§ 59A-22A-4 — Preferred provider arrangements

Notwithstanding any provisions of law to contrary, any health care insurer may enter into preferred provider arrangements. A. Such arrangements shall: (1) establish the amount and manner of payment to the preferred provider. Such amount and manner of payment may include capitation payments for preferred providers; (2) include mechanisms which are designed to minimize the cost of the health benefit plan; for example: (a) the review or control of utilization of health care services; or (b) procedures for determining whether health care services rendered are medically necessary; and (3) assure reasonable access to covered services available under the preferred provider arrangement and an adequate number of preferred providers to render those services. B. Such arrangements shall not unfairly deny health benefits for medically necessary covered services. C. If an entity enters into a contract providing covered services with a health care provider, but is not engaged in activities which would require it to be licensed as a health care insurer, such entity shall file with the superintendent information describing its activities, a description of the contract or agreement it has entered into with the health care providers, and such other information as is required by the provisions of the Health Care Benefits Jurisdiction Act [59A-15-14 to 59A-15-19 NMSA 1978] and any regulations promulgated under its authority. Employers who enter into contracts with health care providers for the exclusive benefit of their employees and dependents are subject to the Health Care Benefits Jurisdiction Act and are exempt from this requirement only to the extent required by federal law.

Legislative History

1978 Comp., § 59A-22A-4, enacted by Laws 1993, ch. 320, § 62.