reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.9 - POLICY OR PLAN CRITERIA; MINIMUM REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Mandatory provisions:
Policies or plans issued pursuant to the Minimum Healthcare Protection Act
				shall meet the criteria set forth in Section 59A-23B-3B NMSA 1978 regarding
				eligibility, managed care provisions and minimum healthcare services to covered
				individuals.
B.
Optional
				provisions:
Policies or plans issued pursuant to the Minimum Healthcare
				Protection Act may include the managed care and cost control features provided
				in Section 59A-23B-3C NMSA 1978 regarding panels of healthcare service
				providers, second opinions before elective surgery, utilization review and a
				maximum limit on the cost of healthcare services covered in any calendar year
				of not less than $50,000. Pursuant to Section 59A-23B-3D NMSA 1978 a policy or
				plan may include additional managed care and cost control provisions that the
				superintendent of insurance determines to have the potential for controlling
				costs in a manner that does not cause discriminatory treatment of individuals,
				families or groups covered by the policy or plan.
C.
Pre-existing conditions:
Pursuant to Section 59A-23B-3E NMSA 1978, notwithstanding any other provisions
				of law, a policy or plan shall not exclude coverage for losses incurred for a
				pre-existing condition more than six months from the effective date of
				coverage. The policy or plan shall not define a pre-existing condition more
				restrictively than a condition for which medical advice was given or treatment
				recommended by or received from a physician within six months before the
				effective date of coverage.
D.
Home healthcare coverage:
(1)
				For purposes of the Minimum Healthcare Protection Act and this rule, home
				healthcare coverage offered shall include:
(a) services provided by a registered nurse
				or a licensed practical nurse;
(b)
				health services provided by physical, occupational and respiratory therapists
				and speech pathologists;
(c) health
				services provided by a home health aide; and
(d) medical supplies, drugs and medicines and
				laboratory services, to the extent they would have been covered if provided to
				the insured on an inpatient basis.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.10 - POLICY OR PLAN DISCLOSURE REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon offering coverage under a policy or
				plan for any individual, family or group member, an insurer, fraternal benefit
				society, health maintenance organization or nonprofit healthcare plan shall
				provide the individual, family or group member with a written disclosure
				statement in accordance with the requirements of Section 59A-23B-5A and B NMSA
				1978. Provided, however, that in the event of a lapse in healthcare coverage, a
				disclosure statement need not be offered by the same carrier upon reinstatement
				of the same policy or plan.
B.
				Before any insurer, fraternal benefit society, health maintenance organization
				or nonprofit healthcare plan issues a policy or plan contract, the insurer,
				fraternal benefit society, health maintenance organization or nonprofit
				healthcare plan shall obtain from the prospective policyholder, contract holder
				or member a signed written statement in accordance with the requirements of
				Section 59A-23B-5C and D NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.11 - FORMS AND RATES; RATING STANDARDS

Current through Register Vol. 35, No. 13, July 16, 2024
A. All policy or plan forms, including
				applications, enrollment forms, policies, plans, certificates, evidences of
				coverage, riders, amendments, endorsements, and disclosure forms shall be
				submitted to the department of insurance for approval prior to use.
B. No policy or plan may be issued in the
				state unless the rates have first been filed with and approved by the
				superintendent of insurance.
C. The
				superintendent shall approve rates for individual and family policies or plans
				and disapprove any rate if the benefits offered in such policies or plans are
				unreasonably restricted in relation to the premium charged.
D. Rates for group policies or plans, as such
				terms are defined in this rule, shall be reviewed for approval by the
				superintendent in accordance with the rating standards contained in the Small
				Group Rate and Renewability Act, Section 59A-23C-1 NMSA 1978, et seq.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.12 - ADVERTISING

