reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.21 - ELIGIBILITY OF EMPLOYEES OF SMALL EMPLOYERS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Eligible employees.
(1) An employee of a small employer (or a
				self-employed person who is eligible under Subparagraph (b) of Paragraph (3) of
				Subsection A of 13.10.11.20 NMAC) is eligible to enroll in an approved health
				plan if:
(a) the employee (or the
				self-employed person) has completed the employer's waiting period;
(b) the employee (and any self-employed
				person) is working at least 20 hours per week on a regular basis (other than as
				a volunteer); and
(c) the employee
				(or the self-employed person) does not come within one of the categories of
				ineligible employees described in Subsection B of 13.10.11.21 NMAC.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.22 - DOCUMENTATION REQUIRED

Current through Register Vol. 35, No. 13, July 16, 2024
The
alliance
shall require documentation that
				  the employer qualifies as a small employer and satisfies eligibility and
				  participation requirements. The
alliance
is particularly concerned
				  that self-employed individuals are actively working for their business at least
				  20 hours per week. Required documentation must be received in the
alliance
office by the 15th of the month in order to be eligible
				  for an effective date of the first of the following month. If the 15th of the
				  month falls on a weekend or holiday, the documentation must be received by the
alliance
before 5:00 p.m. on the next business
				  day.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.23 - DOCUMENTATION FOR NEW GROUPS AND EXISTING GROUPS ENROLLING WITH A NEW CARRIER

Current through Register Vol. 35, No. 13, July 16, 2024
The
alliance
requires:
A. a completed application;
B. the employer's federal EID and New Mexico
				gross receipts tax ID numbers; or, for a new business that has not yet obtained
				tax ID numbers, a current valid business license;
C. a waiver of coverage, in the form
				specified by the
alliance
, signed by each eligible employee who
				does not desire coverage. If the employee has other coverage, the name of the
				carrier, as well as the subscriber and group names must be specified;
				and
D. for groups that file New
				Mexico department of labor employer's quarterly wage and contribution report
				(schedule A - SUTA), seq level1 \h \r0 the employer's most recent SUTA.
(1) The employer must identify on the SUTA
				form each employee who is not eligible for coverage and must specify the reason
				that the employee is ineligible, e.g., on medicare, working less 20 hours per
				week, etc. For each employee who is not eligible, the employer must specify the
				employee's date of hire and hours per week worked.
(2) If an employer submits a SUTA but desires
				to enroll employees who are not identified on that report, the employer must
				submit the following applicable documentation for each such employee:
(a) for any new employees not yet identified
				on the most recent SUTA, W-4 forms;
(b) for each working owner, dependent or
				partner not identified on the SUTA, an affidavit, signed under oath, that the
				individual is working in the business at least 20 hours per week on a regular
				basis.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.24 - DOCUMENTATION FOR GROUPS RENEWING WITH THE SAME CARRIER

Current through Register Vol. 35, No. 13, July 16, 2024
A. For groups that file New Mexico department
				of labor employer's quarterly wage and contribution report (schedule A - SUTA),
				tseq level1 \h \r0 he employer's most recent SUTA.
(1) The employer must identify on the SUTA
				form each employee who is not eligible for coverage and must specify the reason
				that the employee is ineligible, (e.g., on medicare, working part time (i.e.,
				less 20 hours per week), terminated, etc). For each employee who is not
				eligible, the employer must specify the employee's date of hire and hours per
				week worked.
(2) The employer must
				submit an enrollment application for each employee desiring coverage who has
				not previously submitted an application and a waiver of coverage, in the form
				specified by the
alliance
, for each eligible employee who does not
				desire coverage and who has not previously submitted a waiver to the
alliance
. If the employee has other coverage, the name of the
				carrier, as well as the subscriber and group names must be specified;
(3) If an employer submits a SUTA but desires
				to enroll employees who are not identified on that report, the employer must
				submit the following applicable documentation for each such employee:
(a) for any new employees not yet identified
				on the most recent SUTA, W-4 forms;
(b) for each owner, working spouse or partner
				not identified on the SUTA, a witnessed affidavit that the individual is
				working in the business at least 20 hours per week on a regular
				basis.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.25 - HMO SERVICE AREA REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
In order to be eligible to enroll in an
alliance
plan offered by an HMO, an employee or spouse must live or work within the
				  HMO's service area. The HMO may approve exceptions on an individual basis in
				  accordance with the HMO's usual business practice.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.26 - WAITING PERIOD

