reglab/statecodes huggingface dataset:
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-9 - Annual report.

A. Every health maintenance organization shall annually, on or before the first day of March, file a report, verified by at least two principal officers, with the superintendent covering the preceding calendar year.
B. The report shall be on forms prescribed by the superintendent and shall include:
(1) a financial statement of the organization prepared pursuant to forms prescribed by the superintendent, including its balance sheet and receipts and disbursements for the preceding year;
(2) any material changes in the information submitted pursuant to Subsection C of Section 59A-46-3 NMSA 1978;
(3) the number of persons enrolled during the year and the number of enrollees as of the end of the year; and
(4) such other reasonable information materially relating to the performance of the health maintenance organization as is necessary to enable the superintendent to carry out the superintendent's duties under the Insurance Code.
C. In addition, the health maintenance organization shall file by the dates indicated:
(1) on or before March 1, an annual statement in accordance with the requirements of Section 59A-5-29 NMSA 1978 and a risk-based capital report in accordance with the requirements of Section 59A-5A-3 NMSA 1978;
(2) a list of the providers who have executed a contract that complies with Subsection E of Section 59A-46-13 NMSA 1978 on or before March 1; and
(3) a description of the grievance procedures and the total number of grievances handled through such procedures, a compilation of the causes underlying those grievances and a summary of the final disposition of those grievances, on or before March 1.
D. The superintendent may require such additional reports as are deemed necessary and appropriate to enable the superintendent to carry out the superintendent's duties under the Health Maintenance Organization Law.
History:
1978 Comp., § 59A-46-9, enacted by Laws 1993, ch. 266, § 9; 2014, ch. 59, § 51.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-9 NMSA 1978, as amended by Laws 1986, ch. 51 § 3, and Laws 1993, ch. 266, § 9 enacted a new section, effective January 1, 1994.
The 2014 amendment,
effective July 1, 2014, required insurers to annually file a statement of financial condition and transactions and a risk-based capital report; in Subsection C, Paragraph (1), deleted "audited financial statements as of the end of the preceding calendar year on or before June 1 or within one hundred twenty days following the end of its fiscal year, whichever is later" and added the current language of the paragraph.
Severability.
— Laws 2014, ch. 59, § 54 provided that if any part or application of the provisions of Laws 2014, ch. 59 is held invalid, the remainder or its application to other situations or persons shall not be affected.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-10 - Information to enrollees or subscribers.

A. A health maintenance organization shall provide to its subscribers or to its group contract holders for distribution to subscribers a list of providers upon enrollment and re-enrollment.
B. Every health maintenance organization shall notify its subscribers within thirty days of any material change in the operation of the organization that will affect the service to subscribers directly.
C. An enrollee shall be notified in writing by the health maintenance organization of the termination of any designated primary care provider who provided health care services to that enrollee. The health maintenance organization shall provide assistance to the enrollee in transferring to another participating primary care provider.
D. The health maintenance organization shall provide to subscribers information on how services may be obtained, where additional information on access to services may be obtained and a number where the enrollee may contact the health maintenance organization at no cost to the enrollee.
History:
1978 Comp., § 59A-46-10, enacted by Laws 1993, ch. 266, § 10.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-10 NMSA 1978, as enacted by Laws 1984, ch. 127, § 857, related to a complaint system, and Laws 1993, ch. 266, § 10 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-11 - Grievance procedures.

A. Every health maintenance organization shall establish and maintain a grievance procedure that has been approved by the superintendent to provide procedures for the resolution of grievances initiated by enrollees. The health maintenance organization shall maintain records regarding grievances received since the date of its last examination of such grievances.
B. The superintendent or his designee may examine such grievance procedures and records.
History:
1978 Comp., § 59A-46-11, enacted by Laws 1993, ch. 266, § 11.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-11 NMSA 1978, as enacted by Laws 1984, ch. 127, § 858, related to investments, and Laws 1993, ch. 266, § 11 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-12 - Investments.