Current through Register Vol. 35, No. 13, July 16, 2024
All printed, radio or television communication intended to be
				  used for marketing a policy or plan in the state and the disclosures required
				  by NMSA 1978 Section 59A-23B-5 A NMSA 1978 shall be submitted for review and
				  approval by the superintendent of insurance prior to use. The superintendent of
				  insurance shall complete the review within thirty days or the materials
				  submitted shall be deemed approved for use.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.13 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
The superintendent of insurance may revoke, suspend or refuse
				  to continue the license or certificate of authority of any person who fails to
				  comply with this rule and may impose such other applicable administrative
				  penalties as may be authorized by the Insurance Code.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to all insurers as defined in Section
				  59A-54-3 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to implement the Medical
				  Insurance Pool Act, Chapter 59A, Article 54 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the definitions in Section 59A-54-3 NMSA 1978,
				  as used in this rule:
A. Act means the
				Medical Insurance Pool Act, Chapter 59A, Article 54 NMSA 1978.
B. plan or plan of operation means this
				rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.8 - MEMBERSHIP

Current through Register Vol. 35, No. 13, July 16, 2024
A. All insurers
				admitted in New Mexico as of June 19, 1987 shall be members of this pool. Each
				insurer admitted after June 19, 1987 shall automatically become a member of the
				pool on the date of its admission. An insurer which ceases to be admitted after
				June 19, 1987 shall automatically cease to be a member effective on the day
				following the termination or expiration of its certificate of authority to
				transact health insurance; provided, however, that such insurer shall remain
				liable for any assessment based on net losses sustained by the pool prior to
				the cessation of its status as a member in the pool.
B. The board shall make all determinations
				regarding the eligibility of insurers as pool members. If an insurer is
				aggrieved by a final action or decision of the board, or if the board does not
				act on such complaint within 60 days, the insurer may appeal to the
				superintendent within 60 days after the action or decision of the board or the
				board's failure to act on such complaint.
C. Any member who is determined by the board
				to have failed to pay, in a timely fashion, any assessment or penalty due to
				the pool shall cease to be a member. The superintendent shall be advised of any
				insurer failing to continue its membership.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.9 - BOARD OF DIRECTORS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Appointed members.
The superintendent shall announce his
				appointments to the board at the annual membership meeting.
B.
Elected members.
(1) Prior to the annual membership meeting,
				members shall be contacted by mail by the administrator, or as otherwise
				directed by the board, to solicit nominations to succeed each board director
				who was elected by the general membership of the pool and whose term is
				scheduled to expire on June 30 of that year. If applicable, such nominee will
				ensure the required representation as set forth in Subsection C of Section
				59A-54-4 NMSA
				1978. Such nominees shall be made known to the members of the pool at least 30
				days prior to the annual membership meeting.
(2) The board shall compile a list of all
				members of the pool. At least 30 days prior to the annual membership meeting, a
				notice and proxy shall be sent to all members of the pool soliciting votes for
				membership on the board.
(3) At the
				annual membership meeting, the pool administrator shall tabulate the results
				and prepare a list of the nominees who have received the most votes for
				election to the board. Each pool member shall be entitled to cast one vote in
				electing a member to the board and shall be permitted to cast such vote in
				person or by proxy.
(4) In order to
				achieve consistent participation and representation, each elected member of the
				pool shall designate a person to serve on the board as its representative, with
				the ability to reappoint a person in the case of a permanent vacancy, with the
				provision for one identified alternate person.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.10 - ANNUAL MEMBERSHIP MEETING