Current through Register Vol. 35, No. 13, July 16, 2024
The employer must establish a waiting period for new
				  employees. The minimum waiting period is 30 days. The maximum waiting period is
				  180 days. The waiting period must be the same for all employees of a small
				  employer. At the time a small employer first obtains coverage through the
alliance
, the small employer, at its discretion, may elect to
				  waive the waiting period for all employees who are otherwise then eligible for
				  and enrolling in the plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.27 - ENROLLMENT PERIODS

Current through Register Vol. 35, No. 13, July 16, 2024
Applications must be received by the
alliance
office within the time period for enrollment specified above.
A.
Timely enrollment.
Employees
				and their dependents shall be entitled to enroll in an
alliance
plan during the following timely enrollment periods.
(1) New employees and their dependents may
				enroll in the plan within 31 days of completion of their employer's waiting
				period.
(2) An individual may
				enroll in the plan if:
(a) at the time the
				individual was first eligible to be covered under the small employer's plan,
				the individual was covered under another group health benefit plan;
(b) the individual's coverage under the other
				group plan terminates involuntarily except for cause; and
(c) the individual enrolls in the small
				employer's plan within 31 days of the effective date of termination of his or
				her coverage under the other group plan.
(3) A new dependent of an eligible or
				enrolled employee may enroll in the plan within 31 days of becoming eligible by
				virtue of marriage, birth, adoption or placement for adoption, or entry of a
				guardianship order. If the eligible employee is not then enrolled in the plan,
				he must also enroll in the plan within this period in order to obtain coverage
				for the dependent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.28 - EFFECTIVE DATES