With the exception of investments made in accordance with Paragraph (1) of Subsection A of Section 59A-46-5 NMSA 1978, the funds of a health maintenance organization shall be invested only in accordance with Chapter 59A, Article 9 NMSA 1978 and such regulations as the superintendent may promulgate consistent with that article and the provisions of the Health Maintenance Organization Law.
History:
1978 Comp., § 59A-46-12, enacted by Laws 1993, ch. 266, § 12.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-12 NMSA 1978, as enacted by Laws 1984, ch. 127, § 859, related to trust deposits, and Laws 1993, ch. 266, § 12 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-16 - Filing requirements for rating information.

A. No premium rate may be used until either a schedule of premium rates or methodology for determining premium rates has been filed with and approved by the superintendent. At the time the health maintenance organization files the rate with the superintendent it shall also file a schedule of benefits to which the rate applies.
B. Either a specific schedule of premium rates, or a methodology for determining premium rates, shall be established in accordance with actuarial principles for various categories of enrollees; provided that the premium applicable to an enrollee shall not be individually determined based on the status of the enrollee's health. A certification by a qualified actuary or other qualified person acceptable to the superintendent as to the appropriateness of the rates or of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.
C. The superintendent may disapprove any such rates, or methodology for determining rates, found by him to be excessive, inadequate or unfairly discriminatory, considering the benefits to be provided. If the superintendent disapproves such filing, he shall notify the health maintenance organization, specifying the reasons for his disapproval. A hearing shall be conducted within thirty days after a request in writing by the person filing. The schedule or methodology shall be deemed approved if the superintendent does not disapprove the filing within thirty days, but the superintendent in his sole discretion may postpone taking action for an additional thirty days as necessary for proper consideration of the filing.
History:
1978 Comp., § 59A-46-16, enacted by Laws 1993, ch. 266, § 16.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-16 NMSA 1978, as enacted by Laws 1984, ch. 127, § 863, related to examination, and Laws 1993, ch. 266, § 16 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-18 - Powers of insurers.

A. An authorized insurer may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of the Health Maintenance Organization Law. Notwithstanding any other law that may be inconsistent with the cited law, any two or more such insurance companies, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.
B. An authorized insurer may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. Among other things, under such contracts the insurer may make benefit payments to health maintenance organizations for health care services rendered by providers.
History:
1978 Comp., § 59A-46-18, enacted by Laws 1993, ch. 266, § 18.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-18 NMSA 1978, as enacted by Laws 1984, ch. 127, § 865, related to rehabilitation, liquidation, or conservation of health maintenance organizations, and Laws 1993, ch. 266, § 18 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-19 - Examinations.

A. The superintendent may make an examination of the affairs of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state but not less frequently than once every three years.
B. The superintendent may make or request the secretary of health to make an examination concerning the quality assurance program of the health maintenance organization and of any providers with whom such organization has contracts, agreements or other arrangements as often as is reasonably necessary for the protection of the interests of the people of this state.
C. Every health maintenance organization and provider shall submit its books and records for such examinations and in every way facilitate the completion of the examination. Medical records of individuals and contract providers shall not be subject to such examination. For the purpose of examinations, the superintendent and the secretary of health may administer oaths to and examine the officers and agents of the health maintenance organization and the principals of such providers concerning their business.
D. The expenses of examinations under this section shall be assessed against the health maintenance organization being examined and remitted to the superintendent.
E. In lieu of such examination, the superintendent may accept the report of an examination made by the superintendent or secretary of health of another state.
F. Examination procedures shall be governed by the applicable provisions of Chapter 59A, Article 4 NMSA 1978.
History:
1978 Comp., § 59A-46-19, enacted by Laws 1993, ch. 266, § 19.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-19 NMSA 1978, as enacted by Laws 1984, ch. 127, § 866, related to regulations, and Laws 1993, ch. 266, § 19 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-21 - Rehabilitation, liquidation or conservation of health maintenance organizations.