Current through Register Vol. 35, No. 13, July 16, 2024
An annual meeting of the board shall be held no later than
				  March 31 of each year, at such time and place as the board may determine. At
				  each annual meeting, the board shall:
A. review the plan and submit to the
				superintendent any amendments to the plan necessary or suitable to assure the
				fair, reasonable, and equitable administration of the pool; review each
				outstanding contract or agreement, if any, and make necessary or desirable
				corrections, improvements, or additions;
B. review operating expenses and outstanding
				contractual obligations and determine if an assessment is necessary for the
				proper administration of the pool and, if so, the amount; if such assessment is
				deemed to be necessary, the board shall levy such assessment based on the
				criteria set forth in Section
				59A-54-10 NMSA 1978;
				the board may adopt other or additional methods of adjusting the formula to
				achieve equity of assessments among pool members; the board may abate or defer
				in any part the assessment of a member, if, in the opinion of the board,
				payment of the assessment would endanger the ability of the member to fulfill
				its contractual obligations; the assessment shall be imposed annually as
				provided by Subsection F of Section
				59A-54-5 NMSA
				1978 by the pool administrator; any assessment of less than $50 may be deferred
				by the board;
C. review operating
				policies and practices, policy forms, and rates for coverage issued by the
				pool;
D. review, consider, and act
				on any other matters deemed by it to be necessary and proper for the
				administration of the pool;
E.
				review and evaluate the performance of the pool administrator.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.12 - OFFICERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The officers of
				the board will be the chairman of the board, a vice-chairman, a secretary and
				treasurer, and such other officers as the board may decide, who will be elected
				annually by the board at its annual meeting to serve until their successors are
				elected and qualified. An officer, except the chairman, may be removed with or
				without cause by the board, or may resign. Vacancies and newly created offices
				will be filled by the board. One person may hold more than one office, but no
				person may be both chairman of the board and secretary. Officers will perform
				the duties, and will have the power and authority, assigned by the board,
				incident to the office, and provided in this plan.
B. The chairman of the board shall preside at
				meetings of the board and shall assume such duties as shall be designated from
				time to time by the board. The chairman, when authorized by the board, will
				execute and deliver documents in the name of the pool.
C. The vice-chairman of the board shall
				function in the absence of the chairman.
D. The secretary will review the records of
				the pool and the minutes of the proceedings of the directors; will give all
				notices required; and when authorized will execute, attest, seal, and deliver
				documents of the board.
E. The
				treasurer will be responsible for reviewing financial records and accounts for
				the pool.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.13 - COMMITTEES

Current through Register Vol. 35, No. 13, July 16, 2024
A. Appointment. The
				board shall appoint such committees as it may from time to time deem necessary.
				Such committees may include, but are not limited to, an executive, finance,
				policy, procurement and legal committees.
B. Delegation of authority. The board may
				authorize a committee to take any action that the board has the power to take
				except for action on assessments, premiums, changes in policy benefits, and
				changes in the plan of operation as long as the motion to delegate the
				authority passes by a vote sufficient to fulfill the vote requirements for the
				board itself to take the delegated action.
C. Expenses. Members of special or standing
				committees may be allowed expenses for attending committee meetings as
				determined by the board subject to the Per Diem and Mileage Act.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.15 - POOL RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				pool will provide and accept applications for health insurance, and for any
				other insurance plans developed by the board, which contain standard policy
				provisions as specified by the act.
B. The pool shall develop a plan for the
				periodic advertising of the general availability of health insurance coverage
				from the pool.
C. The pool may
				develop and promulgate a list of health conditions, the existence of which
				would make an applicant eligible for coverage without demonstrating the need
				for rejection of coverage by one carrier.
D. The pool may adopt any additional
				provisions necessary or proper for the execution of the powers and duties of
				the pool.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.16 - INTERESTED PARTIES

Current through Register Vol. 35, No. 13, July 16, 2024
No contract or transaction between the pool and one or more
				  of its directors, or between the pool and any other corporation, partnership,
				  association, or other organization in which one or more of its directors are
				  directors or officers, or have a financial interest, shall be void or voidable
				  solely for this reason, or solely because the director is present at or
				  participates in the meeting of the board or committee thereof which authorizes
				  the contract or transaction, or solely because his or their votes are counted
				  for such purpose, if:
A. the material
				facts as to his relationship or interest and as to the contract or transaction
				are disclosed or are known to the board or the committee, and the board or
				committee in good faith authorizes the contract or transaction by the
				affirmative votes of a majority of the disinterested directors, even though the
				disinterested directors be less than a quorum; or
B. the material facts as to his relationship
				or interest and as to the contract or transaction are disclosed or are known to
				the directors entitled to vote thereon, and the contract or transaction is
				specifically approved in good faith by vote of the directors; or
C. the contract or transaction is fair to the
				pool as of the time it is authorized, approved, or ratified, by the board, or a
				committee thereof; common or interested directors may be counted in determining
				the presence of a quorum at a meeting of the board or of a committee which
				authorizes the contract or transaction.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.17 - RECORDS AND REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The fiscal
				year of the pool shall coincide with the calendar year.
B. The board shall make an annual report to
				the superintendent as required by the act. The annual report shall include an
				audited financial report for the preceding calendar year in a form approved by
				the superintendent and a review of the activities of the pool during the
				preceding calendar year.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.18 - BROKER/AGENT POLICY