Current through Register Vol. 35, No. 13, July 16, 2024
A. If the
				documentation required by the
alliance
is received by the 15th of
				the month, coverage shall be reviewed for an effective date as of the first day
				of the following month. If the documentation required by the
alliance
is received after the 15th of the month, coverage shall
				not be effective until the first day of the month after the month following
				that in which the complete documentation is received. (Note: If the 15th of the
				month falls on a weekend or holiday, the documentation must be received by the
alliance
, or delivered to its post office box, before 5:00 p.m. on
				the next business day.)
B. Coverage
				for an eligible employee and/or dependent shall be effective as of the first
				day of the month following fulfillment of enrollment and eligibility
				requirements, unless an earlier effective date is required by law (as in the
				case of newborn or adopted children). (See 13.10.11.29 NMAC.)
C. Coverage for persons eligible to enroll
				and enrolling during an open enrollment period held pursuant to Subsection B of
				13.10.11.27 NMAC shall be effective as of the first day of the month following
				enrollment.
D. The small employer
				shall notify the
alliance
of the termination of, or cancellation
				of insurance for, any employee or dependent by the end of the month following
				the month in which the employee was terminated or his coverage cancelled.
				Premiums for the month following the month in which termination or cancellation
				is effective shall be refunded if previously paid, provided that the
alliance
has been timely notified in writing.
E. The small employer shall notify the
alliance
of its intent to terminate its group insurance through
				the
alliance
no later than the 10th of the month following the
				last month of coverage. Premiums for any month following the last intended
				month of coverage will not be refunded unless notice of termination is received
				by the
alliance
on or before the 10th of that month. (Note: If the
				10th of the month falls on a weekend or holiday, the documentation must be
				received by the
alliance
, or delivered to its post office box,
				before 5:00 pm on the next business day.)
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.29 - FAMILY COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Family
				coverage must be offered for:
(1) the
				employee's lawful spouse;
(2) the
				employee's natural-born or legally adopted unmarried child;
(3) the employee's stepchild who is living in
				the employee's home and is chiefly dependent on the employee for support;
				and
(4) a child who is living in
				the employee's home and for whom the employee or his or her spouse has been
				appointed the legal guardian by a state court of competent
				jurisdiction.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.30 - PRE-EXISTING CONDITION EXCLUSIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Definitions.
As used in this section:
(1)
pre-existing condition
means a limitation or exclusion of benefits relating to a condition based on
				the fact that the condition was present before the date of enrollment for
				coverage for the benefits whether or not any medical advice, diagnosis, care or
				treatment was recommended or received before that date, but genetic information
				is not included as a preexisting condition for the purposes of limiting or
				excluding benefits in the absence of a diagnosis of the condition related to
				the genetic information;
(2)
creditable coverage
means, with respect to an individual, coverage of
				the individual pursuant to:
(a) an
				employment-based group health plan;
(b) health insurance coverage;
(c) Part A or Part B of Title 18 of the
				Social Security Act (medicare);
(d)
				Title 19 of the Social Security Act (medicaid) except coverage consisting
				solely of benefits pursuant to section 1928 of that title;
(e) 10 USCA Chapter 55 (military
				benefits);
(f) a medical care
				program of the Indian Health Service or of an Indian nation, tribe or
				pueblo;
(g) the Comprehensive
				Health Insurance Pool Act (CHIP);
(h) a health plan offered pursuant to 5 USCA
				Chapter 89;
(i) a public health
				plan as defined in federal regulations; or
(j) a health benefit plan offered pursuant to
				section 5(e) of the federal Peace Corps Act; and
(3)
enrollment date
means the
				date of enrollment of the individual in the
alliance
plan or, if
				earlier, the first day of the waiting period for that enrollment.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.31 - CONTINUATION COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A. In
				addition to continuation coverage under the act, other forms of continuation
				coverage may be available under federal law or other provisions of state
				law.Details of these other programs may be obtained from an employer, an agent,
				or the insurance division. With respect to continuation of coverage provided
				under the act:
(1) An employee is eligible
				for continuation coverage under the act only if the employee has been
				continuously covered under an
alliance
plan as an active employee
				for at least six months, even if the employer group ceases to do business or
				terminates its group coverage under the
alliance
. If the employee
				has family coverage, this coverage would continue as well, provided other
				conditions of eligibility continue to be met. An employee must apply for
				continuation coverage through the
alliance
within 31 days of the
				loss of his or her eligibility for group coverage through the
alliance
.
(2) A
				covered dependent is eligible for individual continuation coverage under the
				Alliance Act only if the dependent has been continuously covered under an
alliance
plan as a dependent of an active employee for at least
				six months, and then only if the dependent applies for continuation coverage
				within 31 days of:
(a) the death of the
				employee;
(b) the divorce,
				annulment or dissolution of marriage or legal separation of the spouse from the
				employee;
(c) termination of the
				employee's employment for any reason, including the termination of the
				employer's group coverage or dissolution of the group; or
(d) for covered dependent children, upon
				attainment of the limiting age of 26, as provided in Subsection C of
				13.10.11.29 NMAC.
(e) a covered
				dependent may not continue coverage if, at the time of the qualifying event
				specified above, the employee himself is covered under continuation coverage;
				provided that a spouse and any dependent children may continue coverage if the
				qualifying event is the death of the continuee.
(3) No person is eligible to enroll or to
				remain on continuation coverage if he or she resides outside of the United
				States for a period of over six months or, if continuation coverage under this
				section became effective after the effective date of this rule, he or she
				either moves from the state of New Mexico or resides outside of the state of
				New Mexico for a period of over six months.
(4) Continuation coverage under the act is
				considered to be individual coverage for purposes of state and federal law.
				Persons electing to continue coverage under the act shall be subject to the
				provisions of 13.10.11.34 NMAC. Premiums for this continuation coverage shall
				be calculated at individual coverage rates.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.32 - COVERAGE OF OUT-OF-COUNTRY SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Services provided outside of the United States will be
				  covered only if they are for emergency treatment.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.33 - CHANGES TO COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A group must select one carrier (member) for all participants
				  as of the effective date of the group coverage. A group may only change
				  carriers and plan design, (e.g., level of deductible or co-pay/co-insurance),
				  at the group's anniversary date. All changes must be received by the
alliance
by the 15th day of the month prior to the group's
				  anniversary date. (Note: If the 15th of the month falls on a weekend or
				  holiday, the documentation must be received by the
alliance
, or
				  delivered to its post office box, before 5:00 p.m. on the next business
				  day.)
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA › Section 13.10.11.34 - INDIVIDUAL COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Eligibility as an individual.
(1) An
				individual is eligible for an
alliance
plan outside of a small
				employer if:
(a) as of the date of
				application for coverage the individual is a resident of the state of New
				Mexico and has an aggregate of 18 or more months of creditable coverage, as
				defined in the act, provided that during this period the individual did not
				have a break in creditable coverage lasting 95 days or longer; and either
(i) the individual's most recent coverage was
				under a group health plan, governmental plan or church plan, or
(ii) the individual was covered by a group
				health plan, governmental plan or church plan less than 95 days prior to the
				date the individual applies for coverage through 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 13.10.11.35 - CERTIFICATES OF CREDITABLE COVERAGE

