuring corporation or its successor."
D. Each contract shall contain a provision
				clearly stating the rights and responsibilities of the MHCP, and of the
				contracted health care professionals and health care facilities, with respect
				to administrative policies and programs, including, but not limited to, payment
				systems, utilization review, quality assessment and improvement programs,
				credentialing, confidentiality requirements, and any applicable federal or
				state programs.
E. Each contract
				shall contain a provision regarding the availability and confidentiality of
				those health records maintained by health care professionals and health care
				facilities to monitor and evaluate the quality of care, to conduct evaluations
				and audits, and to determine on a concurrent or retrospective basis the medical
				necessity and appropriateness of health care services provided to covered
				persons. The provision shall include terms requiring the health care
				professional or health care facility to make these health records available to
				appropriate state and federal authorities involved in assessing the quality of
				care or in investigating the grievances or complaints of covered persons, and
				requiring the health care professional or health care facility to comply with
				applicable state and federal laws related to the confidentiality of medical or
				health records.
F. Each contract
				shall provide that contractual rights and responsibilities may not be assigned
				or delegated by the provider without the prior written consent of the
				contracting MHCP.
G. Each contract
				shall contain a provision requiring the health care professional or health care
				facility to maintain adequate professional liability and malpractice insurance.
				The provision shall also require the health care professional or health care
				facility to notify the health care insurer or MHCP not more than ten days after
				the provider's receipt of notice of any reduction or cancellation of such
				coverage.
H. Each contract shall
				require the health care professional or health care facility to observe,
				protect, and promote the rights of covered persons as patients.
I. Each contract shall require the health
				care professional or health care facility to provide health care services
				without discrimination on the basis of a patient's participation in the health
				care plan, age, gender, ethnicity, religion, sexual orientation, health status,
				or disability, and without regard to the source of payments made for health
				care services rendered to a patient. This requirement shall not apply to
				circumstances when the health care professional or health care facility
				appropriately does not render services due to limitations arising from the
				health care professional's or health care facility's lack of training,
				experience, or skill, or due to licensing restrictions. Each contract shall
				require the health care insurer or MHCP to provide interpreters for limited
				English proficient (LEP) individuals and interpretative services for patients
				who qualify under the Americans with Disabilities Act (ADA). Such interpretive
				services will be made available to provider's office at no cost to the
				provider.
J. Each contract shall
				contain a provision detailing the specifics of any obligation on the health
				care professional or health care facility to provide, or to arrange for the
				provision of, covered health care services twenty-four hours per day, seven
				days per week.
K. Each contract
				shall set forth procedures for the resolution of disputes arising out of the
				contract.
L. Each contract shall
				state that the hold harmless provision required by Subsection C of 13.10.22.12
				NMAC shall survive the termination of the contract regardless of the reason for
				the termination, including the insolvency of the health care insurer or
				MHCP.
M. Each contract shall
				provide that those terms used in the contract and that are defined by New
				Mexico statutes and division regulations will be used in the contract in a
				manner consistent with any definitions contained in said laws or
				regulations.
N. A health care
				insurer or MHCP is prohibited from including the following provisions in any of
				its contracts with health care professionals or health care facilities:
(1) offer an inducement, financial or
				otherwise, to provide less than medically necessary services to a covered
				person;
(2) penalize a health care
				professional or health care facility that assists a covered person to seek a
				reconsideration of the health care insurer's or MHCP's decision to deny or
				limit benefits to the covered person;
(3) prohibit a participating health care
				professional from discussing treatment options with covered persons
				irrespective of the health care insurer's or MHCP's position on treatment
				options, or from advocating on behalf of a patient or patients within the
				utilization review or grievance processes established by the MHCP or a person
				contracting with the health care insurer or MHCP;
(4) prohibit a participating health care
				professional from using disparaging language or making disparaging comments
				when referring to the health care insurer or MHCP; or