New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.8 - PATIENT RIGHTS AND RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. Each health care insurer through its
				managed health care plan (MHCP) shall implement written policies and procedures
				regarding the rights of covered persons and implementation of such
				rights.
B. At the time of
				enrollment, each health care insurer through its MHCP shall provide each
				subscriber, and upon request, a covered person, or a covered person's
				representative, in compliance with state or federal law, with a summary of
				benefits and exclusions, premium information and provider listing, along with
				information on how to access or obtain the evidence of coverage. Basic consumer
				information, including the phone number of the managed health care bureau,
				shall be included on a newly issued covered person's health insurance card, or
				on a separate wallet-sized card, to include the phone number and website of the
				managed health care bureau, issued simultaneously with the newly issued health
				insurance card.
C. The evidence of
				coverage shall include a complete statement that a covered person shall have
				the right, at a minimum:
(1) to available and
				accessible services when medically necessary, and in an HMO, as determined by
				the primary care or treating physician in consultation with the MHCP, 24 hours
				per day, 7 days per week for urgent or emergency care services, and for other
				health care services as defined by the contract or the evidence of
				coverage;
(2) to be treated with
				courtesy and consideration, and with respect for the covered person's dignity
				and need for privacy;
(3) to be
				provided with information concerning the health care insurer's policies and
				procedures regarding products, services, providers, appeals procedures and
				other information about the MHCP and the benefits provided;
(4) in an HMO, to choose a primary care
				practitioner within the limits of the covered benefits, plan network, and as
				provided by this rule, including the right to refuse care of specific health
				care professionals;
(5) to receive
				from the covered person's physician(s) or provider, in terms that the covered
				person understands, an explanation of his or her complete medical condition,
				recommended treatment, risk(s) of the treatment, expected results and
				reasonable medical alternatives, irrespective of the health care insurers or
				MHCP's position on treatment options; if the covered person is not capable of
				understanding the information, the explanation shall be provided to his or her
				next of kin, guardian, agent or surrogate, if available, and documented in the
				covered person's medical record;
(6) to all the rights afforded by law, rule,
				or regulation as a patient in a licensed health care facility, including the
				right to refuse medication and treatment after possible consequences of this
				decision have been explained in language the covered person
				understands;
(7) to prompt
				notification, as required in this rule, of termination or changes in benefits,
				services or provider network;
(8)
				to file a complaint or appeal with the health care insurer or the
				superintendent and to receive an answer to those complaints in accordance with
				existing law;
(9) to privacy of
				medical and financial records maintained by the health care insurer and its
				health care providers, in accordance with existing law;
(10) to know upon request of any financial
				arrangements or provisions between the health care insurer and its providers
				which may restrict referral or treatment options or limit the services offered
				to covered persons;
(11) to
				adequate access to qualified health professionals for the treatment of covered
				benefits near where the covered person lives or works within the service area
				of the MHCP;
(12) in an HMO, and to
				the extent available and applicable to the MHCP, to affordable health care,
				with limits on out-of-pocket expenses, including the right to seek care from a
				non-participating provider, and an explanation of a covered person's financial
				responsibility when services are provided by a non-participating provider, or
				provided without required preauthorization;
(13) in a MHCP that provides benefits for
				out-of-network coverage, to an approved example of the financial responsibility
				incurred by a covered person when going out-of-network; inclusion of the entire
				"billing examples" provided by the superintendent available on the division's
				website at the time of the filing of the plan will be deemed satisfaction of
				this requirement; any substitution for, or changes to, the division's "billing
				examples" requires written approval by the superintendent;
(14) to detailed information about coverage,
				maximum benefits, and exclusions of specific conditions, ailments or disorders,
				including restricted prescription benefits, and all requirements that a covered
				person must follow for prior authorization and utilization review;
(15) to a complete explanation of why care is
				denied, an opportunity to appeal the decision to the health care insurer's
				internal review, the right to a secondary appeal, and the right to request the
				superintendent's assistance.