A. Any rehabilitation, liquidation or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation or conservation of an insurer and shall be conducted under the supervision of the superintendent pursuant to the law governing the rehabilitation, liquidation or conservation of insurers. The superintendent may apply for an order directing him to rehabilitate, liquidate or conserve a health maintenance organization upon any one or more grounds set out in Chapter 59A, Article 41 NMSA 1978 or when in his opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state. Enrollees shall have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
B. For purpose of determining the priority of distribution of general assets, claims of enrollees and enrollees' beneficiaries shall have the same priority as established by Subsection C of Section 59A-41-44 NMSA 1978 for policyholders and beneficiaries of insureds of insurance companies. If an enrollee is liable to any provider for services provided pursuant to and covered by the health care plan, that liability shall have the status of an enrollee claim for distribution of general assets.
C. Any provider who is obligated by statute or agreement to hold enrollees harmless from liability for services provided pursuant to and covered by a health care plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollees' beneficiaries as described in Subsection B of this section and immediately preceding the priority of distribution described in Subsection D of Section 59A-41-44 NMSA 1978.
History:
1978 Comp., § 59A-46-21, enacted by Laws 1993, ch. 266, § 21.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-21 NMSA 1978, as enacted by Laws 1984, ch. 127, § 868, related to fees, and Laws 1993, ch. 266, § 21 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-22 - Summary orders and supervision.

A. Whenever the superintendent determines that the financial condition of any health maintenance organization is such that its continued operation might be hazardous to its enrollees, creditors or the general public, or that it has violated any provision of the Health Maintenance Organization Law, he may, after notice and hearing, order the health maintenance organization to take such action as may be reasonably necessary to rectify such condition or violation, including but not limited to one or more of the following:
(1) reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the superintendent;
(2) reduce the volume of new business being accepted;
(3) reduce expenses by specified methods;
(4) suspend or limit the writing of new business for a period of time;
(5) increase the health maintenance organization's capital and surplus by contribution; or
(6) take such other steps as the superintendent may deem appropriate under the circumstances, including suspension or revocation of the certificate or authority or assessment of administrative penalties as provided in Section 59A-46-20 NMSA 1978.
B. For purposes of this section, the violation by a health maintenance organization of any law of this state to which such health maintenance organization is subject shall be deemed a violation of the provisions of the Health Maintenance Organization Law.
C. The superintendent is authorized to make rules and regulations setting uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors or the general public and setting standards for evaluating the financial condition of any health maintenance organization, which standards shall be consistent with the purposes expressed in Subsection A of this section.
D. The remedies and measures available to the superintendent under this section shall be in addition to, and not in lieu of, the remedies and measures available to the superintendent under the provisions of Chapter 59A, Article 41 NMSA 1978.
History:
Laws 1993, ch. 266, § 22.
ANNOTATIONS
Repeals.
— Laws 1991, ch. 9, § 45 repealed former 59A-46-22 NMSA 1978, as amended by Laws 1988, ch. 75, § 2, relating to premium tax, effective July 1, 1993.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-22.1 - Repealed.

ANNOTATIONS
Repeals.
— Laws 1991, ch. 9, § 45 repealed 59A-46-22.1 NMSA 1978, as enacted by Laws 1988, ch. 75, § 2, relating to supplemental premium tax, effective July 1, 1993. For provisions of former section,
see
the 1990 NMSA 1978 on
NMOneSource.com
.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-23 - Regulations.

The superintendent may, after notice and hearing, adopt and promulgate reasonable rules and regulations as are necessary or proper to carry out the provisions of the Health Maintenance Organization Law.
History:
1978 Comp., § 59A-46-23, enacted by Laws 1993, ch. 266, § 23.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-23 NMSA 1978, as enacted by Laws 1984, ch. 127, § 870, related to penalties and enforcement, and Laws 1993, ch. 266, § 23 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-24 - Fees.

Every health maintenance organization subject to the provisions of the Health Maintenance Organization Law shall pay to the superintendent all applicable fees specified in Section 59A-6-1 NMSA 1978.
History:
1978 Comp., § 59A-46-24, enacted by Laws 1993, ch. 266, § 24.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-24 NMSA 1978, as amended by Laws 1991, ch. 111, § 14, related to statutory construction and relationship to other laws, and Laws 1993, ch. 266, § 24 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-26 - Filings and reports as public documents.

All applications, filings and reports required under the Health Maintenance Organization Law shall be treated as public documents, except those that are trade secrets or privileged or confidential quality assurance, commercial or financial information, other than any annual financial statement that may be required under Section 59A-46-9 NMSA 1978.
History:
1978 Comp., § 59A-46-26, enacted by Laws 1993, ch. 266, § 26.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-26 NMSA 1978, as enacted by Laws 1984, ch. 127, § 873, related to confidentiality of health information, and Laws 1993, ch. 266, § 26 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-26.1 - Employer utilization and loss experience availability.

