reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 5 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 13.10.5.8 - EFFECTIVE DATE OF DISCONTINUANCE FOR NON-PAYMENT OF PREMIUM

Current through Register Vol. 35, No. 13, July 16, 2024
A. If a group
				contract provides for automatic discontinuance of the contract after a premium
				has remained unpaid through the grace period allowed for the payment, the
				carrier shall be liable for valid claims for covered losses incurred prior to
				the end of the grace period. The carrier shall, however, be entitled to the
				premium due for coverage provided during the grace period.
B. If the carrier treats the group contract
				as continuing in force after the end of the grace period by recognizing claims
				incurred after the end of the grace period, the carrier shall be liable for
				valid claims for losses beginning prior to the effective date of written notice
				of discontinuance to the group contract holder responsible for making premium
				payments to the carrier. The effective date of discontinuance shall not be
				prior to midnight at the end of the third scheduled work day after the date
				upon which the notice is delivered to the last known address of the
				policyholder.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 5 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 13.10.5.9 - REQUIREMENTS FOR NOTICE OF DISCONTINUANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A. The carrier shall notify the group
				contract holder of the date the group contract will discontinue and that,
				unless otherwise provided in the group contract, the carrier shall not be
				liable for claims for losses incurred after the date of
				discontinuance.
B. The carrier
				shall also be responsible for notifying all persons covered by the group
				contract of the discontinuance within ten working days of notice to the group
				contract holder in whatever manner the carrier customarily uses to provide such
				notice. The notice shall:
(1) indicate the
				effective date of the discontinuance;
(2) advise, in any instance in which the plan
				involves employee contributions, that if the group contract holder continues to
				collect contributions for the coverage after the date of discontinuance, the
				group contract holder may be held solely liable for the benefits with respect
				to the period for which the contributions have been collected;
(3) state that, unless otherwise provided in
				the group contract, the carrier shall not be liable for claims for losses
				incurred after the date of discontinuance; and
(4) encourage covered persons to refer to
				their certificates in order to determine what rights, if any, are available to
				them upon the discontinuance.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 5 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 13.10.5.10 - EXTENSION OF BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
Every group contract must include a provision for reasonable
				  extension of benefits in the event of total disability on the date of
				  discontinuance of the group contract, as required by this section.
A. In the case of a group life plan which
				contains a disability benefit extension of any type (e.g., premium waiver
				extension, extended death benefit in event of total disability, or payment of
				income for a specified period during total disability), discontinuance of the
				group contract shall not operate to terminate the extension.
B. In the case of a disability income
				contract providing benefits for loss of time from work, or specific indemnity
				during hospital confinement on an accrued liability basis, discontinuance of
				the group contract during a disability or confinement shall have no effect on
				benefits payable for that disability or confinement.
C. In the case of hospital or medical expense
				coverage and HMO plans other than dental and maternity expense, a reasonable
				extension of benefits or accrued liability provision is required. The provision
				will be considered reasonable if it provides an extension of at least twelve
				months under major medical and comprehensive medical type coverage and HMO
				plans, and under other types of hospital or medical expense coverage provides
				either an extension of at least ninety days or an accrued liability for
				expenses incurred during a period of disability or during a period of at least
				ninety days starting with a specific event which occurred while coverage was in
				force (e.g., an accident).
D. Any
				applicable extension of benefits or accrued liability shall be described in the
				group contract as well as in group insurance certificates. The benefits payable
				during any period of extension or accrued liability may be subject to the group
				contract's regular benefit limits (e.g., benefits ceasing at exhaustion of a
				benefit period or of maximum benefits or benefit restrictions for services
				provided by unaffiliated providers of an HMO) but in no event shall benefits be
				reduced solely because of the discontinuance of the group contract except as
				otherwise permitted by this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 5 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 13.10.5.11 - LIABILITY OF PRIOR CARRIER WHEN GROUP CONTRACT REPLACED

Current through Register Vol. 35, No. 13, July 16, 2024
A. The prior carrier remains liable only to
				the extent of its accrued liabilities and extensions of benefits. The position
				of the prior carrier shall be the same whether the group contract holder or
				other entity secures replacement coverage from a new carrier, the same carrier,
				self-insures, or foregoes the provision of coverage.
