New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 2 - MOTHERS AND NEWLY BORN CHILDREN HEALTH SECURITY › Section 13.10.2.10 - HEALTH MAINTENANCE ORGANIZATION CONTRACTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. All individual and group health
				maintenance organization contracts delivered or issued for delivery in this
				state and which provide maternity coverage shall also provide coverage for a
				minimum of 48 hours of inpatient care following a vaginal delivery and a
				minimum of 96 hours of inpatient care following a caesarian section for a
				mother and her newly born child in a health facility unless earlier discharge
				is made in accordance with the medical criteria outlined in the most current
				version of the "Guidelines for Perinatal Care" prepared by the American academy
				of pediatrics and the American college of obstetricians and gynecologists,
				including, but not limited to, the criterion that family members or other
				support person(s) should be available to the mother for the first few days
				following discharge. In addition, a decision for early discharge should be
				individualized and should be a mutual decision between the mother and the
				attending physician. Inpatient care in excess of a minimum of 48 hours
				following a vaginal delivery and a minimum of 96 hours following a caesarian
				section for a mother and her newly born child in a health facility shall be
				covered if determined to be medically necessary by the attending
				physician.
B. Notwithstanding the
				provisions of subsection 10.1 of this section [now Subsection A of 13.10.2.10
				NMAC], an individual or group health maintenance organization contract
				delivered or issued for delivery in this state that provides coverage for
				postpartum care to a mother and her newly born child in the home shall not be
				required to provide for coverage for a minimum of 48 hours of inpatient care
				following a vaginal delivery and a minimum of 96 hours of inpatient care
				following a caesarian section, unless such inpatient care is determined to be
				medically necessary by the attending physician, or early discharge is
				inconsistent with the most current version of the "Guidelines for Perinatal
				Care" prepared by the American academy of pediatrics and the American college
				of obstetricians and gynecologists, or this rule.
C. Postpartum care in the home shall be made
				in accordance with accepted maternal and neonatal physician assessments, by a
				person with appropriate licensure, training and experience to provide
				postpartum care. Services provided by such person shall include, but not be
				limited to, parent education, assistance and training in breast and bottle
				feeding, and the performance of any necessary and appropriate clinical
				tests.
D. Postpartum care in the
				home shall consist of a minimum of three home visits, unless one or two home
				visits are determined to be sufficient by the attending physician or person
				with appropriate licensure, training and experience to provide postpartum care,
				and the mother. The home visits shall be conducted within the time period
				ordered by the attending physician or person with appropriate licensure,
				training and experience to provide postpartum care.
E. Each health maintenance organization which
				provides maternity coverage in this state shall mail a written description of
				the coverage required under this rule, in a form approved by the
				superintendent, to the expectant mother enrolled in the health maintenance
				organization and to her attending physician, upon receipt by the health
				maintenance organization of notification of the diagnosis of pregnancy of the
				expectant mother.
F. In addition to
				the notification provided in subsection 10.5 [now Subsection E of 13.10.2.10
				NMAC], each health maintenance organization which provides maternity coverage
				in this state shall mail a written statement, in a form approved by the
				superintendent, to the expectant mother covered by the health maintenance
				organization, notifying the expectant mother of her right to complain to the
				superintendent if there is concern that the mother or her newly born child has
				not received the coverage required by this rule. In the event of a complaint,
				the health maintenance organization will have the burden of proof to
				demonstrate that the coverage provided was in compliance with this
				rule.