Current through Register Vol. 35, No. 13, July 16, 2024
Members shall be responsible for issuing certificates of
				  creditable coverage for groups and individuals. A member may transfer this
				  responsibility to an individual group only by means of a written agreement
				  signed by both parties. The member may charge a reasonable fee for such
				  service, subject to the approval of the
alliance
.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.1 - 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 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Except as
				otherwise specifically provided, the requirements of this rule apply to issuers
				as defined herein.
B. Nothing in
				this rule shall prevent an issuer from requesting additional information that
				is not contained on the forms required under this rule to determine eligibility
				of the claim for payment if required under the terms of the policy or
				certificate issued to the claimant.
C. Nothing in this rule shall prohibit an
				issuer from accepting alternative forms or procedures for filing claims as are
				specified in a written contract between the health care practitioner or
				institutional care practitioner and issuer; however, such a contract does not
				relieve a health care practitioner, institutional care practitioner or issuer
				from data reporting requirements under federal law or other state
				law.
D. Nothing in this rule shall
				prohibit electronic claims submission if agreed upon by the issuer and health
				care practitioner or institutional care practitioner.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-2-9 and 59A-18-27.1 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 1994, 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 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose and intent of this rule is to implement the
				  provisions of Section 59A-18-27.1 NMSA 1978, to standardize the forms used in
				  the billing and reimbursement of health care expenses, to reduce the number of
				  forms utilized, to increase efficiency in the reimbursement of health care
				  through standardization and to encourage the use of and prescribe a timetable
				  for implementation of electronic interchange of health care expense and
				  reimbursement data.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
"CDT -
				1"
codes means the current dental terminology prescribed by the American
				dental association.
B.
"CPT -
				4"
codes means the current procedural terminology published by the
				American medical association.
C.
"HCFA"
means the health care financing administration of the U.S.
				department of health and human services.
D.
"HCFA form 1450"
means the
				health insurance claim form published by HCFA for use by institutional care
				practitioners, or any successor form published by HCFA to replace form
				1450.
E.
"HCFA form
				1500"
means the health insurance claim form published by HCFA for use by
				health care practitioners, or any successor form published by HCFA to replace
				form 1500.
F.
"HCPCS"
means HCFA's common procedure coding system, a coding system which describes
				products, supplies, procedures and health professional services and includes
				the American medical association's (AMA's)
Physician Current Procedural
				Terminology
,
Fourth Edition
(CPT-4) codes,
				alphanumeric codes, and related modifiers. This includes:
(1)
HCPCS level 1 codes
which
				are the AMA's CPT-4 codes and modifiers for professional services and
				procedures;
(2)
HCPCS level 2
				codes
which are national alphanumeric codes and modifiers for health
				care products and supplies, as well as some codes for professional services not
				included in the AMA's CPT-4;
(3)
HCPCS level 3 codes
which are local alphanumeric codes and
				modifiers for items and services not included in HCPCS level 1 or HCPCS level
				2.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.8 - REQUIREMENTS FOR USE OF HCFA FORM 1500

