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SANTA FE, N.M.-A comprehensive managed care regulation for New Mexico that apparently satisfies major segments of the state's health care market took effect last Saturday.
While New Mexico has regulated health maintenance organizations since 1985, this more broadly covers all managed care organizations (BI, Nov. 4, 1996).
New regulations deal with patients' rights and responsibilities; basic health care services to be provided; access to health care services; prescription drugs; licensing of health care professionals and facilities; and information to be provided to enrollees.
The regulation also calls for the establishment of a grievance system, outlines complaint procedures and details circumstances under which coverage can be terminated.
Among other provisions, it also calls for managed health care plans to establish utilization management programs and continuous quality improvement programs.
Certain provisions of the original proposal, which was developed last year, had been criticized. Some of the rules that drew objections were removed, some were revised and some remained after the work of a special task force.
"I don't think there were drastic changes," however, said Gloria Tristani, chairman of the three-person State Corporation Commission. The commission oversees the New Mexico Insurance Department, which developed the regulation. "It's not that different from the original rule but somewhat refined," said Ms. Tristani.
J.D. Bullington, vp-government affairs for the Assn. of Commerce & Industry of New Mexico in Albuquerque, which operates as the state Chamber of Commerce, said his impression is the final provisions "appear to represent all interests fairly."
Lynn Pitcher, director of government and media relations for Blue Cross & Blue Shield of New Mexico, based in Albuquerque, said her organization "is pleased with the final version, and we feel they will protect consumers. We appreciate the Department of Insurance and State Corporation Commission's diligence in working on the regulations with the industry."
Among the original provisions that came under fire was one that called for having at least two primary care physicians available no more than 45 miles or 45 minutes' average drive time from where a majority of the population lives. This was considered infeasible in a rural state such as New Mexico.
The provision was changed to say in population areas of 50,000 or more residents, two primary care physicians must be available no more than 20 miles or 20 minutes' average driving time for 90% of the enrolled population, while in less densely populated areas, the criteria is 60 miles or 60 minutes away.