Current through Register Vol. 35, No. 13, July 16, 2024
A. The board
				may enter into an agreement with a licensed insurance broker or agent to submit
				pool applications for insurance coverage.
B. The applications submitted must conform to
				pool rules and regulations.
C. Upon
				submission of an application by the broker or agent and issuance of a policy by
				the pool, the broker or agent shall become entitled to a referral fee
				established by the board.
D. In
				order to be entitled to the payment established by the board, the broker or
				agent must execute an agreement entered into between the pool and the broker or
				agent.
E. No broker or agent shall
				be authorized to accept applications for pool coverage unless he or she has an
				errors and omissions insurance policy in an amount not less than $500,000.
				Proof of such coverage must be provided to the pool administrator.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.19 - INDEMNIFICATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. All persons,
				except the superintendent and his staff, described in the act shall be
				indemnified by the pool for all expenses incurred in the defense of any action,
				suit, or proceeding brought against such person on account of any action taken
				by him in the performance of his powers and duties under the act, unless such
				person shall be finally adjudged to have committed a breach of duty involving
				gross negligence, bad faith, dishonesty, willful misfeasance, or reckless
				disregard of the responsibilities of his office. In the event of settlement
				before final adjudication, such indemnity shall be provided only if the pool is
				advised by independent counsel that such person did not, in such counsel's
				opinion, commit such a breach of duty. The expense of such indemnification
				shall be assessed against member insurers in accordance with Section
				59A-54-10 NMSA 1978.
				Any reference to persons in this section shall include the board or a committee
				thereof.
B. The indemnification
				provided by this section will not be deemed exclusive of any other rights to
				which those indemnified may be entitled under any other laws, including but not
				limited to Section
				59A-54-18 NMSA
				1978, agreements, votes of disinterested directors, or otherwise, both as to
				action in such person's official capacity and as to action in another capacity
				while holding such office, and will continue as to a person who has ceased to
				be a director, employee, or agent and will inure to the benefit of the heirs
				and personal representative of that person.
C. The pool, upon resolution adopted by the
				board, may purchase and maintain insurance on behalf of any person who is or
				was a director, employee, or agent of the pool who, while a director, employee,
				or agent of the pool, is or was serving at the request of the pool as a
				director, employee, or agent of another foreign or domestic corporation,
				partnership, joint venture, trust, other enterprise or employee benefit plan,
				against any liability asserted against and incurred by the person in any such
				capacity or arising out of the person's status as such, whether or not the pool
				would have the power to indemnify the person against such liability under the
				provisions of this section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.20 - CONFORMITY TO STATUTE

Current through Register Vol. 35, No. 13, July 16, 2024
In case of a conflict between the provisions of the act and
				  this plan, the provisions of the act shall control.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.21 - GRIEVANCE PROCEDURES

Current through Register Vol. 35, No. 13, July 16, 2024
Any person, including any pool member, applicant for
				  coverage, or any claimant, aggrieved by actions of the pool, shall submit their
				  complaints in writing to the pool administrator and those complaints shall be
				  resolved in accordance with grievance procedures established by the board. The
				  grievance procedures must be exhausted before commencement of any suit against
				  the pool, the pool administrator, or the board.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.22 - INITIAL ASSESSMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Each insurer, as defined in Section 59A-54-3 NMSA 1978 shall
				  be assessed an initial assessment of $500 at the time it becomes a member of
				  the pool.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.23 - PREMIUM INFORMATION