Current through Register Vol. 35, No. 13, July 16, 2024
A. Issuers shall accept from health care
				practitioners other than dentists the HCFA form 1500 for claims for
				professional services.
B. Issuers
				may not require health care practitioners to use any coding system for the
				initial filing of claims for health care services other than the following:
(1) HCPCS codes; and
(2) ICD - 9 - CM codes.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.9 - REQUIREMENTS FOR USE OF HCFA FORM 1450

Current through Register Vol. 35, No. 13, July 16, 2024
A. Issuers shall accept from institutional
				care practitioners the HCFA form 1450 for claims for health care
				services.
B. Issuers may not
				require institutional care practitioners to use any coding system for the
				initial filing of claims for health care services other than the following:
(1) ICD - 9 - CM codes;
(2) revenue codes;
(3) HCPCS codes; and
(4) if charges include direct service
				furnished by a health care practitioner, the information outlined in Section 5
				of this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.10 - REQUIREMENTS FOR USE OF J512 FORM

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Issuers shall accept the J512 form for claims for professional dental
				services.
B. Issuers may not
				require a dentist to use any code other than the CDT-1 codes for the initial
				filing of claims for dental care services, unless the use of supplemental codes
				are defined and permitted in a written contract between the issuer and
				dentist.
C. Dentists utilizing the
				J512 form for submission of claims for professional dental services shall:
(1) follow the instructions for the form
				provided by the American dental association CDT - 1; and
(2) if billing patients directly, provide a
				properly completed J512 form in addition to any other form used to bill the
				patient when requested by the patient.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 12 - STANDARDIZED HEALTH CLAIM FORMS › Section 13.10.12.11 - GENERAL PROVISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Issuers shall:
(1) accept the most current
				editions of the HCFA form 1500, HCFA form 1450, or J512 form completed in
				accordance with the most current instructions for these forms from health care
				practitioners and institutional care practitioners; and
(2) modify their claim reimbursement
				practices to encompass the coding changes for all billing and claim filing by
				the effective date of the changes set forth by the developers of the forms,
				codes and procedures required under this rule.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Public Regulation Commission, Division of
				  Insurance, Post Office Box 1269, Santa Fe, New Mexico
				  87504-1269.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Applicability.
This rule applies to health care insurers that are
				required to obtain a certificate of authority or licensure in this state and
				which provide, offer, or administer managed health care plans.
B.
Exemptions.
This rule does
				not apply to policies or certificates that provide coverage for:
(1) traditional fee-for-service indemnity
				plans;
(2) only short-term travel,
				accident-only, student health, specified disease, or other limited benefits;
				or
(3) credit, disability income,
				hospital indemnity, long-term care insurance, vision care or any other limited
				supplemental benefit, including a stand-alone dental benefit plan, whether
				indemnity, PPO, or non-profit plan.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-1-18, 59A-2-8, 59A-2-9, 59A-4-4, 59A-4-5,
				  59A-15-16, 59A-18-21, 59A-19-5, 59A-19-6, 59A-22-19, 59A-22-20, 59A-22-21,
				  59A-22-42, 59A-22-43, 59A-22A-4, 59A-22A-5, 59A-22A-6, 59A-22A-7, 59A-23E-15,
				  59A-44-41, 59A-46-23, 59A-46-25, 59A-46-30, 59A-47-24, 59A-47-25, 59A-47-27,
				  59A-47-33,
5
9A-57-2,
5
9A-57-4, 59A-57-5, 59A-57-6,
				  59A-57-8, and 59A-57-11 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The purpose of this rule is to ensure the availability,
				  accessibility, and quality of health care services provided by health care
				  insurers through managed health care plans. The rule provides uniform
				  definitions; standards regarding patient rights and responsibilities;
				  requirements regarding supplemental services and prescription drug coverage,
				  when offered; and requirements for consumer assistance offices and consumer
				  advisory boards within managed health care plans.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the following, this rule is subject to the
				  definitions found in the Grievance Procedures Rule, 13.10.17 NMAC.
A. "
Certified nurse-midwife
"
				means any person who is licensed by the board of nursing as a registered nurse
				and who is licensed by the New Mexico department of health as a certified
				nurse-midwife.
B. "
Certified
				nurse practitioner
" means a registered nurse whose qualifications are
				endorsed by the board of nursing for expanded practice as a certified nurse
				practitioner and whose name and pertinent information is entered on the list of
				certified nurse practitioners maintained by the board of nursing.
C. "
Continuous quality
				improvement
" means an ongoing and systematic effort to measure,
				evaluate, and improve a managed health care plan's process in order to
				continually improve the quality of health care services provided to its covered
				persons.
D.
"Covered
				person"
means an individual entitled to receive health care benefits
				provided by a health benefits plan, and includes individuals whose health
				insurance coverage is provided by an entity that purchases or is authorized to
				purchase health care benefits pursuant to the New Mexico Health Care Purchasing
				Act.
E.
"Cytologic
				screening"
means a papanicolaou test or liquid based cervical
				cytopathology, a human papillomavirus test and a pelvic exam for symptomatic as
				well as asymptomatic female patients.
F.
"Division"
means the New
				Mexico division of insurance.
G.
				"
Emergency care
" means health care procedures, treatments, or
				services delivered to a covered person after the sudden onset of what
				reasonably appears to be a medical condition that manifests itself by symptoms
				of sufficient severity, including severe pain, that the absence of immediate
				medical attention could reasonably be expected by a reasonable layperson, to
				result in:
(1) jeopardy to the person's
				health;
(2) serious impairment of
				bodily functions;
(3) serious
				dysfunction of any bodily organ or part; or
(4) disfigurement to the person.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.10 - PRESCRIPTION DRUGS