B. The prior carrier, if an HMO, may limit
				the extension of benefits for a totally disabling illness, injury, or condition
				to services provided by or through its participating providers, unless services
				are rendered on an emergency basis.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 5 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 13.10.5.12 - LIABILITY OF SUCCEEDING CARRIER WHEN GROUPCONTRACT REPLACED

Current through Register Vol. 35, No. 13, July 16, 2024
A. Each person who
				is eligible for coverage in accordance with the succeeding carrier's plan of
				benefits shall be covered by that carrier's plan of benefits.
B. Each person not covered under the
				succeeding carrier's plan of benefits in accordance with 13 NMAC 10.5.12.1 [now
				Subsection A of 13.10.5.12 NMAC] must nevertheless be covered by the succeeding
				carrier in accordance with the following standards if the individual was
				validly covered (including by extension of benefits) under the prior plan on
				the date of discontinuance and if the individual is a member of the class of
				individuals eligible for coverage under the succeeding carrier's plan. Any
				reference in this rule to an individual who was or was not totally disabled is
				a reference to the individual's status immediately prior to the date the
				succeeding carrier's coverage becomes effective.
(1) The minimum level of benefits to be
				provided by the succeeding carrier:
(a) when
				the succeeding carrier is not an HMO, shall be the applicable level of benefits
				of the prior carrier's plan reduced by any benefits payable by the prior
				plan;
(b) when the succeeding
				carrier is an HMO, shall be the HMO's own level of benefits, reduced by
				benefits provided or payable by the prior plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 5 - GROUP COVERAGE DISCONTINUANCE AND REPLACEMENT › Section 13.10.5.13 - LIABILITY WHEN THE SUCCEEDING CARRIER IS AN HMO

Current through Register Vol. 35, No. 13, July 16, 2024
A. 13 NMAC 10.5.12.2.1 and 10.5.12.4 [now
				Paragraph (1) of Subsection B of 13.10.5.12 NMAC and Subsection D of 13.10.5.12
				NMAC] do not apply to federally qualified HMOs as long as they are not
				permitted to require actively at work, hospital non-confinement rules, medical
				evidence of insurability, or pre-existing condition limitations.
B. In situations where services for a totally
				disabled person are provided by the succeeding HMO, the succeeding HMO may bill
				the prior carrier for the reasonable cash value of services provided when the
				prior carrier has an obligation under its required extension of benefits. The
				prior carrier shall make direct payment to the succeeding HMO for the cost of
				the services provided.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico State Corporation Commission [Public Regulation
				  Commission], Department of Insurance, Post Office Box 1269, Santa Fe, NM
				  87504-1269.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A. This rule
				applies to all prepaid dental organizations in the state of New
				Mexico.
B. The health services
				division may issue further rules in areas of its responsibilities from time to
				time and those rules must be considered when interpreting this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
November 20, 1979, unless a later date is cited at the end of
				  a section or paragraph. Repromulgated in NMAC format effective July 1,
				  1997.
Compiler's note: The words or paragraph, above, are no
					 longer applicable. Later dates are now cited only at the end of sections, in
					 the history notes appearing in
					 brackets.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to specify the requirements for
				  prepaid dental organizations in accordance with the Prepaid Dental Plan Law,
				  Section 59A-48-1 NMSA 1978 et seq.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For the purpose of this rule:
A.
"Agent"
means a person
				appointed by a prepaid dental plan to transact business in this state to act as
				its representative in any given locality for the purpose of soliciting members
				to be enrolled by contract providing dental care.
B.