Current through Register Vol. 35, No. 13, July 16, 2024
All reports regarding premium information requested of the
				  members by the pool for purposes of determining assessment amounts must be
				  signed by an officer of the member. No adjustments to that premium information
				  will be accepted from any member after the date for submission of the
				  information has passed, with the exception of errors relating to categories of
				  premiums not allowed to be assessed by the Act or other laws.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.24 - ASSESSMENT POLICY

Current through Register Vol. 35, No. 13, July 16, 2024
A. Interim and
				final assessments to pool members shall be mailed at least 30 days prior to the
				due date for payment.
B. To
				determine the amount of premium upon which a member's final assessment will be
				based for a particular year, the administrator shall mail the reporting form to
				each member no later than April 1 of the following year. The reporting form
				shall be completed, signed by an officer of the member, and returned to the
				pool. The amount of premium reported shall be reviewed by the pool
				administrator with the assistance of the Office of Superintendent of
				Insurance.
C. Any proposed
				adjustment to the amount of premium reported shall be reviewed for approval by
				the board. If any adjustment to the amount of premium is made as a result of
				that review, the member affected by the adjustment will be notified in writing
				of the adjustment.
D. Any member
				who wishes to appeal the amount of its interim or final assessment may do so in
				writing to the board. Any appeal must be submitted to the board within 30 days
				of notice of the assessment. The submission must include the basis for the
				appeal and all relevant facts and legal argument the appellant wishes the board
				to have before it when deciding the appeal. At the discretion of the board,
				oral presentations to the board may be allowed.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 10 - MEDICAL INSURANCE POOL PLAN OF OPERATION › Section 13.10.10.25 - REFUNDS AND ADJUSTMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
After the final assessments for a particular year have been
				  determined and collected, the pool administrator and the board shall determine
				  if any member has overpaid its assessments. If any such overpayment has been
				  made, the pool administrator, upon approval by the board, shall refund to the
				  member the amount of the overpayment. No interest shall be paid by the pool on
				  the overpayment, unless such payment was paid under protest as specified in
				  Subsection F of Section 14 of this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to all persons who transact the business of
				  health insurance in New Mexico or have dealings with the
alliance
.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-56-5 and 59A-56-21 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
June 1, 2001, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to implement the Health Insurance
				  Alliance Act, Chapter 59A, Article 56 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the definitions in Section 59A-56-3 NMSA 1978,
				  as used in this rule:
A.
act
means the Health Insurance Alliance Act, Chapter 59A, Article 56
				NMSA 1978;
B.
alliance
means the New Mexico health insurance alliance;
C.
plan or plan of operation
means this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.8 - MEMBERSHIP

Current through Register Vol. 35, No. 13, July 16, 2024
A. All persons
				listed in Section 59A-56-4 NMSA 1978 of the act shall organize and remain
				members of the
alliance
as a condition of their authority to
				transact insurance business in New Mexico.
B. Such persons who were authorized to
				transact insurance business in New Mexico as of March 4, 1994, shall be members
				of this
alliance
. Each insurer admitted thereafter shall
				automatically become a member of the
alliance
effective on the
				date of its admission. A member which ceases to be admitted after said date
				shall automatically cease to be a member effective on the day following the
				termination or expiration of its certificate of authority to transact the
				business of health insurance as defined in the act; provided, however, that
				such member shall remain liable for any assessment or assessments based on net
				losses sustained by the
alliance
through the end of the year of
				cessation. This liability shall constitute a claim against the member's deposit
				with the insurance division.
C.
				Issues of determination of eligibility of any person or entity as an
alliance
member shall be resolved by the board of directors. If a
				member is aggrieved by the final action or decision of the board, or if the
				board does not act on such complaint within 60 days, the member may appeal to
				the superintendent. Such appeal must be filed within 60 days after the action
				or decision of the board or the board's failure to act on such
				complaint.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.9 - BOARD OF DIRECTORS