Employer claims information, including utilization and loss experience under health insurance provided under Chapter 59A, Article 46 NMSA 1978 shall be made available by the carrier only upon the written request of and to employers of enrollees with such coverage within thirty days of an employer's written request for such information to the carrier, provided the employer's coverage extends to no less than twenty-five individual enrollees, regardless of whether family coverage is included. Each carrier shall provide to the employer claims information that provides sufficient detail, subject to state and federal privacy laws, to enable the employer to obtain and compare rates from multiple carriers or establish a plan of self-insurance.
History:
Laws 2003, ch. 252, § 4; 2007, ch. 53, § 2.
ANNOTATIONS
The 2007 amendment,
effective June 15, 2007, required insurers to provide claims experience information to employers to permit the employer to obtain and compare group health care rates and coverage from other carriers.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-28 - Authority to contract.

The secretary of health, in carrying out his obligations as requested by the superintendent under the provisions of the Health Maintenance Organization Law, may contract with qualified persons to make recommendations concerning the determinations required to be made by him, which recommendations may be accepted in full or in part or rejected entirely.
History:
1978 Comp., § 59A-46-28, enacted by Laws 1993, ch. 266, § 28.
ANNOTATIONS
Recompilations.
— Laws 1993, ch. 266, § 31, recompiled former 59A-46-28 NMSA 1978, as enacted by Laws 1984, ch. 127, § 875 relating to a requirement for maternity transport coverage, as 59A-46-39 NMSA 1978, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-31 - Coordination of benefits.

A. Health maintenance organizations are permitted, but not required, to adopt coordination of benefits provisions to avoid overinsurance and to provide for the orderly payment of claims when a person is covered by two or more group health insurance or health care plans.
B. If health maintenance organizations adopt coordination of benefits, the provisions shall be consistent with the coordination of benefits provisions that are in general use in the state for coordinating coverage between two or more group health insurance or health care plans.
C. To the extent necessary for health maintenance organizations to meet their obligations as secondary carriers under the regulations established by the superintendent, health maintenance organizations shall make payments for services that are:
(1) received from non-participating providers;
(2) provided outside their service areas; or
(3) not covered under the terms of their group contracts or evidence of coverage.
History:
1978 Comp., § 59A-46-31, enacted by Laws 1993, ch. 266, § 30.
ANNOTATIONS
Repeals and reenactments.
— Laws 1993, ch. 266, § 43 repealed former 59A-46-31 NMSA 1978, as enacted by Laws 1984, ch. 127, § 877, related to contractual relations, and Laws 1993, ch. 266, § 30 enacted a new section, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-32.1 - Recompiled.

ANNOTATIONS
Recompilations.
— Laws 1993, ch. 266, § 31, recompiled 59A-46-32.1 NMSA 1978, as enacted by Laws 1989, ch. 96, § 2, relating to prohibition of acupuncture practitioner discrimination, as 59A-46-36 NMSA 1978, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-33 - Governing body.

The governing body of any health maintenance organization may include providers or other individuals, or both. Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions or through the use of other mechanisms.
History:
Laws 1984, ch. 127, § 853; 1978 Comp., § 59A-46-6, recompiled as 1978 Comp., § 59A-46-33 by Laws 1993, ch. 266, § 31.
ANNOTATIONS
Recompilations.
— Laws 1993, ch. 266, § 31, recompiled former 59A-46-33 NMSA 1978, as enacted by Laws 1988, ch. 89, § 2, relating to coverage for adopted children, as 59A-46-37 NMSA 1978, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-34 - Prohibited practices.

A. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this article:
(1) a statement or item of information is deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in a health maintenance organization;
(2) a statement or item of information is deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health maintenance organization, if such benefit or advantage or absence of limitation, exclusion, or disadvantage does not in fact exist; and
(3) an evidence of coverage is deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health care coverage and evidences of coverage therefor, to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health maintenance organization issuing such evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.
B. An enrollee may not be canceled or nonrenewed on the basis of the status of his health.
C. No health maintenance organization, unless licensed as an insurer, may use in its name, contracts or literature any of the words "insurance," "casualty," "surety," "mutual" or any other words descriptive of the insurance, casualty or surety business if such words are used in a manner to imply that such coverages are being illegally offered by the health maintenance organization or if deceptively similar to the name or description of any insurance or surety corporation doing business in the state.
D. Any person not in possession of a valid certificate of authority issued pursuant to this article shall not use the phrase "health maintenance organization" or "HMO" in the course of operation.
History:
Laws 1984, ch. 127, § 860; 1978 Comp., § 59A-46-13, recompiled as 1978 Comp., § 59A-46-34 by Laws 1993, ch. 266, § 31.
ANNOTATIONS
Recompilations.
— Laws 1993, ch. 266, § 31, recompiled former 59A-46-34 NMSA 1978, as enacted by Laws 1989, ch. 183, § 6, relating to individuals eligible for medicaid, as 59A-46-29 NMSA 1978, effective January 1, 1994.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-35 - Provider discrimination prohibited.

No class of licensed individual providers willing to meet the terms and conditions offered by a health maintenance organization shall be excluded from a health maintenance organization. For purposes of this section, "providers" means those persons licensed pursuant to:
A. the Optometry Act [Chapter 61, Article 2 NMSA 1978];
B. Section 61-3-23.2 NMSA 1978;
C. the Chiropractic Physician Practice Act [Chapter 61, Article 4 NMSA 1978];
D. the Dental Health Care Act [Chapter 61, Article 5A NMSA 1978];
E. the Medical Practice Act [Chapter 61, Article 6 NMSA 1978];
F. the Podiatry Act [Chapter 61, Article 8 NMSA 1978];
G. the Professional Psychologist Act [Chapter 61, Article 9 NMSA 1978];
H. Chapter 61, Article 10 NMSA 1978; or
I. the Pharmacy Act [Chapter 61, Article 11 NMSA 1978].
History:
1978 Comp., § 59A-46-32, enacted by Laws 1987, ch. 335, § 1; 1989, ch. 55, § 1; recompiled as 1978 Comp., § 59A-46-35 by Laws 1993, ch. 266, § 31; 1998, ch. 39, § 1; 2003, ch. 343, § 3.
ANNOTATIONS
Recompilations.
— Laws 1993, ch. 266, § 31, recompiled former 59A-46-35 NMSA 1978, as enacted by Laws 1990, ch. 5, § 1, relating to coverage for mammograms, as 59A-46-41 NMSA 1978, effective January 1, 1994.
The 2003 amendment,
effective June 20, 2003, changed references to the chapter and article to the named acts in Subsections A through I.
The 1998 amendment,
effective May 20, 1998, substituted "pursuant to Section 61-3-23.2 NMSA 1978 or Article" for "under Articles" and "5A" for "5" near the end of the section.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 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 and shall not be discriminated against relative to other classes of licensed providers regarding services provided within their scope of practice that are in compliance with nationally recognized coding systems. Health maintenance organizations may determine the specific procedure codes that a doctor of oriental medicine is contracted to provide. Health maintenance organizations may choose to contract a doctor of oriental medicine as a primary care provider.
History:
Laws 1989, ch. 96, § 2; 1993, ch. 158, § 4; 1978 Comp., § 59A-46-32.1, recompiled as 1978 Comp., § 59A-46-36 by Laws 1993, ch. 266, § 31; 2003, ch. 96, § 1.
ANNOTATIONS
Recompilations.
— Laws 1993, ch. 266, § 31, recompiled former 59A-46-36 NMSA 1978, as enacted by Laws 1992, ch. 56, § 1, relating to coverage for cytologic screening, as 59A-46-42 NMSA 1978, effective January 1, 1994.
Cross references.
— For prohibition of discrimination against oriental medical doctors,
see
59A-47-28.2 NMSA 1978.
The 2003 amendment,
effective June 20, 2003, inserted "and shall not be discriminated against relative to other classes of licensed providers regarding services provided within their scope of practice that are in compliance with nationally recognized coding systems." following "health maintenance organization" and added the last two sentences.
The 1993 amendment,
effective June 18, 1993, substituted "Doctor of Oriental Medicine" for "Acupuncture Practitioner" in the section heading and substituted "Doctors of oriental medicine" for "Acupuncture practitioners" at the beginning of the section.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-37 - Coverage for adopted children.