"Director of the health services
				division"
means the chief officer of the health services division of the
				department of health of the state of New Mexico.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.8 - LICENSING OF PREPAID DENTAL PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
For the protection of the public in New Mexico, the
				  superintendent will issue, renew and permit to exist any prepaid dental plan to
				  enroll members in a group to provide a prepaid dental plan in compliance with
				  the provisions of Section 59A-48-1 NMSA 1978 et seq., with respect to the
				  requirements in this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.9 - GENERAL REQUIREMENTS AND COMPLIANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Where this rule requires a prepaid dental
				plan to have policies, procedures, plans, class specification, orders, reports,
				minutes of meetings, contracts, agreements, records, duty schedules, or other
				such items, such requirement means written documents compiled and indexed in
				one or more manuals which shall be readily available for examination by the
				superintendent or the director of the health services division or their
				representatives.
B. Any prepaid
				dental plan submitting an application for a certificate of authority to the
				superintendent shall, at the same time, submit to the director of the health
				services division a plan of compliance detailing the manner in which the
				prepaid dental plan will comply with the requirements of the rules of the
				department of insurance and the health services division.
C. The prepaid dental plan shall be cleared
				by the director of the health services division first before it may be approved
				for a certificate of authority by the superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.10 - PREPAID DENTAL PLAN CERTIFICATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. The prepaid dental plan shall submit a
				statement describing its proposed dental care plan, facilities, and personnel
				to the director of the health services division for certification. The
				statement shall indicate the manner which the prepaid dental plan will comply
				with the following requirements:
(1) The
				prepaid dental plan shall have an organized system for the delivery of those
				dental care services. The system shall include general dentists, and may
				include specialists, licensed dental hygienists and other professional and
				technical personnel. The system shall include a procedure which promotes a
				continuing relationship to be established between a member and the same general
				dentist and a procedure for effective referrals to assure continuity of care to
				members.
(2) The prepaid dental
				plan shall list (using full-time equivalents for providers) the proposed or
				actual:
(a) names of members enrolled and
				whether they have elected dependent coverage;
(b) dentist staffing for the projected
				enrollment, identifying board of eligibility or certification of each dentist
				listed when such identification exist; in lieu of such identification all staff
				dentists will be considered general dentists;
(c) dental support staff by number and
				type;
(d) provision for providing
				specialty dental services.
(3) All care provided by the prepaid dental
				plan whether provided by its own personnel or on a contract basis shall be by
				licensed practitioners of the healing arts when such licensure is required by
				law and shall otherwise be in accordance with applicable laws and
				rules.
(4) Emergency dental
				services described in 13 NMAC 10.6.11.1 [now Subsection A of 13.10.6.11 NMAC]
				shall be available for enrolled members on a seven day per week and 24 hours
				per day basis.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.11 - MINIMUM BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
All plans shall include at least the following basic dental
				  services which shall be covered by the prepaid charges set forth in the
				  evidence of coverage. If other dental services will be available to eligible
				  members on a voluntary basis, they must be listed in the plan. Dental services
				  not included in the plan shall be shown as exclusions.
A.
Emergency services:
Emergency
				dental services are those necessary to control bleeding, relieve pain, and
				eliminate acute infection.
B.
Diagnostic services:
Diagnostic dental services are those services
				necessary to identify dental abnormalities. They shall include but need not be
				limited to radiographs and clinical examination.
C.
Preventive services:
Preventive dental services shall include but need not be limited to oral
				prophylaxis, the application of topical fluorides when applicable, and a viable
				maintenance care recall system accompanied by evidence that this recall system
				is fully implemented.
D.
Therapeutic services:
Therapeutic services shall include:
(1) pulp therapy for permanent and primary
				teeth exclusive of root canal therapy,
(2) restoration of carious (decayed)
				permanent and primary teeth with materials other than cast
				restorations,
(3) routine tooth
				extractions.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.12 - GEOGRAPHIC AREA STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				prepaid dental plan shall submit a statement which describes the geographic
				area or areas to be served.
(1) A geographic
				area should be reasonably contiguous and one within which services offered and
				provided will be reasonably accessible to members and prospective
				members.