Current through Register Vol. 35, No. 13, July 16, 2024
A. There
				shall be a board of directors, who shall be appointed or elected in accordance
				with the provisions of the act.
(1) The
				elected directors shall be elected by the members of the
alliance
as hereinafter provided.
(a) There shall be
				an annual membership meeting of all the
alliance
members no later
				than June 30 of each year for transaction of any appropriate business,
				including the election of member representatives to the board of
				directors.
(b) Prior to the annual
				membership meeting, the board of directors or its nominating committee shall
				select a nominee to succeed each board director who was elected by the general
				membership of the
alliance
and not appointed by the governor, and
				whose term is scheduled to expire on June 30 of that year. Such nominee will
				ensure that the required representation of members as set forth in the act is
				maintained. Nominees shall be made known to the members of the
alliance
at least 30 days prior to the annual membership
				meeting.
(c) The board of directors
				shall compile a list of all members of the
alliance
. At least 30
				days prior to the annual membership meeting, a notice and proxy shall be sent
				to all members of the
alliance
soliciting votes for membership of
				the board of directors. Each
alliance
member shall be entitled to
				cast one vote in electing a member to the board and shall be permitted to cast
				such vote in person, by mail or facsimile, or by proxy.
(d) The results of the election shall be
				tabulated and announced at the annual meeting.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.10 - OFFICERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The officers of
				the board will be the chair of the board, a vice chair, and a secretary, and
				such other officers as the board may decide, who, except for the chair, will be
				elected annually by the board at its annual meeting to serve until their
				successors are elected and qualified. The superintendent shall serve as chair,
				unless he declines, in which event he shall appoint the chair. An officer,
				except the chair, may be removed with or without cause by the board, or may
				resign. Vacancies and newly created offices will be filled by the board. One
				person may hold more than one office, but no person may be both chair of the
				board and secretary. Officers will perform the duties, and will have the power
				and authority, assigned by the board, incident to the office, and provided in
				this plan.
B. The chair shall
				preside at meetings of the board of directors and shall assume such duties as
				shall be designated from time to time by the board of directors and as are
				consistent with the provisions of the act. The chair, when authorized by the
				board, will execute and deliver documents in the name of the
alliance
.
C. The vice
				chair of the board of directors shall function in the absence of the
				chair.
D. The secretary shall be
				responsible for the records of the
alliance
and the minutes of the
				proceedings of the directors; will give all notices required; and when
				authorized will execute, attest, seal, and deliver documents of the
				board.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.11 - COMMITTEES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The board shall
				have the standing committees set forth below. Members of the committees shall
				be named by and serve at the pleasure of the chair. In addition to the
				authority specified, the committees shall have such duties and responsibilities
				as may be delegated to them from time to time by the board.
(1)
Executive committee.
The
				executive committee shall be comprised of the chair, the vice-chair, and the
				secretary, as well as the chairs of the finance and marketing committees and
				such other members of the board as the chair may designate. The executive
				committee shall have the authority to act for the board between meetings,
				subject to ratification by the board, and shall act as the board's audit
				committee.
(2)
Finance
				committee.
The finance committee shall be comprised of the chair and
				such other persons as the chair may designate. The finance committee shall be
				responsible for oversight of the financial affairs of the
alliance
, and for developing policies and procedures to manage
				such affairs, subject to approval by the board.
(3)
Marketing committee.
The
				marketing committee shall be comprised of at least one member of the board and
				such other persons as the chair may designate. The marketing committee shall
				have the authority to approve marketing expenditures within a budget and limits
				approved by the board.
(4)
Grievance committee.
The grievance committee shall be comprised of
				members of the board. The committee shall include at least three members, and
				shall be responsible for hearing and determining grievances in accordance with
				13.10.11.17 NMAC and for resolving such other matters as may be delegated to it
				by the board. The chair may designate alternates to serve in the event a
				conflict of interest prevents a board member from participating in any
				grievance procedure.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.13 - INTERESTED PARTIES

