HISTORY OF INSURANCE LAW LEGISLATION RELATING TO DOCTORS OF ORIENTAL MEDICINE IN NEW MEXICO

The healthcare and medical insurance laws in New Mexico, pertaining to the practice of acupuncture and oriental medicine, are among the best in the nation. The New Mexico Acupuncture and Oriental Medicine Practice Act defines "oriental medicine" as a "system of primary health care" [61-14A-3.E.] and defines a “doctor of oriental medicine” as a “physician” and as a “primary care provider” [61-14A-3.C.].

Below is a brief history of the legislation that created the laws that govern medical insurance reimbursement for D.O.M.s, followed by the relevant excerpts from New Mexico law. A comprehensive explanation of the various laws can be found under the menu item "Laws" and then "Insurance Laws."

 

HISTORY OF LEGISLATION

In 1989, the first major event to shape medical insurance reimbursement for our profession was the passage of Senate Bill 88. Our services were covered by Indemnity Health Insurance and we were defined as “practitioners of the healing arts” along with medical doctors, osteopaths and dentists. The profession was apprehensive about legislation and felt that “rocking the boat” was risky and expensive. So Drs. Angelique Cook, Lou Talento and Glenn Wilcox asked Senator Tito Chavez to sponsor the bill and went to the Capitol to lobby it. A professional lobbyist could not be afforded. The greenhorns were successful.

SB 88 was Signed by: Governor Gary Carruthers
Sponsored by: Senator Tito Chavez
Drafted by: Dr. Glenn Wilcox
Initiated by: Dr. Angelique Cook-Lowry, Dr. Lou Talento and Dr. Glenn Wilcox
Professional Lobbyist: None
Lobbied by: Dr. Angelique Cook-Lowry, Dr. Lou Talento and Dr. Glenn Wilcox

59A-22-32. Freedom of choice of hospital, practitioner.
A. Within the area and limits of coverage offered an insured and selected by him in the application for insurance, the right of any person to exercise full freedom of choice in the selection of any hospital for hospital care or of any practitioner of the healing arts or optometrist, psychologist, podiatrist, certified nurse-midwife, registered lay midwife or registered nurse in expanded practice, as defined in Subsection B of this section, for treatment of any illness or injury within his scope of practice shall not be restricted under any new policy of health insurance, contract or health care plan issued after June 30, 1967 in this state or in the processing of any claim thereunder. Any person insured or claiming benefits under any such health insurance policy, contract or health care plan providing within its coverage for payment of service benefits or indemnity for hospital care or treatment of persons for the cure or correction of any physical or mental condition shall be deemed to have complied with the requirements of the policy, contract or health care plan as to submission of proof of loss upon submitting written proof supported by the certificate of any hospital currently licensed by the health and environment department [department of health] or any practitioner of the healing arts or optometrist, psychologist, podiatrist, certified nurse-midwife, registered lay midwife or registered nurse in expanded practice.
B. As used in this section:
(1) "hospital care" means hospital service provided through a hospital which is maintained by the state or any political subdivision of the state or any place which is currently licensed as a hospital by the health and environment department [department of health] and has accommodations for resident bed patients, a licensed professional registered nurse always on duty or call, a laboratory and an operating room where surgical operations are performed, but the term does not include a convalescent or nursing or rest home;
(2) "practitioner of the healing arts" means any person holding a license or certificate provided for in Chapter 61, Article 4, 5, 6, 10 or 14A (Editor’s note: 14A is the DOM licensing law) NMSA 1978 authorizing the licensee to offer or undertake to diagnose, treat, operate on or prescribe for any human pain, injury, disease, deformity or physical or mental condition;
(3) "optometrist" means any person holding a license provided for in Chapter 61, Article 2 NMSA 1978;
(4) "podiatrist" means any person holding a license provided for in Chapter 61, Article 8 NMSA 1978;
(5) "psychologist" is one who is duly licensed or certified in the state where the service is rendered and has a doctoral degree in psychology and has had at least two years clinical experience in a recognized health setting or has met the standards of the national register of health service providers in psychology;
(6) "certified nurse-midwife" means any person licensed by the board of nursing as a registered nurse and who is registered with the health services division of the health and environment department [department of health] as a certified nurse-midwife;
(7) "registered lay midwife" means any person who practices lay midwifery and is registered as a registered lay midwife by the health services division of the health and environment department [department of health]; and
(8) "registered nurse in expanded practice" means any person licensed by the board of nursing as a registered nurse approved for expanded practice pursuant to the Nursing Practice Act [61-3-1 to 61-3-30 NMSA 1978] as a certified nurse practitioner; certified registered nurse anesthetist; certified clinical nurse specialist in psychiatric mental health nursing or clinical nurse specialist in private practice and who has a master's degree or doctorate in a defined clinical nursing specialty and is certified by a national nursing organization.
C. This section shall apply to any such policy which is delivered or issued for delivery in this state on or after July 1, 1979 and to any existing group policy or plan on its anniversary or renewal date after June 30, 1979 or at expiration of the applicable collective bargaining contract, if any, whichever is later.