Current through Register Vol. 35, No. 13, July 16, 2024
A. No MHCP that
				provides coverage for prescription drugs as a basic or supplemental health care
				service or pursuant to inpatient, urgent, or emergency medical services shall
				limit or exclude coverage for any drug approved by the FDA on the basis that
				the drug has not been approved by the FDA for the treatment of the particular
				indication for which the drug has been prescribed, provided that:
(1) the drug has been recognized as safe and
				effective for the treatment of that indication in one or more of the standard
				medical reference compendia, including the "AMA drug evaluations," the
				"American hospital formulary service drug information," and "drug information
				for the healthcare provider," or
(2) as provided for cancer clinical trials,
				pursuant to Section 59A-22-43 NMSA.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.11 - COORDINATION OF BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				health care insurer may or may not coordinate benefits in some or all of its
				group and individual managed health care plan contracts. However, a health care
				insurer which does coordinate benefits may do so only pursuant to the
				provisions in its plan contracts, all of which shall be fair, reasonable, and
				consistent with the objectives of this rule and shall comply with all
				applicable rules and regulations governing coordination of benefits.
B. A provision regarding coordination of
				benefits shall be presumed to be unfair and unreasonable if it:
(1) may relieve the health care insurer of a
				duty otherwise arising from a contract to deliver any health care service to
				any covered person in need of such service because the covered person may be or
				is entitled to coverage of the service by another health carrier; or
(2) results in any covered person who
				cooperates with such provision having greater personal liability for any
				particular health care service furnished by or through the health care insurer
				or received in reliance on the health care insurer than such person would have
				had in the absence of any other health carrier.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.12 - COST SHARING