Current through Register Vol. 35, No. 13, July 16, 2024
No contract or transaction between the
alliance
and one or more of its directors, or between the
alliance
and any
				  other corporation, partnership, association or other organization in which one
				  or more if its directors are directors or officers, or have a financial
				  interest, shall be void or voidable based only on one or more of the
				  following:
A. the financial
				interest;
B. the presence at or
				participation in the meeting authorizing the contract or transaction;
				or
C. the counting of the
				director's vote for such purpose, if:
(1) the
				material facts as to his relationship or interest and as to the contract or
				transaction are disclosed or are known to the board of directors or the
				committee, and the board or committee in good faith authorized the contract or
				transaction by the affirmative votes of a majority of the disinterested
				directors or the committee, and the board or committee in good faith authorized
				the contract or transaction by the affirmative votes of a majority of the
				disinterested directors, even though the disinterested directors be less than a
				quorum; or
(2) the material facts
				as to his relationship or interest and as to the contract or transaction are
				disclosed or are known to the directors entitled to vote thereon, and the
				contract or transaction is specifically approved in good faith by vote of the
				directors; or
(3) the contract or
				transaction is fair as to the
alliance
as of the time it is
				authorized, approved or ratified, by the board of directors, or a committee
				thereof. Common or interested directors may be counted in determining the
				presence of a quorum at a meeting of the board of directors or of a committee
				which authorized the contract or transaction.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.14 - RECORDS AND REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				fiscal year of the
alliance
shall be determined by the
				board.
B. The board of directors
				shall conduct periodic audits to assure the general accuracy of the financial
				data submitted to the
alliance
pursuant to Section 59A-56-11 NMSA
				1978. The board shall cause the
alliance
to have an annual audit
				of its financial statements by an independent certified public
				accountant.
C. The
alliance
shall be subject to and responsible for examination by
				the superintendent. Not later than March 1 of each year, the board of directors
				shall submit to the superintendent an audited financial report for the
				preceding calendar year in a form approved by the superintendent. The report
				shall also review the activities of the
alliance
during the
				preceding calendar year.
D. All
				policy forms issued through the
alliance
shall conform to the
				requirements of the act and must be filed with and approved by the
				superintendent before their use.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.15 - AGENTS

Current through Register Vol. 35, No. 13, July 16, 2024
The
alliance
may pay referral or servicing fees
				  or commissions subject to applicable provisions in the Insurance Code, or may
				  require carriers to pay a commission to the insurance agent who refers an
				  applicant to the
alliance
if that applicant is accepted. No agent
				  shall be eligible to receive a commission or referral fee on or in connection
				  with a plan issued through the
alliance
unless the agent has
				  completed a continuing education course sanctioned by the
alliance
and has been certified by the
alliance
. Agents that have not
				  enrolled any individual or group in the
alliance
for a period of
				  two (2) years shall recertify. The
alliance
may decertify an agent
				  for good cause, subject only to review pursuant to the grievance procedures set
				  forth in
				  13.10.11.17
				  NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.16 - INDEMNIFICATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. All persons,
				except the superintendent and his staff, described in the act shall be
				indemnified by the
alliance
for all expenses incurred in the
				defense of any action, suit or proceeding brought against such person on
				account of any action taken by him in the performance of his powers and duties
				under the act, unless such person shall be finally adjudged to have committed a
				breach of duty involving gross negligence, bad faith, dishonesty, willful
				misfeasance or reckless disregard of the responsibilities of his office. This
				right of indemnification shall not extend to acts or omissions arising solely
				from a member's administration of an approved health plan. In the event of
				settlement before final adjudication, such indemnity shall be provided only if
				the
alliance
is advised by independent counsel that such person
				did not, in such counsel's opinion, commit such a breach of duty. The expense
				of such indemnification shall be assessed against member insurers in accordance
				with Section 59A-56-11 NMSA 1978. Any reference to persons in this article
				shall include the board or a committee thereof.
B. The indemnification provided by this
				section will not be deemed exclusive of any other rights to which those
				indemnified may be entitled under any other laws, agreements, voted of
				disinterested directors, or otherwise, both as to action in such person's
				official capacity and as to the action in another capacity while holding such
				office, and will continue as to a person who had ceased to be a director,
				employee or agent and will inure to the benefit of the heirs and personal
				representative of that person.
C.
				The
alliance
, upon resolution adopted by the board, may purchase
				and maintain insurance on behalf of any person who is or was a director,
				employee or agent of the
alliance
who, while a director, employee
				or agent of the
alliance
or is or were serving at the request of
				the
alliance
as a director, employee or agent of another foreign
				or domestic corporation, partnership, joint venture, trust, other enterprise or
				employee benefit plan, against any liability asserted against and incurred by
				the person in any such capacity or arising out of the person's status as such,
				whether or not the
alliance
would have the power to indemnify the
				person against such liability under the provisions of this section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.17 - COMPLAINT AND GRIEVANCE PROCEDURES