 

In 1991, The Association initiated two bills relating to medical insurance reimbursement. SB 179 added us to the Medicaid statute. SB 180 mandated coverage in the HMO and Non Profit Health Care Plans (Blue Cross Blue Shield) statutes.

SB 179 and SB 180 were Signed by: Governor Bruce King
Sponsored by: Senator Tito Chavez
Drafted by: Dr. Glenn Wilcox, Association President
Initiated by: The Association
Professional Lobbyist: Peter Mallery
Lobbied by: Dr. Angelique Cook-Lowry, Dr. Jonas Skardis, Dr. Lou Talento and Dr. Glenn Wilcox

27-2-12. Medical assistance programs.
Consistent with the federal act and subject to the appropriation and availability of federal and state funds, the medical assistance division of the human services department may by regulation provide medical assistance, including the services of licensed doctors or oriental medicine and licensed chiropractors, to persons eligible for public assistance programs under the federal act.

59A-47-28.2. Doctor of oriental medicine discrimination prohibited.
All individual and group subscriber contracts delivered or issued for delivery in New Mexico by a nonprofit health care plan that, on a service or indemnity basis, or both, provide for treatment of persons for the prevention, cure or correction of any illness or physical or mental condition, shall not contain any provisions that exclude a licensed doctor of oriental medicine as a provider of oriental medical services and shall not discriminate in the reimbursement levels for such services between types of licensed health care providers.

59A-46-36. Doctor of oriental medicine discrimination prohibited.
Doctors of oriental medicine as a class of licensed providers willing to meet the terms and conditions offered by a health maintenance organization shall not be excluded from a health maintenance organization.

 

In 1997, House Bill 856 mandated vehicle medical payment insurance for the services of D.O.M.s.

HB 856 was Signed by: Governor Gary Johnson.
Sponsored by: Representative Rick Miera
Drafted by: Dr. Glenn Wilcox, BAOM Chairman
Initiated by: The Board of Acupuncture and Oriental Medicine and The Association
Professional Lobbyist: Peter Mallery
Lobbied by: Dr. David Canzone, Dr. Jonas Skardis and Dr. Glenn Wilcox

59A-7-7. "Vehicle insurance" defined
"Vehicle" insurance is insurance covering:
A. Physical Damage. Insurance against loss of or damage to any land vehicle or aircraft or any draft or riding animal resulting from or incident to ownership, maintenance or use of any such vehicle, aircraft or animal;
B. Public Liability and Property Damage. Insurance against any hazard or cause, and against any loss, liability or expense resulting from or incident to ownership, maintenance or use of any such vehicle, aircraft or animal;
C. Cargo. Insurance against loss of or damage to property contained in a vehicle or being loaded or unloaded therein or therefrom or incident to the ownership, maintenance or use of any such vehicle, aircraft or animal; and
D. Medical Payments. Insurance for payment on behalf of the injured party or for reimbursement of the insured for payment, irrespective of legal liability of the insured, of medical, hospital, surgical and disability benefits, to persons injured and funeral and death benefits to dependents, beneficiaries or personal representatives of persons killed as the result of an accident, resulting from or incident to ownership, maintenance or use of any such vehicle, aircraft or animal. Such coverage shall not be deemed to be "health" insurance for purposes of the Insurance Code [this chapter, except Articles 16A, 23A, 23B, 24A and Section 59A-33-14 NMSA 1978].

