New Mexico Administrative Code › Title 13 - INSURANCE › Chapter 10 - HEALTH INSURANCE › Part 2 - MOTHERS AND NEWLY BORN CHILDREN HEALTH SECURITY › Section 13.10.2.11 - FRATERNAL BENEFIT SOCIETY CONTRACTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. All fraternal benefit society contracts
				delivered or issued for delivery in this state which provide maternity coverage
				shall also provide coverage for a minimum of 48 hours of inpatient care
				following a vaginal delivery and a minimum of 96 hours of inpatient care
				following a caesarian section for a mother and her newly born child in a health
				facility unless earlier discharge is made in accordance with the medical
				criteria outlined in the most current version of the "Guidelines for Perinatal
				Care" prepared by the American academy of pediatrics and the American college
				of obstetricians and gynecologists, including, but not limited to, the
				criterion that family members or other support person(s) should be available to
				the mother for the first few days following discharge. In addition, a decision
				for early discharge should be individualized and should be a mutual decision
				between the mother and the attending physician. Inpatient care in excess of a
				minimum of 48 hours following a vaginal delivery and a minimum of 96 hours
				following a caesarian section for a mother and her newly born child in a health
				facility shall be covered if determined to be medically necessary by the
				attending physician.
B.
				Notwithstanding the provisions of subsection 11.1 of this section [now
				Subsection A of 13.10.2.11 NMAC], a fraternal benefit society contract
				delivered or issued for delivery in this state that provides coverage for
				postpartum care to a mother and her newly born child in the home shall not be
				required to provide for coverage for a minimum of 48 hours of inpatient care
				following a vaginal delivery and a minimum of 96 hours of inpatient care
				following a caesarian section, unless such inpatient care is determined to be
				medically necessary by the attending physician, or early discharge is
				inconsistent with the most current version of the "Guidelines for Perinatal
				Care" prepared by the American academy of pediatrics and the American college
				of obstetricians and gynecologists, or this rule.
C. Postpartum care in the home shall be made
				in accordance with accepted maternal and neonatal physician assessments, by a
				person with appropriate licensure, training and experience to provide
				postpartum care. Services provided by such person shall include, but not be
				limited to, parent education, assistance and training in breast and bottle
				feeding, and the performance of any necessary and appropriate clinical
				tests.
D. Postpartum care in the
				home shall consist of a minimum of three home visits, unless one or two home
				visits are determined to be sufficient by the attending physician or person
				with appropriate licensure, training and experience to provide postpartum care,
				and the mother. The home visits shall be conducted within the time period
				ordered by the attending physician or person with appropriate licensure,
				training and experience to provide postpartum care.
E. Each fraternal benefit society which
				provides maternity coverage in this state shall mail a written description of
				the coverage required under this rule, in a form approved by the
				superintendent, to the expectant mother covered by the fraternal benefit
				society and to her attending physician, upon receipt by the fraternal benefit
				society of notification of the diagnosis of pregnancy of the expectant
				mother.
F. In addition to the
				notification provided in subsection 11.5 [now Subsection E of 13.10.2.11 NMAC],
				each fraternal benefit society which provides maternity coverage in this state
				shall mail a written statement, in a form approved by the superintendent, to
				the expectant mother covered by the fraternal benefit society, notifying the
				expectant mother of her right to complain to the superintendent if there is
				concern that the mother or her newly born child has not received the coverage
				required by this rule. In the event of a complaint, the fraternal benefit
				society will have the burden of proof to demonstrate that the coverage provided
				was in compliance with this rule.