Current through Register Vol. 35, No. 13, July 16, 2024
In the event an insured, an agent, a group or a member
				  believes the performance of the
alliance
or a member does not meet
				  its expectations or conform to a policy or plan issued by a member through the
alliance
, that person may bring the matter to the attention of the
alliance
by a complaint or grievance. The
alliance
shall act promptly and impartially when considering all complaints and
				  grievances.
A.
Definitions.
As used in this section:
(1)
complaint
means a
				relatively minor verbal or written expression of concern which may lend itself
				to resolution on an informal basis and which relates to the operation or
				decision of the
alliance
or a member of the
alliance
;
(2)
grievance
means a more serious written expression of concern or a
				complaint which had not been resolved to the person's satisfaction; both
				situations require a thorough investigation and a formal response to the
				parties;
(3)
group
means a small employer group eligible for coverage or covered by an insurance
				policy, nonprofit health care plan contract or HMO plan issued through the
alliance
by a member; and
(4)
insured
means a person
				covered under an insurance policy or a nonprofit health care plan contract, or
				enrolled in an HMO plan issued through the
alliance
by a
				member;
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.18 - AMENDMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
The plan of operation may be altered, amended, or repealed by
				  a two-thirds vote of directors elected or appointed, and approval of such
				  action by the superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.19 - ELIGIBILITY CRITERIA

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				eligibility criteria in 13.10.11.20 NMAC through 13.10.11.33 NMAC apply to
				approved health plans for small employers; the eligibility criteria in
				13.10.11.34 NMAC apply to approved health plans for individual
				coverage.
B. Members may utilize
				their normal business practices in implementing an approved health plan to the
				extent such practices are not inconsistent with the act, this rule, other
				applicable laws and regulations, or the approved health plan's benefit
				design.
C. Any misrepresentation
				relating to an employer's eligibility as a small employer or to an individual's
				eligibility for coverage may be grounds for rescission or cancellation of
				coverage and such other action as may be appropriate under law.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.20 - ELIGIBILITY AS A SMALL EMPLOYER

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				An employer is eligible as a small employer if:
(1) the employer, if a corporation, is
				incorporated in New Mexico or is authorized to do business in New Mexico; if a
				person or other organization, is a resident of this state or has its principal
				place of business in this state; and
(2) at least 50 percent of all of its
				employees, eligible or not, live in New Mexico; and
(3) on at least 50 percent of its working
				days during either of the two preceding calendar years, the employer had at
				least two and no more than 50 eligible employees.
(a) If the employer has been in business for
				less than one calendar year, the determination of whether an employer is a
				small employer shall be based on the average number of employees that it is
				reasonably expected to employ on working days in the current calendar
				year.
(b) A spouse or dependent of
				an employee, whether or not working in the business, may, at the employer's
				discretion, be counted as a separate employee for the sole purpose of
				determining the number of eligible employees. A spouse or dependent enrolling
				who is not employed in the business must still enroll for dependent coverage
				and need not complete an employee application; a spouse or dependent employed
				in the business has the option of enrolling as a dependent or an
				employee.
(c) Any self-employed
				person and all employees who comprise the "two to 50 group" of eligible
				employees must work for the qualifying business a minimum of 20 hours per week
				on a regular basis.
(d) Casual
				laborers and volunteers are not eligible.
(e) An employee eligible or enrolled in
				medicare shall be considered an eligible employee for the sole purpose of
				determining whether an employer is a small employer, provided that that
				employee otherwise qualifies as an eligible employee.