(2) The organization shall
				attach a map or maps to the statement on which are indicated the boundaries of
				the proposed geographic area or areas and the locations of all facilities in
				which dental care will be provided by contractors to the
				organization.
(3) All advertising
				matter and sales material provided to prospective enrollees must include a
				description on the geographic area or areas in terms readily understandable by
				the general public.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.13 - CHIEF EXECUTIVE OFFICER OF PREPAID DENTAL PLAN

Current through Register Vol. 35, No. 13, July 16, 2024
A. The prepaid dental plan shall appoint a
				designated representative who shall have appropriate education and/or
				experience to qualify him for the management of the organization. The prepaid
				dental plan shall define in writing, the authority and duties of the chief
				executive officer. The chief executive officer shall be appointed
				representative of the prepaid dental plan and shall be the executive officer of
				the prepaid dental plan. The person shall be responsible for implementation of
				established policies in the operation of the organization and for providing
				liaison between prepaid dental plan providers of dental care and providers of
				other services for the prepaid dental plan. The person shall be in charge of
				the management of the prepaid dental plan and shall be authorized and empowered
				to carry out the provisions of this article and shall be charged with the
				responsibility of doing so. The chief executive officer shall establish in
				writing a plan indicating the line of authority during periods of his
				absence.
B. When there is a change
				of chief executive officer, the prepaid dental plan shall notify the director
				of the health services division and the superintendent within ten days after
				the effective date of change.
C.
				The prepaid dental plan shall require providers to assure that all employees
				and health practitioners covered by service agreements are adequately
				knowledgeable and qualified to perform the duties assigned to them through
				employment or by contract.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.14 - DENTAL DIRECTOR

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				prepaid dental plan shall designate a New Mexico licensed dentist as dental
				director.
B. The dental director
				shall be responsible for planning and implementing the method for the
				continuing review and evaluation of dental care provided and the continuing
				education of the providers of dental services. The dental director may also
				serve as the chief executive officer provided he has appropriate education
				and/or experience to qualify him for the management of the
				organization.
C. The dental
				director's responsibility shall include, but not be limited to:
(1) supervision including performance
				planning and evaluation of dental staff.
(2) coordination of activities of dental
				staff.
(3) development of dental
				care policies.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.15 - DENTAL RECORDS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The prepaid
				dental plan shall assure that a unit dental record system capable of readily
				providing necessary clinical information is maintained.
B. The dental record shall be maintained at
				the appropriate provider facility in accordance with acceptable professional
				standards and shall include records covering all symptoms presented, diagnosis
				made and dental treatment provided to each member of the prepaid dental plan by
				its provider group(s) during the term of his membership. This requirement
				applies to all dental services provided to members whether provided by
				employees of the organization or nonemployees (contractors) at the request of
				the prepaid dental plan.
C. Dental
				records shall be confidential and shall not be disclosed except upon release by
				the patient, subpoena or court order.
D. Pursuant to the requirements of Section
				59A-48-1 NMSA 1978 et seq., the dental records of the prepaid dental plan's
				provider group(s) shall be made available for review by representatives of the
				health services division or the superintendent. During routine surveys, the
				health services division or the superintendent or their representatives will
				review dental records of members of the prepaid dental plan on a random sample
				basis. On complaint or special investigations, specific dental records will be
				reviewed. Confidentially of patient records shall be maintained.
E. If the member discontinues membership in
				the prepaid dental plan it shall furnish, upon his request, copies of his
				records. A reasonable charge may be made for these copies based upon the cost
				of duplicating them.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 6 - PREPAID DENTAL PLANS › Section 13.10.6.16 - QUALITY ASSURANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				prepaid dental plan shall provide an effective method for a continuing review
				and evaluation of the dental care provided to ensure that treatment and level
				of care were appropriate and adequate, that the quality of dental care provided
				met with acceptable standards, and that corrective action occurred or will
				occur if indicated.
