2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 23G - Short-Term Health Plan and Excepted Benefit › Section 59A-23G-12 - Dental plan; provider network leasing.

A. For purposes of this section:
(1) "contracting entity" means any person or entity that enters into direct contracts with a provider for the delivery of services in the ordinary course of business;
(2) "provider" means a person acting within the scope of licensure to provide dental services or supplies;
(3) "provider network contract" means a contract between a contracting entity and a provider specifying the rights and responsibilities of the contracting entity and providing for the delivery of and payment for services to covered persons; and
(4) "third party" means a person or entity that enters into a contract with a contracting entity or with another third party to gain access to the services or contractual discounts of a provider network contract.
B. At a time when a contract relevant to granting access to a provider network to a third party is entered into or renewed, or when there are material modifications made, a contracting entity shall not require a provider to participate in third-party access to the provider network contract or contract directly with a third party that acquired the provider network. If a provider opts out, the contracting entity shall not cancel or otherwise end a contractual relationship with the provider. When initially contracting with a provider, a contracting entity must accept a qualified provider even if the provider rejects a network lease provision.
C. A contracting entity shall not grant a third party access to a provider network contract, a provider's services or discounts provided pursuant to a provider network contract unless:
(1) the provider network contract states that the contracting entity may enter into an agreement with a third party, allowing the third party to obtain the health insurance carrier's rights and responsibilities as though the third party were the contracting entity;
(2) the third party accessing the provider network contract agrees to comply with all of the terms of the provider network contract; and
(3) the contracting entity:
(a) identifies all third parties with which it contracts in a list on its website that is updated every ninety days;
(b) notifies a provider that a new third party is planning to lease or purchase the provider network contract at least thirty business days before the lease or purchase takes effect;
(c) requires the third party to identify the source of the discount on all remittances or explanation of benefits under which the discount is taken; and
(d) makes available a copy of the provider network contract relied upon in the adjudication of a claim to a provider within thirty days of the provider's request.
D. A third party's right to a provider's discounted rate shall cease upon the termination date of the provider network contract.
E. The provisions of this section shall not apply if access to a provider network contract is granted to a dental carrier of an entity operating in accordance with the same brand licensee program as the contracting entity or to an entity that is an affiliate of the contracting entity. A list of the contracting entity's affiliates shall be made available to a provider on the contracting entity's website.
History:
Laws 2023, ch. 169, § 11.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 169 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 16, 2023, 90 days after adjournment of the legislature.
Applicability.
— Laws 2023, ch. 169, § 12 provided that the provisions of Laws 2023, ch. 169 apply to dental plans issued for delivery or renewed in this state on or after January 1, 2024.