New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 23 - MANAGED HEALTH CARE PLAN CONTRACTING › Section 13.10.23.8 - INFORMATION PROVIDED TO COVERED PERSONS AND READABILITY OF MANAGED HEALTH CARE PLAN CONTRACTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Evidence of coverage:
At the time of enrollment, each managed health
				care plan (MHCP) shall provide each covered person with information on how to
				access and obtain an evidence of coverage. Upon request at any time after
				enrollment, the covered person shall be provided with the evidence of coverage.
				Each evidence of coverage offered to covered persons, and prospective covered
				persons shall state in clear, accurate, and conspicuous language, in not less
				than 10 point font, written such that it can be easily understood by the
				average covered person, and so that it comports with the requirements of the
				"Policy Language Simplification Law," Chapter 59A, Article 19 NMSA 1978, the
				following information:
(1) the name of the
				health care insurer and managed health care plan and its principal place of
				business, including its address and telephone number;
(2) definitions for words that have meanings
				other than common general usage;
(3) for an HMO, a description of the HMO's
				service area;
(4) a complete list
				or description of the comprehensive basic health care services, urgent health
				care services, emergency health care services, and, if applicable, supplemental
				health care services available within the MHCP's service or geographical area,
				and any other benefits to which the covered person is entitled under the
				particular plan;
(5) an explanation
				of how participation in the managed health care plan may affect the potential
				covered person's choice of physician, hospital, or other health care
				provider;
(6) eligibility
				requirements for coverage, including a statement of conditions on eligibility
				for benefits;
(7) conditions of
				cancellation, which shall include a statement that if a covered person believes
				coverage was canceled due to health status or health care requirements, race,
				gender, age, or sexual orientation, he may appeal termination to the
				superintendent;
(8) the name,
				address, and toll-free telephone number of the superintendent;
(9) a statement that a copy of the evidence
				of coverage will be provided upon request if the covered person is unable to
				obtain a copy of the contract from the covered person's employer or other
				contract holder;
(10) conditions
				for renewal and reinstatement;
(11)
				any procedures for filing claims;
(12) in bold typeface, or through an equally
				or more effective means, highlight any and all exclusions or limitations on the
				health care services, type of health care services, benefits, or type of
				benefits to be provided, including deductibles or copayments, or co-insurance;
				when presented on the plan's website or through other internet means, this
				information may be highlighted with movement, color, pop-up material, and other
				devices;
(13) any other
				requirements or procedures necessary for covered persons to obtain particular
				health care services, such as additional copayments, prior authorizations,
				second opinions, and consultations with or referrals to specialists,
				physicians, or other providers other than the primary care physician;
(14) the covered person's personal financial
				obligation for non-covered health care services;
(15) a clear and complete summary of where,
				and in what manner, information is available regarding how a covered person
				obtains services, including emergency and out-of-area services;
(16) a toll-free telephone number and a
				web-based or other electronic methods through which the covered person may
				contact the MHCP for additional information on obtaining health care services
				or for other inquiries regarding the plan, including benefit information and
				plan requirements;
(17) for all
				contracts, a list of relevant copayments and all other out of pocket expenses
				paid by the covered person;
(18)
				for individual and conversion contracts, the contractual periodic prepayment or
				premium, which may be contained in a separate insert and the total of payment
				for health services and the indemnity or services benefits, if any, which the
				covered person is obligated to pay;
(19) a description of the MHCP's grievance
				procedures and method for resolving covered person complaints, including a
				description of the appeals process available if the MHCP limits or excludes
				coverage of a treatment or procedure, the address and telephone number to which
				grievances are to be directed, and a statement identifying the superintendent
				as an external source with whom grievances may be filed, including the division
				of insurance contact information, as provided at Paragraph (2) of Subsection A
				of 13.10.17.24 NMAC, so that the covered person may submit the
				complaint;
(20) if the MHCP
				provides prescription drug coverage, the evidence of coverage must convey in
				clear and concise language:
(a) whether
				participating providers are restricted to prescribing drugs from a drug
				formulary;
(b) whether or not
				brand-name products or specialty drugs require a higher copayment;
(c) the extent, if at all, to which an
				enrollee will be reimbursed for costs of a drug that is not on the plan's
				formulary;
(d) how covered persons
				may obtain, upon request, a complete list of drugs covered by the plan or
				listed on the MHCP's drug formulary; and
(e) any exclusions or limitations for
				coverage of "experimental," "investigational," or "specialty" drugs and
				definitions of "experimental," "investigational," and "specialty" as those
				terms are used by the MHCP, and in accordance with this chapter;
(21) a list of providers which
				contains all of the information listed in Subsection D of 13.10.22.8 NMAC, and
				shall include a statement, if applicable, that providers may be deleted or
				added within the coverage year;
(22) a statement regarding whether or not
				participating providers must comply with any specified numbers, targeted
				averages, or maximum durations of patient visits; and if so, a description of
				the specific requirements;
(23) a
				statement reflecting that a covered person will not be liable to a provider for
				any sums owed to the provider by the MHCP;
(24) language reflecting that the enrollee
				may be liable for sums owed to a non-contracting provider, except when an
				enrollee or covered person is mistakenly referred to a non-participating
				provider by a MHCP provider as discussed in Subsection C of 13.10.22.8 NMAC;
				and
(25) a statement explaining the
				covered person's rights and responsibilities as required by 13.10.13.8
				NMAC.