B. There shall
				be a quality assurance committee appointed by the prepaid dental plan
				consisting of the chief executive officer or his designee, the dental director,
				practitioners of the dental healing arts, allied health professionals, and
				consumers who shall be members of the plan. Services performed by practitioners
				of the dental healing arts shall be reviewed and evaluated by members of this
				committee and evaluated by colleagues within their disciplines. The committee
				shall adopt administrative procedures covering frequency of meetings, types of
				records to be kept, and arrangements for committee reports and their
				dissemination.
C. The plan shall
				submit for approval of the director of the health services division a quality
				assurance plan which shall include procedures to be used for each of the
				following:
(1) establishment of standards for
				dental care at equivalent to those utilized by the professional standards
				review organization for medicare and medicaid reimbursement;
(2) surveillance of care provided;
(3) analysis of problems
				identified;
(4) correction of
				deficiencies including a time schedule for correction of the
				deficiencies;
(5) follow-up
				(periodic reassessment of the plan).
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico State Corporation Commission [Public Regulation
				  Commission], Department of Insurance, Post Office Box 1269, Santa Fe, NM
				  87504-1269.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-46-9, 59A-46-12, 59A-46-22 and 59A-46-23 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
June 1, 1998, unless a later date is cited at the end of a
				  section or paragraph.
Compiler's note: The words or paragraph, above, are no
					 longer applicable. Later dates are now cited only at the end of sections, in
					 the history notes appearing in
					 brackets.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to ensure that HMO's meet minimum
				  fiscal operational requirements sufficient to assume the risk of their covered
				  subscribers and to establish requirements for the membership of HMO
				  policy-making bodies.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the definitions in 59A-46-2 NMSA 1978, the
				  following terms have the meanings given here.
A.
"Health professional"
includes physicians, dentists, registered nurses, licensed practical nurses,
				podiatrists, optometrists, chiropractic physicians, physician assistants,
				certified nurse practitioners, certified nurse-midwives, registered lay
				midwives, clinical psychologists, social workers, pharmacists, nutritionists,
				occupational therapists, physical therapists, and other professionals engaged
				in the delivery of health care services who are licensed to practice in New
				Mexico, are certified, and are practicing under the authority of an HMO,
				medical group, hospital, individual practice association, or other entity
				authorized by applicable New Mexico law.
B.
"Individual practice association
				(IPA)"
means a partnership, association, corporation, or other legal
				entity which delivers or arranges for the delivery of health services and which
				has entered into written services arrangements with health professionals, a
				majority of whom are licensed to practice medicine or osteopathy.
C.
"Medical group"
means a
				partnership, association, corporation, or other group:
(1) that is composed of health professionals
				licensed to practice medicine or osteopathy and of such other licensed health
				professionals (including dentists, optometrists, and podiatrists) as are
				necessary for the provision of health services for which the group is
				responsible;
(2) a majority of the
				members of which are licensed to practice medicine or osteopathy; and
(3) the members of which:
(a) after the end of the 48 month period
				beginning after the month in which the HMO for which the group provides health
				services becomes a qualified HMO, as their principal professional activity
				(over 50 percent individually) engage in the coordinated practice of their
				profession and as a group responsibility have substantial responsibility (over
				35 percent in the aggregate of their professional responsibility) for the
				delivery of health services to enrollees of an HMO;
(b) pool their income from practice as
				members of the group and distribute it among themselves according to a
				prearranged salary or drawing account or other similar plan unrelated to the
				provision of specific health services;
(c) share health (including medical) records
				and substantial portions of major equipment and of professional, technical, and
				administrative staff;
(d) establish
				an arrangement whereby an enrollee's enrollment status is not known to the
				health professional who provides health services to the enrollee.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.8 - INVESTMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