59A-32-22. Freedom of choice; doctor of oriental medicine.
A. Within the areas and limits of coverage offered an insured and selected by him in the application for insurance, for vehicle insurance medical payments as defined in Subsection D of Section 59A‑7‑7 NMSA 1978, the right of any person to exercise full freedom of choice in the selection of any licensed doctor of oriental medicine for treatment within his scope of practice shall not be restricted under any new policy of vehicle insurance issued after July 1, 1997 in this state or in the processing of any claim made pursuant to that policy. Any person insured for claiming benefits under the medical payments portion of such vehicle insurance policy providing within its coverage for payment of benefits or indemnity for any condition or circumstance, described in Subsection D of Section 59A‑7‑7 NMSA 1978 shall be deemed to have complied with the requirements of the policy as to submission of proof of loss upon submitting written proof supported by any doctor of oriental medicine.
B. As used in this section, "doctor of oriental medicine" means a person licensed as a doctor of oriental medicine pursuant to the Acupuncture and Oriental Medicine Practice Act [Chapter 61, Article 14A NMSA 1978].

 

During the 1990s, the D.O.M.s mentioned above worked with the support of The OMA to get oriental medical services covered by other types of medical reimbursement in the New Mexico statutes. Inclusion in the Workers' Compensation Act is one example and the Regulations Governing Managed Care is another. Inclusion in the Health Care Benefits Jurisdiction Act is another important law.

52-1-49. Medical and related benefits; selection of health care provider; artificial members.
A. After an injury to a worker and subject to the requirements of the Workers' Compensation Act [this article], and continuing as long as medical or related treatment is reasonably necessary the employer shall, subject to the provisions of this section, provide the worker in a timely manner reasonable and necessary health care services from a health care provider.
B. The employer shall initially either select the health care provider for the injured worker or permit the injured worker to make the selection. Subject to the provisions of this section, that selection shall be in effect during the first sixty days from the date the worker receives treatment from the initially selected health care provider.
C. After the expiration of the initial sixty-day period set forth in Subsection B of this section, the party who did not make the initial selection may select a health care provider of his choice. Unless the worker and employer otherwise agree, the party seeking such a change shall file a notice of the name and address of his choice of health care provider with the other party at least ten days before treatment from that health care provider begins. The director shall adopt rules and regulations governing forms, which employers shall post in conspicuous places, to enable this notice to be promptly and efficiently provided. This notice may be filed on or after the fiftieth day of the sixty-day period set forth in Subsection B of this section.
D. If a party objects to the choice of health care provider made pursuant to Subsection C of this section, then he shall file an objection to that choice pursuant to Subsection E of the section with a workers' compensation judge within three days from receiving the notice. He shall also provide notice of that objection to the other party. If the employer does not file his objection within the three-day period, then he shall be liable for the cost of treatment provided by the worker's health care provider until the employer does file his objection and the workers' compensation judge has rendered his decision as set forth in Subsection F of this section. If the worker does not file his objection within the three-day period, then the employer shall only be liable for the cost of treatment from the health care provider selected by the employer, subject to the provisions of Subsections E, F and G of this section. Nothing in this section shall remove the employer's obligation to provide reasonable and necessary health care services to the worker so long as the worker complies with the provisions of this section.
E. If the worker or employer disagrees with the choice of the health care provider of the other party at any time, including the initial sixty-day period, and they cannot otherwise agree, then he shall submit a request for a change of health care provider to a workers' compensation judge. The director shall adopt rules and regulations governing forms, which employers shall post in conspicuous places, to submit to a workers' compensation judge a request for change of health care provider.
F. The request shall state the reasons for the request and may state the applicant's choice for a different health care provider. The applicant shall bear the burden of proving to the workers' compensation judge that the care being received is not reasonable. The workers' compensation judge shall render his decision within seven days from the date the request was submitted. If the workers; compensation judge grants the request, he shall designate either the applicant's choice of health care provider or a different health care provider.
G. If the worker continues to receive treatment or services from a health care provider rejected by the employer and not in compliance with the workers' compensation judge's ruling, then the employer is not required to pay for any of the additional treatment or services provided to that worker by that health care provider.
H. In all cases where the injury is such as to permit the use of artificial members, including teeth and eyes, the employer shall pay for the artificial members.

