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Consumer assistance; consumer advisory boards; ombudsman office; reports to consumers; superintendent's orders to protect consumers – N.M. Stat. Ann. §59A-57-5

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New Mexico has adopted a Patient Protection Act.  The Act provides that all individuals enrolled in a managed care plan have the right to be treated fairly, and are due high quality health care services.  The law also calls for insurers to adopt regulations to implement its provisions providing for utilization review, quality improvement, and health care standards. 

The regulations must provide that at the minimum:

  1. Managed care companies provide a summary of benefits and exclusions, premium information, and provider listings in clear, understandable language.  The information must also include patients’ rights, grievance procedures, and appeal rights.
  2. Provide appropriate, accessible services in a timely manner.
  3. Provides a variety of providers and adequate staff. The providers must provide all basic health services.  If in network providers are not available, accessibility to out of network providers for medically necessary procedures.
  4. Emergency services must be provided without prior authorization.
  5. The plan must address linguistic and cultural diversity of its enrollees.
  6. The care plan must adopt fair and reasonable grievance procedures.
  7. The care plan must adopt a complete utilization review program, with full disclosure of a claim denial given to the enrollee. 
  8. The care plan must adopt and implement a quality improvement program that monitors quality of care.

Current as of June 2015