A. No individual or group health maintenance organization contract shall be offered, issued or renewed in New Mexico on or after July 1, 1988, unless the contract covers adopted children of the subscriber or enrollee on the same basis as other dependents.
B. The coverage required by this section is effective from the date of placement for the purpose of adoption and continues unless the placement is disrupted prior to legal adoption and the child is removed from placement. Coverage shall include the necessary care and treatment of medical conditions existing prior to the date of placement.
C. As used in this section, "placement" means in the physical custody of the adoptive parent.
History:
1978 Comp., § 59A-46-33, enacted by Laws 1988, ch. 89, § 2; recompiled as 1978 Comp., § 59A-46-37 by Laws 1993, ch. 266, § 31.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-38 - Newly born children coverage.

A. All individual and group health maintenance organization contracts delivered or issued for delivery in this state shall also provide that the health benefits applicable for children shall be payable with respect to a newly born child of the subscriber or the subscriber's spouse from the moment of birth.
B. All individual and group health maintenance organization contracts delivered or issued for delivery in this state that do not provide health benefits applicable for children shall provide for an option to add to the coverage any newly born child of the insured provided that the requirements of Subsection D of this section have been met.
C. The coverage for newly born children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, where necessary to protect the life of the infant, transportation, including air transport, to the nearest available tertiary care facility for newly born infants.
D. If a specific payment is required to provide coverage for a child, the contract may require that a notification of birth of a newly born child and payment must be furnished to the health maintenance organization within thirty-one days after the date of birth in order to have the coverage from birth.
E. As used in this section and in Section 59A-46-28 NMSA 1978 [59A-46-39 NMSA 1978], "tertiary care facility" means a hospital unit which provides complete perinatal care and intensive care of intrapartum and perinatal high-risk patients with responsibilities for coordination of transport, communication, education and data analysis systems for the geographic area served.
History:
Laws 1984, ch. 127, § 874; 1993, ch. 169, § 2; 1978 Comp., § 59A-46-27, recompiled as § 59A-46-38 by Laws 1993, ch. 266, § 31.
ANNOTATIONS
The 1993 amendment,
effective June 18, 1993, added Subsection B; redesignated former Subsections B through D as Subsections C through E; substituted "from birth" for "continue beyond such thirty-one day period" in Subsection D; and substituted "Section 59A-46-28 NMSA 1978" for "Section 875 of this article" in Subsection E.
Applicability.
— Laws 1993, ch. 169, § 3 provided that the provisions of the act apply to policies, plans, contracts and certificates delivered or issued for delivery or renewed, extended or amended in the state on or after July 1, 1993.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-38.2 - Childhood immunization coverage required.

A. Each individual and group health maintenance contract delivered or issued for delivery in this state shall provide coverage for childhood immunizations, in accordance with the current schedule of immunizations recommended by the American academy of pediatrics, including coverage for all medically necessary booster doses of all immunizing agents used in childhood immunizations.
B. Coverage for childhood immunizations and necessary booster doses may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract.
History:
1978 Comp., § 59A-46-38.2, enacted by Laws 1997, ch. 250, § 4.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-38.3 - Maximum age of dependent.

Each individual or group health maintenance organization contract delivered or issued for delivery or renewed in New Mexico that provides coverage for an enrollee's dependents shall not terminate coverage of an unmarried dependent by reason of the dependent's age before the dependent's twenty-sixth birthday, regardless of whether the dependent is enrolled in an educational institution; provided that this requirement does not apply to the medicaid managed care system.
History:
Laws 2003, ch. 391, § 5; 2005, ch. 41, § 2; 2021, ch. 108, § 27.
ANNOTATIONS
Cross references.
— For age of dependents,
see
59A-22-2 and 59A-22-34.2 NMSA 1978.
The 2021 amendment,
effective July 1, 2021, after "before the dependent's", changed "twenty-fifth" to "twenty-sixth".
The 2005 amendment,
effective July 1, 2005, provides that individual and group health maintenance organization contracts delivered or renewed in New Mexico that provide coverage for an enrollee's dependents shall not terminate coverage of unmarried dependents by reason of age before the twenty-fifth birthday.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-38.4 - Coverage of circumcision for newborn males.