52-4-1. Definition; health care provider.
As used in Chapter 52 NMSA 1978, "health care provider" means:
A. any hospital maintained by the state or any political subdivision of the state or any place currently licensed as a hospital by the health and environment department [department of health] that has:
(1) accommodations for resident bed patients;
(2) a licensed professional registered nurse always on duty or call;
(3) a laboratory; and
(4) an operating room where surgical operations are performed;
B. an optometrist licensed pursuant to the provisions of Chapter 61, Article 2 NMSA 1978;
C. a chiropractor licensed pursuant to the provisions of Chapter 61, Article 4 NMSA 1978;
D. a dentist licensed pursuant to the provisions of Chapter 61, Article 5 NMSA 1978;
E. a physician licensed pursuant to the provisions of Chapter 61, Article 6 NMSA 1978;
F. a podiatrist licensed pursuant to the provisions of Chapter 61, Article 8 NMSA 1978;
G. an osteopathic physician licensed pursuant to the provisions of Chapter 61, Article 10 NMSA 1978;
H. a physician assistant registered pursuant to the provisions of Section 61-6-7 NMSA 1978;
I. a certified nurse practitioner licensed pursuant to Section 61-3-14 NMSA 1978;
J. a physical therapist licensed pursuant to the provisions of Chapter 61, Article 12 NMSA 1978;
K. an occupational therapist licensed pursuant to the provisions of Chapter 61, Article 12A NMSA 1978;
L. a doctor of oriental medicine licensed pursuant to the provisions of Chapter 61, Article 14A NMSA 1978;
M. a psychologist who is duly licensed or certified in the state where the service is rendered, holding a doctorate degree in psychology and having at least two years clinical experience in a recognized health setting, or who has met the standards of the national register of health services providers in psychology;
N. a certified nurse-midwife licensed by the board of nursing as a registered nurse and registered with the behavioral health services division of the health and environment department as a certified nurse-midwife; or
O. any person or facility that provides health-related services in the health care industry, as approved by the director.

 

59A-15-16. Jurisdiction over health care benefits providers presumed.
Notwithstanding any other provision of law, and except as provided in the Health Care Benefits Jurisdiction Act [59A-15-14 to 59A-15-19 NMSA 1978], any person that provides coverage in this state for health benefits, including coverage for medical, surgical, hospital, osteopathic, acupuncture and oriental medical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental or optometric expenses, whether such coverage is by direct payment, reimbursement or otherwise, shall be presumed to be subject to the provisions of the Insurance Code [this chapter, except Articles 16A, 23A, 23B, 24A and Section 59A-33-14 NMSA 1978] and the jurisdiction of the superintendent unless the person provides evidence satisfactory to the superintendent that it is subject exclusively to the jurisdiction of another agency of this state or the federal government.

 

MORE INFORMATION

The complete Acupuncture and Oriental Medicine Practice Act can be found at the New Mexico Board of Acupuncture and Oriental Medicine website at www.rld.state.nm.us/acupuncture.

The complete New Mexico Insurance Code can be found at the New Mexico Legislature website at www.legis.state.nm.us.

New Mexico Doctors of Oriental Medicine are encouraged to join and participate in The Oriental Medicine Association. Participation provides doctors the opportunity to learn more about these issues, to exchange information and resources, and to influence the ongoing effort to shape these laws in the NM Legislature. For more information log onto www.TheOrientalMedicineAssociation.com.