Current through Register Vol. 35, No. 13, July 16, 2024
A. All cost
				sharing (including copayments, deductibles, co-insurance, or similar charges)
				required of covered persons by the health care insurer or managed health care
				plan for the provision of health care services shall be reasonable and shall
				include any applicable state and federal taxes.
B.Any cost sharing requirement for the
				provision of testing and delivery of health care services for COVID-19
				(including testing/screening for pneumonia and influenza, treatment for
				pneumonia when due to or a result of COVID-19 infection, and treatment for
				influenza when a co-infection with COVID-19) or any disease or condition which
				is the cause of, or subject of, a public health emergency is presumptively
				unreasonable and is prohibited. For purpose of this rule, a public health
				emergency exists when declared by the state of New Mexico or federal government
				.
C. Cost sharing requirements,
				including any variations in contribution requirements based on the type of
				health care service rendered or provider used, shall be disclosed to covered
				persons in MHCP contracts, enrollment materials, and in the evidence of
				coverage.
D. No female covered
				person shall be assessed a higher cost sharing requirement, over and above the
				cost sharing required of all covered persons to be seen by a primary care
				physician, for choosing a women's health care provider as her primary care
				physician
E.Health care services
				for any disease or condition for which cost sharing is prohibited under
				Paragraph B of this section shall be subject to the Surprise Billing Protection
				Act, Sections 59A-57A-1 through 13, NMSA 1978 (the "Act"). Where there is no
				data available in the Act's benchmarking databases for a particular billing
				code, then the health care insurer or managed health care plan shall reimburse
				under the Act at one hundred fifty percent of the Medicare reimbursement rate
				applicable for the year in which the benchmarking data first becomes available.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.13 - CONSUMER ASSISTANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Consumer assistance office: Each MHCP shall establish and adequately staff a
				consumer assistance office. Those MHCPs currently doing business in New Mexico
				shall submit to the superintendent for approval a plan of how the MHCP's
				consumer assistance office will be organized and established. At a minimum, the
				plan shall address:
(1) the staffing of the
				consumer assistance office, including whether the planned hours and level of
				staffing are sufficient for the numbers and types of covered persons served by
				the MHCP;
(2) the MHCP's
				arrangements to meet the needs of covered persons with special needs;
(3) how the consumer assistance staff will be
				trained;
(4) how the independence
				of staff assigned to assist consumers is assured; and
(5) whether staff will have the authority to
				assist consumers in filing and pursuing a grievance or appeal.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.14 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to any applicable suspension, revocation or
				  refusal to continue any certificate of authority or license under the Insurance
				  Code, a penalty for any material violation of this rule may be imposed against
				  a health care insurer by the superintendent in accordance with Sections
				  59A-1-18, 59A-46-25, 59A-57-11 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 13 - MANAGED HEALTH CARE - BENEFITS › Section 13.10.13.15 - SEVERABILITY

Current through Register Vol. 35, No. 13, July 16, 2024
If any section of this rule, or the applicability of any
				  section to any person or circumstance, is for any reason held invalid by a
				  court of competent jurisdiction, the remainder of the rule, or the
				  applicability of such provisions to other persons or circumstances, shall not
				  be affected.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Sections 59A-2-8, 59A-2-9, 59A-8-4, 59A-8-6, 59A-8-7, and
				  59A-8-8 NMSA 1978.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
October 1, 2003, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to promote solvency by
				  establishing minimum standards for the computation of reserves, which place a
				  sound value on liabilities issued under both individual and group health
				  insurance contracts.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.8 - GENERAL PROVISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A. When
				an insurer determines that adequacy of its health insurance reserves requires
				reserves in excess of the minimum standards specified herein, such increased
				reserves shall be held and shall be considered the minimum reserves for that
				insurer.
B. With respect to any
				block of contracts, or with respect to an insurer's health business as a whole,
				a prospective gross premium valuation is the ultimate test of reserve adequacy
				as of a given valuation date. Such a gross premium valuation will take into
				account, for contracts in force, in a claims status, or in a continuation of
				benefits status on the valuation date, the present value as of the valuation
				date of: all expected benefits unpaid, all expected expenses unpaid, and all
				unearned or expected premiums, adjusted for future premium increases reasonably
				expected to be put into effect.
C.
				Such a gross premium valuation is to be performed whenever a significant doubt
				exists as to reserve adequacy with respect to any major block of contracts, or
				with respect to the insurer's health business as a whole. In the event
				inadequacy is found to exist, immediate loss recognition shall be made and the
				reserves restored to adequacy. Adequate reserves (inclusive of claim, premium
				and contract reserves, if any) shall be held with respect to all contracts,
				regardless of whether contract reserves are required for such contracts under
				these standards.
D. Whenever
				minimum reserves, as defined in these standards, exceed reserve requirements as
				determined by a prospective gross premium valuation, such minimum reserves
				remain the minimum requirement under these standards.
E. Adequacy of an insurer's health insurance
				reserves is to be determined on the basis of claim, premium, and contract
				reserves combined. However, 13.10.14.9 through 13.10.14.20 NMAC emphasize the
				importance of determining appropriate reserves for claim, premium, and contract
				reserves separately.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.9 - CLAIM RESERVES