An HMO shall be treated as a life insurance company for
				  purposes of applying the provisions of Chapter 59A, Article 9 NMSA
				  1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.9 - ANNUAL REPORTS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the requirements of Section 59A-46-9 NMSA
				  1978, each HMO shall provide to the superintendent on or before March 1 of each
				  year, unless for good cause shown the superintendent authorizes an extension of
				  time, the following:
A. a copy of the
				report, if any, filed with the U.S. department of health and human services'
				health care financing administration containing the information required to be
				reported by disclosing entities under regulations implementing Sections 1124
				and 1902(a)(38) of the Social Security Act (see
				42
				CFR 420.206 and
				42
				CFR 455.104, respectively); and
B. a description of any of the following
				significant business transactions between the HMO and any party-in-interest
				that occurred during the previous fiscal year, and a justification that the
				costs of any such transaction do not exceed the costs which would have been
				incurred if the transaction had been undertaken with someone not a
				party-in-interest (or, if the costs are higher, a justification that such costs
				are consistent with prudent management and fiscal soundness):
(1) sale, exchange, or lease of
				property;
(2) furnishing, for
				consideration, goods, services (including management services), or facilities,
				but not including salaries paid to employees for services provided in the
				normal course of their employment and health services provided to enrollees by
				hospitals and other providers and by staff, medical groups, individual practice
				associations, or any combination of them; and
(3) lending money or otherwise extending
				credit.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.10 - ACCOUNTANTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Independent accountant:
Whenever the superintendent orders, or
				this rule requires, that a financial statement or other report be audited or be
				accompanied by the opinion of a certified public accountant or public
				accountant, the accountant shall be independent of the HMO.
B.
Change of independent
				accountant:
When the HMO submits financial statements required by this
				rule and the certifying accountant is an accountant other than the accountant
				who certified the HMO's most recent filing, the HMO must provide the
				superintendent with a separate letter stating whether, in the twenty-four (24)
				months preceding the engagement of the new accountant, there was any
				disagreement with the former accountant on any matter involving accounting
				principles or practices, financial statement disclosures, or auditing
				procedures, which the former accountant would have referred to in his or her
				opinion or report to the superintendent if such issues were not resolved to his
				or her satisfaction. The letter must be verified by a principal officer of the
				HMO. The HMO shall also request the former accountant to provide it with a
				letter addressed to the superintendent stating whether the former accountant
				agrees with the statements contained in the HMO's letter and, if not, stating
				the reasons the former accountant disagrees with the statements in the letter.
				The two letters must be submitted to the superintendent within 45 days after
				the HMO engages the new accountant.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.11 - DUPLICATION OF FEDERAL REPORTING REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
If the reporting requirements of this rule duplicate any
				  federal reporting requirements, the HMO may request a waiver of the reporting
				  requirements of this rule. In requesting such a waiver, the HMO must clearly
				  state which federally required information will be duplicated by complying with
				  which reporting requirement of this rule. The superintendent will grant such
				  waivers only when the HMO's federally reported information is provided and is
				  in a clear and easily discernible format.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.12 - FISCAL OPERATION

Current through Register Vol. 35, No. 13, July 16, 2024
Each HMO shall have a fiscally sound operation as
				  demonstrated by:
A. total assets being
				greater than total unsubordinated liabilities by an amount at least equal to
				the net worth requirements delineated in Section 59A-46-13 NMSA 1978;
B. sufficient cash flow and adequate
				liquidity to meet obligations as they become due;
C. if the HMO did not increase its net worth
				during the three most recent fiscal years, a financial plan satisfactory to the
				superintendent, which shall include:
(1) a
				detailed marketing plan;
(2)