An individual or group health maintenance organization policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in the state shall provide coverage for circumcision for newborn males.
History:
Laws 2004, ch. 122, § 8.
ANNOTATIONS
Effective dates.
— Laws 2004, ch. 122, § 13 made Laws 2004, ch. 122, § 8 effective July 1, 2004.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-38.5 - Hearing aid coverage for children required.

A. An individual or group health maintenance organization contract delivered, issued for delivery or renewed in this state shall provide coverage for a hearing aid and any related service for the full cost of one hearing aid per hearing-impaired ear up to two thousand two hundred dollars ($2,200) every thirty-six months for hearing aids for insured children under eighteen years of age or under twenty-one years of age if still attending high school. The insured may choose a higher priced hearing aid and may pay the difference in cost above the two-thousand-two-hundred-dollar ($2,200) limit as provided in this subsection without financial or contractual penalty to the insured or to the provider of the hearing aid.
B. An insurer that delivers, issues for delivery or renews in this state an individual or group health maintenance organization contract may make available to the policyholder the option of purchasing additional hearing aid coverage that exceeds the services described in this section.
C. Hearing aid coverage offered shall include fitting and dispensing services, including providing ear molds as necessary to maintain optimal fit, provided by an audiologist, a hearing aid dispenser or a physician, licensed in New Mexico. A health maintenance organization has the discretion to determine the provider of hearing aids with which it contracts. Nothing in this section shall be construed to preclude a health maintenance organization from conducting medical necessity or utilization review for hearing aids and related services.
D. The provisions of this section do not apply to short-term travel, accident-only or limited or specified disease policies.
E. Coverage for hearing aids may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate.
F. For the purposes of this section, "hearing aid" means durable medical equipment that is of a design and circuitry to optimize audibility and listening skills in the environment commonly experienced by children.
History:
Laws 2007, ch. 356, § 4.
ANNOTATIONS
Effective dates.
— Laws 2007, ch. 356, § 6 made this section effective July 1, 2007.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-39 - Maternity transport required.

All individual and group health maintenance organization contracts delivered or issued for delivery in this state which provide maternity coverage shall also provide, where necessary to protect the life of the infant or mother, coverage for transportation, including air transport, for the medically high-risk pregnant woman with an impending delivery of a potentially viable infant to the nearest available tertiary care facility as defined in Section 874 [59A-46-38 NMSA 1978] of this article for newly born infants.
History:
Laws 1984, ch. 127, § 875; 1978 Comp., § 59A-46-28, recompiled as § 59A-46-39 by Laws 1993, ch. 266, § 31.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-40 - Home health care service option required.

A. Each health maintenance organization which delivers or issues for delivery in this state an individual or group contract shall make available to the contract holder the option of home health care coverage which includes benefits for the services described in this section.
B. Home health care coverage offered shall include:
(1) services provided by a registered nurse or a licensed practical nurse;
(2) health services provided by physical, occupational and respiratory therapists and speech pathologists; and
(3) health services provided by a home health aide.
C. Home health care coverage may be limited to:
(1) services provided on the written order of a licensed physician, provided such order is renewed at least every sixty days;
(2) services provided, directly or through contractual agreements, by a home health agency licensed in the state in which the home health services are delivered; and
(3) services, as set forth in Subsection B of this section, without which the insured would have to be hospitalized.
D. Coverage shall be provided for at least one hundred home visits per enrollee per year, with each home visit including up to four hours of home health care services.
E. For the purposes of this section, "home health care" means health services provided on a part-time, intermittent basis to an individual confined to his home due to physical illness.
History:
Laws 1984, ch. 127, § 876; 1978 Comp., § 59A-46-29, recompiled as § 59A-46-40 by Laws 1993, ch. 266, § 31.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-41 - Coverage for mammograms.