Current through Register Vol. 35, No. 13, July 16, 2024
A. Claim
				reserves are required for all incurred but unpaid claims on all health
				insurance policies.
B. Appropriate
				claim expense reserves are required with respect to the estimated expense of
				settlement of all incurred but unpaid claims.
C. All such reserves for prior valuation
				years are to be tested for adequacy and reasonableness along the lines of claim
				runoff schedules in accordance with the statutory financial statement including
				consideration of any residual unpaid liability.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.10 - MINIMUM STANDARDS FOR CLAIM RESERVES FOR DISABILITY INCOME

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Interest.
The maximum interest rate for claim reserves is specified in
				13.10.14.24 NMAC.
B.
Morbidity.
Minimum standards with respect to morbidity are those
				specified in 13.10.14.22 and 13.10.14.23 NMAC, except that, at the option of
				the insurer:
(1) For claims with a duration
				from date of disablement of less than two years, reserves may be based on the
				insurer's experience, if such experience is considered credible, or upon other
				assumptions designed to place a sound value on the liabilities.
(2) For group disability income claims with a
				duration from date of disablement of more than two years but less than five
				years, reserves may, with the approval of the superintendent, be based on the
				insurer's experience for which the insurer maintains underwriting and claim
				administration control. The request for such approval of a plan of modification
				to the reserve basis must include:
(a) an
				analysis of the credibility of the experience;
(b) a description of how all of the insurer's
				experience is proposed to be used in setting reserves;
(c) a description and qualification of the
				margins to be included;
(d) a
				summary of the financial impact that the proposed plan of modification would
				have had on the insurer's last filed annual statement;
(e) a copy of the approval of the proposed
				plan of modification by the superintendent of the state of domicile;
				and
(f) any other information
				deemed necessary by the superintendent.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.11 - MINIMUM STANDARDS FOR CLAIM RESERVES FOR ALL OTHER BENEFITS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Interest.
The maximum interest rate for claim reserves is specified in
				13.10.14.24 NMAC.
B.
Morbidity or other contingency.
The reserve should be based on the
				insurer's experience, if such experience is considered credible, or upon other
				assumptions designed to place a sound value on the liabilities.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.12 - CLAIM RESERVE METHODS GENERALLY

Current through Register Vol. 35, No. 13, July 16, 2024
A generally accepted actuarial reserving method or other
				  reasonable method, if, after a public hearing, the method is approved by the
				  superintendent prior to the statement date, or a combination of methods may be
				  used to estimate all claim liabilities. The methods used for estimating
				  liabilities generally may be aggregate methods, or various reserve items may be
				  separately valued. Approximations based on groupings and averages may also be
				  employed. Adequacy of the claim reserves, however, shall be determined in the
				  aggregate.
New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 14 - MINIMUM RESERVE STANDARDS FOR INDIVIDUAL AND GROUP HEALTH INSURANCE CONTRACTS › Section 13.10.14.13 - PREMIUM RESERVES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Unearned premium reserves are required for all contracts with respect to the
				period of coverage for which premiums, other than premiums paid in advance,
				have been paid beyond the date of valuation.
B. If premiums due and unpaid are carried as
				an asset, such premiums must be treated as premiums in force, subject to
				unearned premium reserve determination. The value of unpaid commissions,
				premium taxes, and the cost of collection associated with due and unpaid
				premiums must be carried as an offsetting liability.
C. The gross premiums paid in advance for a
				period of coverage commencing after the next premium due date which follows the
				date of valuation may be appropriately discounted to the valuation date and
				shall be held either as a separate liability or as an addition to the unearned
				premium reserve which would otherwise be required as a minimum.