				statements of revenues and expenses on an accrual basis;
(3) statements of sources and uses of funds;
				and
(4) balance sheets.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.13 - ADMINISTRATIVE AND MANAGERIAL ARRANGEMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Each HMO shall have administrative and managerial
				  arrangements satisfactory to the superintendent as demonstrated by at least the
				  following:
A. a policy-making body
				which exercises oversight and control over the HMO's policies and personnel to
				assure that management actions are in the best interests of the HMO and its
				enrollees; and
B. personnel and
				systems sufficient for the HMO to organize, plan, control and evaluate the
				financial, marketing, health services, quality assurance program,
				administrative and management aspects of HMO. At a minimum, the HMO shall be
				managed by an executive whose appointment and removal are under the control of
				the HMO's policy-making body.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.14 - PROTECTION OF ENROLLEES

Current through Register Vol. 35, No. 13, July 16, 2024
Each HMO shall adopt at least one of the following
				  arrangements to protect its enrollees from incurring liability for payment of
				  any fees which are the legal obligation of the HMO:
A. a contractual arrangement with any
				provider regularly used by the enrollees of the HMO prohibiting the provider
				from holding any enrollee liable for payment of any fees which are the legal
				obligation of the HMO;
B. a
				stand-by reinsurance agreement or membership in a guaranty association that is
				acceptable to the superintendent;
C. adequate financial reserves acceptable to
				the superintendent; or
D. other
				arrangements acceptable to the superintendent to protect enrollees.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.15 - FINANCIAL RISK

Current through Register Vol. 35, No. 13, July 16, 2024
Each HMO shall assume full financial risk on a prospective
				  basis for the provision of basic health services, except that it may:
A. obtain insurance or make other
				arrangements for the cost of providing to any enrollee basic health services
				the aggregate value of which exceeds $5,000 in any year;
B. obtain insurance or make other
				arrangements for the cost of basic health care services provided to enrollees
				other than through the HMO because medical necessity required provision of such
				services prior to the time the services could be secured through the
				HMO;
C. obtain insurance or make
				other arrangements for not more than 90 percent of the amount by which its
				costs for any fiscal year exceed 115 percent of its income for that fiscal
				year; or
D. make arrangements with
				physicians or other health professionals, health care institutions, or any
				combination of individuals or institutions to assume all or part of the
				financial risk on a prospective basis for the provision of basic health care
				services by physicians or other health professionals or through the
				institutions.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.16 - TRANSACTIONS WITH PARTY-IN-INTEREST

Current through Register Vol. 35, No. 13, July 16, 2024
With respect to any significant business transaction by the
				  HMO with a party-in-interest:
A. The
				HMO shall disclose to its policy-making body all material facts concerning the
				transaction and the party-in-interest's interest in the transaction.
B. The policy-making body shall make such
				facts and the policy-making body's actions, if any, part of its minutes or, if
				no minutes are required of the policy-making body, shall otherwise make them a
				record of the HMO.
C. The HMO shall
				hand deliver or send by certified mail to the superintendent prior notice of
				the transaction. Such notice shall be given with reasonable time for the
				superintendent to object. The superintendent shall approve or disapprove such
				transaction within 30 days after receipt of the notice, and if no approval or
				disapproval has been granted within 30 days, the transaction shall be deemed
				approved by the superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.17 - POLICY-MAKING BODIES OF HMOS

Current through Register Vol. 35, No. 13, July 16, 2024
No later than one year after becoming operational as a
				  certified HMO, an HMO shall either:
A.
				assure that at least one-third of the membership of the HMO's policy-making
				body are enrollees of the HMO and that they reside in, or in proximity to, the
				service area of the HMO. No enrollee who is a party-in-interest shall be
				included in the minimum one-third member representation on the policy-making
				body. Persons serving on the policy-making body are not prohibited from
				receiving payments of directors' fees or other similar fees, or interest and
				dividends derived from enrollment in an HMO cooperative.