Each individual and group health maintenance organization contract delivered or issued for delivery in this state shall provide coverage for low-dose screening mammograms for determining the presence of breast cancer. Such coverage shall make available one baseline mammogram to persons age thirty-five through thirty-nine, one mammogram biennially to persons age forty through forty-nine and one mammogram annually to persons age fifty and over. After July 1, 1992, coverage shall be available only for screening mammograms obtained on equipment designed specifically to perform low-dose mammography in imaging facilities that have met American college of radiology accreditation standards for mammography.
History:
Laws 1990, ch. 5, § 1; 1978 Comp., § 59A-46-35, recompiled as § 59A-46-41 by Laws 1993, ch. 266, § 31; 2023, ch. 12, § 7.
ANNOTATIONS
The 2023 amendment,
effective June 16, 2023, removed a provision stating that coverage for mammograms may be subject to deductibles and coinsurance; and deleted former Subsection B, which provided that coverage for mammograms may be subject to deductibles and coinsurance.
Applicability.
— Laws 2023, ch. 12, § 8 provided that Laws 2023, ch. 12 apply to health insurance policies, health care plans, certificates of health insurance and health maintenance organization contracts that are delivered, issued for delivery or renewed in this state on or after January 1, 2024.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-41.1 - Mastectomies and lymph node dissection; minimum hospital stay coverage required.

A. Each individual and group health maintenance contract delivered or issued for delivery in this state shall provide coverage for not less than forty-eight hours of inpatient care following a mastectomy and not less than twenty-four hours of inpatient care following a lymph node dissection for the treatment of breast cancer.
B. Nothing in this section shall be construed as requiring the provision of inpatient coverage where the attending physician and patient determine that a shorter period of hospital stay is appropriate.
C. Coverage for minimum inpatient hospital stays for mastectomies and lymph node dissections for the treatment of breast cancer may be subject to deductibles and co-insurance consistent with those imposed on other benefits under the same contract.
History:
1978 Comp., § 59A-46-41.1, enacted by Laws 1997, ch. 249, § 4.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-41.2 - Prior authorization for gynecological or obstetrical ultrasounds prohibited.

A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state and that provides coverage for gynecological or obstetrical ultrasounds shall not require prior authorization for gynecological or obstetrical ultrasounds.
B. Nothing in this section shall be construed to require payment for a gynecological or obstetrical ultrasound that is not:
(1) medically necessary; or
(2) a covered benefit.
C. As used in this section, "prior authorization" means advance approval that is required by a health maintenance organization as a condition precedent to payment for medical care or related benefits rendered to a covered person, including prospective or utilization review conducted prior to the provision of covered medical care or related benefits.
History:
Laws 2019, ch. 182, § 5.
ANNOTATIONS
Emergency clauses.
— Laws 2019, ch. 182, § 7 contained an emergency clause and was approved April 3, 2019.
2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 46 - Health Maintenance Organizations › Section 59A-46-41.3 - Diagnostic and supplemental breast examinations.

A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that provides coverage for diagnostic and supplemental breast examinations shall not impose cost sharing for diagnostic and supplemental breast examinations.
B. The provisions of this section do not apply to excepted benefit plans as provided pursuant to the Short-Term Health Plan and Excepted Benefit Act [Chapter 59A, Article 23G NMSA 1978], catastrophic plans as defined pursuant to 42 USCA Section 18022(e) or high deductible health plans with health savings accounts until an eligible insured's deductible has been met, unless otherwise allowed pursuant to federal law.
C. As used in this section:
(1) "cost sharing" means a deductible, coinsurance, copayment and any maximum limitation on the application of such a deductible, coinsurance, copayment or similar out-of-pocket expense;
(2) "diagnostic breast examination" means a medically necessary and clinically appropriate examination of the breast using diagnostic mammography, breast magnetic resonance imaging or breast ultrasound that evaluates an abnormality:
(a) seen or suspected from a screening examination for breast cancer; or
(b) detected by another means of examination; and
(3) "supplemental breast examination" means a medically necessary and clinically appropriate examination of the breast using breast magnetic resonance imaging or breast ultrasound that is:
(a) used to screen for breast cancer when there is no abnormality seen or suspected; and
(b) based on personal or family medical history or additional factors that may increase the individual's risk of breast cancer.
History:
Laws 2023, ch. 12, § 4.
ANNOTATIONS
Effective dates.
— Laws 2023, ch. 12 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. 12, § 8 provided that Laws 2023, ch. 12 apply to health insurance policies, health care plans, certificates of health insurance and health maintenance organization contracts that are delivered, issued for delivery or renewed in this state on or after January 1, 2024.