B. create an advisory board to the
				policy-making body. At least one-third of the members of the advisory board
				must be enrollees of the HMO who meet the criteria of 13 NMAC 10.7.17.1 [now
				Subsection A of 13.10.7.17 NMAC]. The advisory board shall meet at least
				annually and at least annually shall file a report of its recommendations with
				the policy-making body of the HMO. The report and any minority reports shall be
				forwarded to the superintendent annually.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 7 - FINANCIAL REPORTING REQUIREMENTS FOR HEALTH MAINTENANCE ORGANIZATIONS › Section 13.10.7.18 - FACILITATING PARTICIPATION BY FEDERAL OR STATE AGENCIES IN HMOS

Current through Register Vol. 35, No. 13, July 16, 2024
The superintendent may waive or modify any part of this rule
				  in order to facilitate the purchase of HMO services by federal or state
				  agencies in New Mexico.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.10 - MINIMUM STANDARDS FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY PRIOR TO JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.11 - GENERAL STANDARDS FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY PRIOR TO JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.12 - RENEWAL AND CONTINUATION OF COVERAGE FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY PRIOR TO JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.13 - MINIMUM BENEFIT STANDARDS FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY PRIOR TO JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.14 - BENEFIT STANDARDS FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY AFTER JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.15 - GENERAL STANDARDS FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY AFTER JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.16 - RENEWAL AND CONTINUATION OF COVERAGE FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY AFTER JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.18 - STANDARDS FOR BASIC ("CORE") BENEFITS COMMON TO BENEFIT PLANS A - J FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY AFTER JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.19 - STANDARDS FOR ADDITIONAL BENEFITS FOR POLICIES OR CERTIFICATES ISSUED FOR DELIVERY AFTER JULY 1, 1992 (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.58 - PROHIBITION AGAINST PRE-EXISTING CONDITIONS, WAITING PERIODS, ELIMINATION PERIODS, AND PROBATIONARY PERIODS IN REPLACEMENT POLICIES OR CERTIFICATES (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 8 - HEALTH INSURANCE FOR SENIORS (REPEALED) › Section 13.10.8.59 - INSTRUCTIONS FOR USE OF THE DISCLOSURE STATEMENTS FOR HEALTH INSURANCE POLICIES SOLD TO MEDICARE BENEFICIARIES THAT DUPLICATE MEDICARE (REPEALED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico State Corporation Commission [Public Regulation
				  Commission], Department of Insurance, Post Office Box 1269, Santa Fe, NM
				  87504-1269.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule applies to policies or plans issued after the
				  effective date of this rule by health insurers, fraternal benefit societies,
				  health maintenance organizations and nonprofit healthcare plans in accordance
				  with the provisions of the Minimum Healthcare Protection Act, Section 59A-23B-1
				  NMSA 1978 , et seq. as amended.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
May 1, 1992, unless a later date is cited at the end of a
				  section or paragraph. Repromulgated in NMAC format effective July 1,
				  1997.
Compiler's note: The words or paragraph, above, are no
					 longer applicable. Later dates are now cited only at the end of sections, in
					 the history notes appearing in
					 brackets.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
This rule is intended to address limitations in access to
				  healthcare by authorizing health insurers, fraternal benefit societies, health
				  maintenance organizations and nonprofit healthcare plans to offer minimum
				  healthcare services, policies or plans at affordable rates to those residents
				  of the state who may not desire or be able to afford more comprehensive
				  healthcare services, policies or plans.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 9 - MINIMUM HEALTHCARE PROTECTION › Section 13.10.9.8 - ELIGIBILITY CRITERIA

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Pursuant to Section 59A-23B-3B NMSA 1978, the individual, family or group
				obtaining coverage under the policy or plan shall have been without healthcare
				insurance, a health services plan or employer sponsored healthcare coverage for
				the six-month period immediately preceding the effective date of their coverage
				under a policy or plan except that for groups in existence for less than six
				months, the group has been without healthcare coverage since the formation of
				the group.
B. For purposes of the
				Minimum Healthcare Protection Act and this rule, a group which is otherwise
				eligible will be deemed to have been without healthcare coverage whether or not
				individuals within the group have other healthcare coverage either individually
				or as the dependents of other persons.
C. With respect to individuals eligible for
				medicaid benefits, the provisions of Sections 59A-18-31, 59A-22-38, 59A-23-7,
				59A-46-34 and 59A-47-36 NMSA 1978 shall apply to policies or plans issued in
				the state on or after the effective date of the Minimum Healthcare Protection
				Act.